The Superficial Back Line
This first line, the Superficial Back Line (SBL) (Fig. 3.1), is presented in considerable detail, in order to clarify some of the general and specific Anatomy Trains concepts. Subsequent chapters employ the terminology and format developed in this chapter. Whichever line interests you, it may help to read this chapter first.
The Superficial Back Line (SBL) connects and protects the entire posterior surface of the body like a carapace from the bottom of the foot to the top of the head in two pieces – toes to knees, and knees to brow (Fig. 3.2/Table 3.1). When the knees are extended, as in standing, the SBL functions as one continuous line of integrated myofascia. The SBL can be dissected as a unity, seen here both on its own and laid over a plastic classroom skeleton (Figs 3.3 and 3.4).
|Bony stations||Myofascial tracks|
|Frontal bone, supraorbital ridge||13|
|12||Galea aponeurotica/epicranial fascia|
|10||Sacrolumbar fascia/erector spinae|
|Condyles of femur||5|
|2||Plantar fascia and short toe flexors|
|Plantar surface of toe phalanges||1|
Fig. 3.3 The Superficial Back Line dissected away from the body and laid out as a whole. The different sections are labeled, but the dissection indicates the limitation of thinking solely in anatomical ‘parts’ in favor of seeing these meridians as functional ‘wholes’.
The overall postural function of the SBL is to support the body in full upright extension, to prevent the tendency to curl over into flexion exemplified by the fetal position. This all-day postural function requires a higher proportion of slow-twitch, endurance muscle fibers in the muscular portions of this myofascial band. The constant postural demand also requires extra-heavy sheets and bands in the fascial portion, as in the Achilles tendon, hamstrings, sacrotuberous ligament, thoracolumbar fascia, the ‘cables’ of the erector spinae, and at the occipital ridge.
The exception to the extension function comes at the knees, which, unlike other joints, are flexed to the rear by the muscles of the SBL. In standing, the interlocked tendons of the SBL assist the cruciate ligaments in maintaining the postural alignment between the tibia and the femur.
With the exception of flexion from the knees on down, the overall movement function of the SBL is to create extension and hyperextension. In human development, the muscles of the SBL lift the baby’s head from embryological flexion, with progressive engagement and ‘reaching out’ through the eyes, supported by the SBL down through the rest of the body to the ground – belly, seat, knees, feet – as the child achieves stability in each of the developmental stages leading to upright standing about one year after birth (Fig. 3.5).
Fig. 3.5 In development, the SBL shortens to move us from a fetal curve of primary flexion toward the counterbalancing curves of upright posture. Further shortening of the muscles of the SBL produces hyperextension.
Because we are born in a flexed position, with our focus very much inward, the development of strength, competence, and balance in the SBL is intimately linked with the slow wave of maturity, as we move from this primary flexion into a full and easily maintained extension. The author of Psalm 121, who wrote ‘I will lift up mine eyes unto the hills, from whence cometh my help’, is enabled to do so by the Superficial Back Line.
NOTE: We begin most of the major ‘cardinal’ lines (those lines on the front, back, and sides) at their distal or caudal end. This is merely a convention; we could have as easily worked our way down from the head. The body will frequently create and distribute tension either way, or a bind in the middle will work its way out toward both ends. No causation is implied in our choice of where to start.
The most general statement that can be made about any of these Anatomy Trains lines is that strain, tension (good and bad), trauma, and movement tend to be passed through the structure along these fascial lines of transmission.
The SBL is a cardinal line primarily mediating posture and movement in the sagittal plane, either limiting forward movement (flexion) or, when it malfunctions, exaggerating or maintaining excessive backward movement (extension).
Although we speak of the SBL in the singular, there are, of course, two SBLs, one on the right and one on the left, and imbalances between the two SBLs should be observed and corrected along with addressing bilateral patterns of restriction in this line.
Common postural compensation patterns associated with the SBL include: ankle dorsiflexion limitation, knee hyperextension, hamstring shortness (substitution for inadequate deep lateral rotators), anterior pelvic shift, sacral nutation, lordosis, extensor widening in thoracic flexion, suboccipital limitation leading to upper cervical hyperextension, anterior shift or rotation of the occiput on the atlas, and eye–spine movement disconnection.
Our originating ‘station’ on this long line of myofascia is the underside of the distal phalanges of the toes. The first ‘track’ runs along the under surface of the foot. It includes the plantar fascia and the tendons and muscles of the short toe flexors originating in the foot.
These five bands blend into one aponeurosis that runs into the front of the heel bone (the antero-inferior aspect of the calcaneus). The plantar fascia picks up an additional and important 6th strand from the 5th metatarsal base, the lateral band, which blends into the SBL on the outside edge of the heel bone (Figs 3.6 and 3.7).
These fasciae, and their associated muscles that pull across the bottom of the foot, form an adjustable ‘bowstring’ to the longitudinal foot arches; this bowstring helps to approximate the two ends, thus maintaining the heel and the 1st and 5th metatarsal heads in a proper relationship (Fig. 3.8). The plantar aponeurosis constitutes only one of these bowstrings – the long plantar ligament and spring ligament also provide shorter and stronger bowstrings deeper (more cephalad) into the tarsum of the foot (visible below the subtalar joint in Fig. 3.9, see also Fig 3.34).
The plantar surface of the foot is often a source of trouble that communicates up through the rest of the line. Limitation here often correlates with tight hamstrings, lumbar lordosis, and resistant hyperextension in the upper cervicals. Although structural work with the plantar surface often involves a lot of knuckles and fairly hefty stretching of this dense fascia, any method that aids in releasing it will communicate to the tissues above (DVD ref: Superficial Back Line, 10:57–16:34). If your hands are not up to the task, consider using the ‘ball under the foot’ technique described below in ‘A simple test’.
Compare the inner and outer aspect of your client’s foot. While the outer part of the foot (base of little toe to heel) is always shorter than the inner aspect (from base of big toe to heel), there is a common balanced proportion. If the inner aspect of the foot is proportionally short, the foot will often be slightly lifted off the medial surface (as if supinated or inverted) and seemingly curved toward the big toe in a ‘cupped hand’ pattern, as if a slightly cupped hand were placed palm down on the table. In these cases, it is the medial edge of the plantar fascia that needs opening.
The plantar surface of the foot is often a source of trouble that communicates up through the leg. If the outer aspect of the foot is short – if the little toe is retracted or the 5th metatarsal base is pulled toward the heel, or if the outer aspect of the heel seems pulled forward – then the outer edge of the plantar fascia, especially its lateral band, needs to be lengthened (DVD ref: Superficial Back Line, 20:29–22:25). This pattern often accompanies a weak inner arch and the dumping of the weight onto the inner part of the foot, but can occur without the fallen arch.
Even in the relatively balanced foot, the plantar surface can usually benefit from enlivening work to make it more supple and communicative, especially in our urbanized culture where the feet stay locked up in leather coffins all day. A default approach to the plantar tissues is to lengthen between each of the points that support the arches: the heel, the 1st metatarsal head, and the 5th metatarsal head (Fig. 3.8).
For a sometimes dramatic and easily administered test of the relatedness of the entire SBL, have your client do a forward bend, as if to touch the toes with the knees straight (Fig. 3.10). Note the bilateral contour of the back and the resting position of the hands. Draw your client’s attention to how it feels along the back of the body on each side.
Fig. 3.10 A forward bend with the knees straight links and challenges all the tracks and stations of the Superficial Back Line. Work in one area, as in this move for the plantar fascia, can affect motion and length anywhere and everywhere along the line. After work on the right plantar surface, the right arm hangs lower.
Have your client return to standing and roll a tennis ball (or a golf ball for the hardy) deeply into the plantar fascia on one foot only, being slow and thorough with the pressure rather than fast and vigorous. Keep it up for at least a couple of minutes, making sure the whole territory is covered from the ball of all five toes back to the front edge of the heel, the whole triangle shown in Figure 3.8.
Now have the client do the forward bend again and note the bilateral differences in back contour and the distance of each hand from the floor (and draw the client’s attention to the difference in feeling). In most people this will produce a dramatic demonstration of how working in one small part can affect the functioning of the whole. This will work for many people, but not all: for the most easily assessable results, avoid those with a strong scoliosis or other bilateral asymmetries.
It is ‘common knowledge’ that the muscles attach to bones – but this commonsense view is simply not the case for most myofasciae. The plantar fascia is a good case in point. People who run on the balls of their feet, for instance, or others who, for some reason, put repetitive strain on the plantar fascia, tug constantly on the calcaneal attachment of the plantar fascia. Since this fascia is not really attached to the calcaneus but rather blends into its periosteal ‘plastic wrap’ covering, it is possible in some cases for the periosteum to be progressively tugged away from the calcaneus, creating a space, a kind of ‘tent’, between this fabric and the bone (Fig. 3.11).
Fig. 3.11 The formation of a heel spur by the osteoblasts which fill in under a pulled-away periosteum illustrates both the adaptability of the connective tissue system and one limitation of the simplistic ‘muscles attach to bones’ concept.
Between most periostea and their associated bones lie many osteoblasts – bone-building cells. These cells are constantly cleaning and rebuilding the outer surface of the bone. In both the original creation and the continuing maintenance of their associated bone, the osteoblasts are programed with a simple commandment: Thou shalt fill in the bag of the periosteum. Clients who create repetitive strain in the plantar fascia are likely to create plantar fascitis anywhere along the plantar surface where it tears and inflames. If instead the periosteum of the calcaneus gives way and comes away from the bone, then the osteoblasts will fill in the ‘tent’ under the periosteum, creating a bone spur. The spur itself and the spurring process are natural and not inherently painful; the pain comes if the spur interferes with a sensory nerve, as a heel spur often does.
As discussed in Chapter 2, the fasciae do not just attach to the heel bone and stop (as implied in Fig. 3.11). They actually attach to the collagenous covering of the calcaneus, the periosteum, which surrounds the bone like a tough plastic wrapping. If we begin to think in this way, we can see that the plantar fascia is thus continuous with anything else that attaches to that periosteum. If we follow the periosteum around the calcaneus, especially underneath it around the heel to the posterior surface (following a thick and continuous band of fascia – see Figs 3.12 and 3.15B), we find ourselves at the beginning of the next long stretch of track that starts with the Achilles tendon (Figs 3.12 and 3.13).
Fig. 3.13 A dissection of the heel area demonstrates the continuity from plantar tissues to the muscles in the superficial posterior compartment of the leg. (© Ralph T. Hutchings. Reproduced from Abrahams, et al. 1998.)
Because the Achilles tendon must withstand so much tension, it is attached not only to the periosteum but also into the collagenous network of the heel bone itself, just as a tree is rooted into the ground. Leaving the calcaneus and its periosteum, our train passes up, getting wider and flatter as it goes (Fig. 3.12). Three myofascial structures feed into the Achilles tendon: the soleus from the profound side, the gastrocnemius from the superficial side, and the little plantaris in the middle.
Let us take this first connection we have made – from the plantar fascia around the heel to the Achilles tendon – as an example of the unique clinical implications that come out of the myofascial continuities point-of-view.
In simple terms, the heel is the patella of the ankle, as we can see in the X-ray of a foot (Fig. 3.14). From a ‘tensegrity’ point of view, the calcaneus is a compression strut that pushes the tensile tissues of the SBL out away from the ankle to create proper tone around the back of the tibio-talar fulcrum, with the soft tissue spanning from knee to toes. (Contrast this leverage with the proximity of the joint-stabilizing muscles: the fibularii (peroneals) of the Lateral Line that snake right around the lateral malleolus. Similarly, the long toe flexors of the Deep Front Line pass close behind the medial malleolus, lending them more stabilization advantage, but less leverage for jumping.)
Fig. 3.14 This X-ray of a dancer’s foot shows how the calcaneus functions in a way parallel to the patella – what the patella does on the front of the knee, the calcaneus does on the back of the ankle – namely, pushing the soft tissue away from the fulcrum of the joint to give it more leverage. (© Bryan Whitney, reproduced with permission.)
To see the clinical problem this patterning can create, imagine this lower section of this Superficial Back fascial line – the plantar fascia and Achilles-associated fascia – as a bowstring, with the heel as an arrow (Fig. 3.15). As the SBL chronically over-tightens (common in those with the ubiquitous postural fault of a forward lean of the legs: an anterior shift of the pelvis), it is capable of pushing the heel forward into the subtalar joint; or, in another common pattern, such extra tension can bring the tibia–fibula complex posteriorly on the talus, which amounts to the same thing.
Fig. 3.15 When the myofascial continuity comprising the lower part of the SBL tightens, the calcaneus is pushed into the ankle, as an arrow is pushed by the tautened bowstring (A). Notice how the fascia around the heel acts as a ‘bridle’ or a ‘cup’ to embrace and control the heel bone (B).
To assess this, look at your client’s foot from the lateral aspect as they stand, and drop an imaginary vertical line down from the lower edge of the lateral malleolus (or, if you prefer, place your index finger vertically down from the tip of the malleolus to the floor). See how much of the foot lies in front of this line and how much behind. Anatomy dictates that there will be more foot in front of the line, but, with a little practice, you will be able to recognize a normal proportion (Fig. 3.16A) versus comparatively little heel behind this line (Fig. 3.16B).
Fig. 3.16 The amount of the foot in front of the ankle joint should be balanced by about to behind the ankle joint. Without this support for the back body, the upper body will lean forward to place the weight in front.
Measure forward from the spot below the lateral malleolus to the 5th metatarsal head (toes are quite variable, so do not include them). Measure back from the spot to the place where the heel leaves the floor (the limit of its support). On a purely empirical clinical basis, this author finds that a proportion of 1 : 3 or 1 : 4 between the hindfoot and the forefoot offers effective support. A ratio of 1 : 5 or more indicates minimal support for the back of the body. This pattern can not only result in tightness in the SBL but also cause more tightness as well, as it is often accompanied by a forward shift at the knees or pelvis to place more weight on the forefoot, which only tightens the SBL further. As long as this pattern remains, it will prevent the client from feeling secure as you attempt to rebalance the hips over the feet.
In more recalcitrant cases, it may be necessary to further release the ligaments of the ankle by working deeply but slowly from the corner of each malleolus (avoiding the nerves) diagonally to the postero-inferior corner of the heel bone. The result will be a small but visible change in the amount of foot behind the malleolar line, and a very palpable change in support for the back of the body in the client. Therefore, strategically, this work should precede any work designed to help with an anterior pelvic shift.
Please note that the mark of success is a visibly increased amount of heel when you reassess using the malleolus as your guide. Repetition may be called for until the forward lean in the client’s posture is resolved by your other efforts (e.g. freeing the distal ends of the hamstrings, lifting the rectus femoris of the Superficial Front Line, etc.).
Two large muscles attach to the Achilles band: the soleus from the deep side, and the gastrocnemius from the superficial side (Fig. 3.15a). The connection of the SBL is with the superficial muscle, the gastrocnemius. First, however, we have an early opportunity to demonstrate another Anatomy Trains concept, namely ‘locals’ and ‘expresses’.
The importance of differentiating expresses and locals lies in this postural position is most often held in the underlying locals, not in the more superficial expresses. Express trains of myofascia cross more than one joint; locals cross, and therefore act on, only one joint. With some exceptions in the forearms and lower leg, the locals are usually deeper in the body – more profound – than the expresses. (See Ch. 2 for a full definition and examples.)
This superficial posterior compartment of the lower leg is not, however, one of these exceptions: the two heads of the gastrocnemius cross both ankle and knee joints, and can act on both. The deeper soleus crosses only the ankle joint – passing from the heel to the posterior aspects of the tibia, interosseous membrane, and fibula – and acts only on this joint. (The so-called ankle joint is really two joints, consisting of the tibio-talar joint, which acts in plantar- and dorsiflexion, and the subtalar joint, which acts in what we will call inversion and eversion. Though the triceps surae – plantaris, gastrocnemius and soleus together – does have some effect on the subtalar joint, we will ignore that effect for now, designating the soleus a one-joint muscle for the purposes of this example.)
If we took the soleus local, we could keep going on the same fascial plane and come onto the fascia on the back of the popliteus, which crosses the knee and flexes it (and also rotates the tibia medially on the femur when the knee is flexed, though that is outside our current discussion). The gastrocnemius express can thus participate in both plantarflexion and knee flexion, while each of the two locals provides one action only. We will see this phenomenon repeated throughout the myofascial meridians.
Fig. 3.17 The relationship between the heads of the gastrocnemii and the tendons of the hamstrings in the popliteal space behind the knee. (© Ralph T. Hutchings. Reproduced from Abrahams, et al. 1998.) See also Figure 3.3.
It is easy to see from comparing with Figure 3.17 that the gastrocnemius and hamstrings are both separate and connected. In dissection, strong areolar fascia clearly links from near the distal ends of the hamstrings to near the proximal ends of the gastrocnemii heads. In Figure 3.17 this tissue has been dissected away; in Figure 3.3 it has been retained. Such areolar tissue, long thought to be simply a passive ‘filler’, has now been shown to be an effective force transmitter when tightened.1
In practice, then, flexion of the knees delinks the one from the other. While by strict Anatomy Trains rules they are a myofascial continuity, they do function as one primarily when the knee is extended. The gastrocnemii heads reach up and around the hamstring tendons to insert onto the upper portions of the femoral condyles. The hamstrings reach down and around the gastrocnemii to attach to the tibia and fibula. As long as the knee is bent, these two myofascial units go their own ways, neighboring but loosely connected (Fig. 3.18A). As the knee joint comes into extension, however, the femoral condyles come back into tightening the tendon complex, engaging these elements with each other, and making them function together almost as if they were two pairs of hands gripped at the wrists (Fig. 3.18B–D). This configuration also bears a strong resemblance to a square knot, loosened when the knee is bent, tightened as the knee straightens.
Fig. 3.18 When the knee is flexed, the myofascia of the thigh and the myofascia of the lower leg function separately (A). When the knee is extended, these myofasciae link into one connected functioning unit (B), like the interlocked hands of a pair of trapeze artists (C – compare to Fig. 3.17