psoas_piriformis

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I 72 Mal'ciljApI;1 1998

P OisEIS t\. N El~SIVE t~U!\LlTY o f P O ~ .ru:.e ormovement. Fred Asraire had If.jackie O.had ir. Princess Diana, blc:ssher soul, wasgoing for it. We em ;ugue about who h : 1 S it now,but we will probably agree that very few of us orour clients really possess poise nowadays.But-what is it?As we are hands-on therapists, le t LIS arrempr

to define poise in its physical sense, nor themental components of urbuniry and quickwits we often associate wi rh it. ]f we stick to. what poise means in the body, em we get close[Q something that we can get our hands on, oreven help to bring about through our work?(To assist you in gening 1 1 more complete

picture than we can provide here, we includereferences to Frank Netter's Atlas of HumanAnatomy, published by eJBA-Gei!:,') ', althoughyou can follow along with any good anatomyarlas.)Surely parr of our assumption as massage

therapists is that if we bring something about


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in the body , we :llst) bring it (0rhe rest of us(whatever our beliefs about what constitutes"the rest of us"). When we bring about relax-ation in right muscles, the whole person

laxcs. New behaviors become possible fo rh~m, like a deep releasing breath. The same

is true when we relieve chronic pain: clientschange how rhey relarc to rh e world and thepeople around them. Likewise, if we canproduce poise in ;1 physical sense, we C


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}~fl.rm:2:M os s o f t he Wt'ight o( a qllfutmped rests in amJ'oilJci~;/ sling 11llllgfiml1 th e mcdiai bordersot/heir two scapulue.

have the elements in place, we can bringthem rogerher and point ro some applica-tions in daily bodywork.Many massage therapists have had little

cause to study the sacroiliac joinr-themajor 'motor mount' for our walkingengine-leaving S1 joint manipulations to[he chiropractors and osteopaths. Although,as a soft-tissue practitioner, this author doesnor manipulateSI joints in the usual high-velocity-thrust manner, nevertheless wehodyworkers can aid in the natural easingand repositioning of these joinrs through asystematic application of the understandingoutlined below.An evolutionary momentA brief look at the mechanics of upright

standing will help clarify how these ele-ments work together in the uniquely humanSItuation.In a four-legged creature, the spine is hor-

izontal, and most of the weight is supportedby the shoulder girdle (Figure 2). Theweight of the spine, ribs, head and organsbears down on the forelegs. Since the shoul-der assembly of most four-legged crea-tures-a horse, for example-does notconnect to the rest of the skeleton by any74 Man


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PSOAS

toward rhe ground (Figure 5). This requiresa lor of muscle power to pull the ischialtuberosities (IT~) and the sacrum closer torhe back side of the femur in order to openthe angle of the hip joinr as well as co erectrhe spine and lift the head.The hamstrings arc in the position [0do

this, by pulling the ITs toward [he back ofthe knee. The adductor magl1t1s can help inFigure 6: Do not ignore the role ot/hese three

m u sc le s in maintaining goot//JOJtltre

5:T he s hift ji- om Il horizontal to n ucrrica] spine requiresIT mdical ,./;ifi ill the [unction of the sacroiliacjoin: or does it?

S AC R O IL IA C J O IN T PIRI fORMIS

/ $ IIC R !)l lI II C J O! N T

char manner also. Bur the hamstrings can-nor be doing this job ;tll the rime, becausethey need to he free W parricip.ue in run-ning, walking, flexing and rotating the knee.The glurells maxirnus would seem to be agood candidate, bur myographic evidenceshows [hat this muscle is almost (Orallysilent during simple standing, and docs norreally get active until we arc walking uphil1.2The lateral rotators, in spite of their name,

arc in a very good position to bring the backof the pelvis closer to the back of the tcmur,and this postural aspect of their funcrioncannot be ignored (Figure 6). The obturaturintcrnus and the quadratus femoris are par-ticularly important in pulling the ITs downto create this extension at the hip joint. Burof the lateral rorarors, only the piriformispulls directly down and forward on thesacrum, rhus crossing an d afTecting the 51joint. The pelvic floor also has a role in thisaction, which we will address in a li tt le while.First we need to return to the 51 joint, and

see how it swings in humans.

Understanding thehuman sacroiliac jointThe essential point to understanding how

our sacroiliac (51) joint works is that, in spireof the radically different orientation, ir doesmuch the same as when we were

quadrupeds: it lungs in rhe pelvic girdle. .uu]i t Iollows the feme)!:d movement in w;!lking.\Xlhoa! \Xlha( do you mean. irhall t~s in rhe

pelvic bones? Mosr of ux, this .uu horincluded, spend our working lives rhinkingof the sacrum as beillg wedged down intothe [WO hip bones. "The sacrum is rhearrowhead," 1 used ro S;fY to my srudcuts."The spine is the arrow." (Figme 7) M ypoint W;IS (0 show how the i l iolumbar alldsacrospinoux ligamcnts were ncccss.rry IUkeep the force of the ;llTOW [rom spliHillgthe hip bones ;lparr. This view is s t i l l valid,bur ir is only parr o f the r rurh.As well as being wedged from side [0side.

it is also true ro S;IY char the spinc-rltCsacrum part of ir-s-srill "hangs" in rhe hipgirdle from cop to borrom. Look at a corona] section through 0111" SI joint. (Figure 8)It is not wedged ill this dimension; rather itis wider nt the bottom [han ir is ar the (OP,and could conceivably hll out of ihcembrace of the hip bones.What holds [he sacrum ill place is rhe

same piece rhar holds it in the horse--llstrong ligament going from our PSIS ro rheposterior edge o f the second sacral segmenr:the dorsal sacroiliac ligarnenL This l igamtn[also becomes the axis, or hub, felr:l tinv blllirnporranr arc of movement in our SI joinr[hat is much like che horse's.

MarchII\plill 'J9S j,/flssa'j' ,; JV(;fiJi12./lI,:l, "_

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Figure 7: T he sa cru m is w ed ged like a n a rro whea dfro m sid e-to -sid e. w ith th e in dica te d lig tJ men ts kee pin g th e a rr ow [rom " s pl it ti ng " t he pe lv is .

I li OL U MB AR l iG A ME N T

The SI joint has been considered a non-moving joint by many in the medical pro-fession, although chiropracrors andosreoparhs have been moving it successfullyfor centuries. Do a dissection on the old andoften misused bodies that come into theanatomy lab and you will find that the jointhas Fused as often as nor, Itwould be our

contention that this is not normal, andprobably contributed to those people's painor dysfunction before they died. You canlive without movement of the 51 joint, butyou cannot live or move Fullywithout it,and without it you certainly cannot havepoise. It is not a joint that we can voluntar-ily move, like our elbow, bur iFthe passive

Figurt ' 8:A c oro na l se ctio n o f th e p elv is s ho ws h ow w eig ht is tra nsfe rre d b etw een ftm ur lindspin e, b ut a lso sh ow s h ow th c sa crum ha ng s ben ocen th e hip b ones, even in h um an s.

D O R SA l S AC R O il IA CL !GAMENT

7 8 MHI'chj April 1998

rocking movement of the joint is not pre-sent, it can cause a l l k ind s of pain and prob-lems in the surrounding tissues, sometimesquire distant From the joint itself.The 51 joint isalso confusing because it is

a combination fibrous joint and synovialjoint. How can it be bo rh? And how does itmove then? If we open the sacroiliac jointaround the vertical axis like a book, all willbe revealed.Here we can see the two corresponding

surfaces of the 51 joint on the medial side ofthe hip bone and the lateral side of thesacrum. They can be seen roughly as arcs ofa circle, like a piece of pie, with the dorsalsacroiliac ligament at the center of the circle,and the auricular surface=-rhe synovial parrof the joint-out at the edge of the circle.

To understand how it moves, think of thedorsal sacroiliac ligament asthe hub. or axle.of a wheel, and the auricular+ surface as partof the rim of the wheel- a wheel which. ifit existed, would stick a couple of inches omof our backs. (Figure 9) If this image issomewhere near the truth, the hip bonecould move like this wheel (there is argu-ment about how much, but surely not morethan a couple of degrees) 011 the S;ICSllIllaround the fixed point of the ligamenr. Or,conversely, the sacrum could move in a sim-ilar way on the hip bone,This image also explains how the synovial

and fibrous parts of the joint could work inharmony. The hub, the dorsal sacroiliac liga-ment, does not move at all;it only twistsa lit-rle.The inner part ofthe wheelhas to move alittle more. and this movement is accommo-dated by collagen fibers, just as the tinymovements of the skull bones are accommo-dated by the fibers of the sutures. The outerrim of the wheel has to move more, and thusrequires the sliding cartilage surfaces and thelubricating synovial Buid.In healthy walking, as the right femur

flexes reward the hip in a step, the wheel ofthe right hip bone rotates posteriorly so thatthe acetabulum follows the movement of thefemur slightly, and the iliac crest moves upand back. As we push through the step andthe femur extends behind us, the hip bonerotates forward so that the acetabulum Fol-lows the femur back, with the iliac crest mov-ing anterior and inferior. This is much thesame movement aswe saw in the horse, onlysmaller and with a more vertical orientation.If this tiny movement is either hypermobileor absent, it can and does create problems Forthe walker and for the manipulator who triestoget it back into proper motion.


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The above explanation-assuming themovement of the hip bones on a steadysacrum-is a b ir oversimplified, bu r weneed to start somewhere. As well as the hipbones moving on rh e sacrum, rhe sacrumitself performs a multidimensional, rota-rional dance in walking, and the two-jointcomplex is subject co getting stuck in a vari-ety of ways and positions, some of themrequiring sophisticated skills to untangle.A similar bur converse movement also

takes place: the sacrum can also movebetween two stabilized hip bones. The free-dom tor this movement is well understoodby craniosacral therapists, who feel for the

f iB RO US S UR fACE

Figure 9: O pen th e SI jo in t lilt' a book and w e secr/Jlu the sacrum moues Oi l th e ilium (or vice uersa}

like the mouemcnt a/It iobeel around a hub,

nutation (nodding) of [he sacral wheel pow-ered by the tides of the cerebrospinal fluidand the pull of the dura on the second sacralsegment-just in front of the wheel's hub.However, if we have gotten this basic

wheel part across. rhe antagonistic role ofpsoas and pir i formis in poise will fall intoplace. If we look a lir rle wider than rh e 51joint itsel( we can see l1uny muscles charcould have an effect 011 the hip bone parr of[his relationship (see Body3, "Fans of theHip .Joint," Issue #71, Jan.lFeb. 1998).')\VO of these fan muscles, though, stand

out as having very strong and specific leverageon the sacrum: the piriformis, just interior to

our 51 wheel pulling forward and downthat spoke, and the psoas, just lip the othway pulling forward and down on the lubar spine spoke. See how they can be antagnists? Need a lir de more clarity? Read Oil,The muscular elementsThe piriformis originates on the anteri

surface of the lower part of the sacrum, ually with three slips f rom S2 - 54, an d pasour through the greater sciatic notch alowith the sciatic nerve to attach to the insof the vcry top of the greater trochant(Netter plates 246, 337 , 465), The psorigin;nes on the transverse processes abodies of the lumbar vertebrae, usuallyo r six slips from Tl2 - L 5, and passes doand forward, staying behind all [he organd thei r peri toneal coverings. It comes cest to the surface of the body where it cros(he front of the pelvis at the groin JUStlarto the pubic bone, and then goes inferioand posteriorly again to insert on the letrochanrcr (Netter plates 246, 4(6),Both of these muscles earn their imp

tance through the man)' things that tconnect. First, both connect the spine tofemur-both "jump over" the hip bonThat means they are connecting updown in the body, both connect axialappendicular in a big way, and (hey bothfrom deep inside to more outside partsthe body-therefore we can reach vdeeply 1 1 1 m the body's structure by affectthese muscles.The actions of these muscles art :1 ma

of some debate, which is why this authfeels OK about throwing this new tWO ceworth into the discussion. The piriforrn


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has always been li~[ed among the lateralrotator group, but because of [he attach-ment posir ion right :1[ the rop of therrochanrcr, ir has never been in much of ;t

ition to rO[ :1C th e femur laterally. In E tC r,there is some evidence to show that whenthe hip is really flexed, the piriformis couldbecome a mild medial roraror."The piriformis'postural performance

I n {:lC,the piriformis is better consideredas working [rom its insertion to its origin, asit could do whenever the lemur {and rhusthe trochanter) is held stable. If we look atFigure 5, we can consider Ilrst the side- to-side action of the piriformis on rhc sacrum.It is a spinal balancer, :lnd here is an imageo f how it works: Remember when you helda broom in th e open palm of your hand,with the head of the broom lip in the .iir?After a linle pr.rcrice YOll could keep thebroom lip there indefinitely by making linkmovements with your hand to steady it. Thespine is like the broom, and your head like[he head of the broom. The spine hangs into[he sacroiliac joints, .md the piriformisexerts irs pull below the level of t hi s jo in r.Thus as the spine leans [0the left, the [,Iii ofe spine-the p:lrt of the sacrum below thed and the coccyx-would tend to move to

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rhc right. The lelr piriformis call [hen exert.a ligament-like restraint 011 this tendency,reducing strain on rhe 51 joints.Returning to th e broom in your hand,

what happens if the broom starts ro tiltbeyond what YOll can compens;He It)r withthe little adjustments of the palm ? It willfall, unless you switch racr ics and grab thelower end of the handle with one or bothhands, thus saving the broom from fallingal l the way. This is what happens to rh e pir-iformis in many of our clients: the spineabove the pelvis ha s :l twist or a lean in onedirection or another, and the piriformisgrabs with ; 1 1 1 its might to prevent the spinefn)Jl) falling further. To be more precise, itgrabs to prevent that spinal lean from over-taxing rhe Sl ligaments. S O :1S we work thepiritorrnii (Wh,u is rhe plural of "piri-formis"?) in our clients, they may relax whilethey are 011 rhe [able, hut as soon :IS theirbodies arc back in gravity, the piriformissays, in effect, "Hey, Ian't aH~)rd to be thisloose and r ela xe d, 1 gotta tighten up again tostabilize this spine 0' mine"-and the wholecycle begins again.We will leave the broom metaphor here,

but it is worthwhile to keep it in mindrh roughour the rest of our discussion.We are not done, however, considering

piriformis function (anyone who tells you

rhat any part of the body serves D i l l y oncfunction si mply has not looked deeplyenough). llwc 100k;1f Figure 5, another jobIor the piriformi, becomes :lpp;ncnt. Inpassing fi'()Jll th e front of th e sacrum [0 therop of the rrochanrer, the piriformis runsanteriorly. That means (hat it not only pullsside to side on the sacrum: it also pulls thetail forward and down. This essential piri-formic action is the one we arc hyporliesiz-ing is opposed by rh e psoas.Turning now to the psoasUpright posture dictated .1 I1CW and

unique pathway for the pSO:L~.Notice [hat ina quadruped rhe muscle does nor touch thepelvis, going directly hom the spine co th efemur (Figure 5). When the hip joint is fullyextended into our upright stance, the psoastakes a str:mgt route forward from the spineto the front of the pelvis, where it touchesbut does not artach, and then back ro thefemur. This means that contracrion of themuscle should pull rhe femur f o rward (intoflexion) and rhc lumbar spine forward,while pushing rhe pelvis back (as if rhc psoaswere a bowstring an d the pelvis is thearrow).However, rhe actions of the PSO;\S muscle,

like th e piriformis, arc m ultip le .rnd o pen toquestion. ') Everyone ;Igret:s rhar iris :1 hip

Figllrt, J 0: A balanced spine nllouis the pirijrJl'mis to make periodic tlnd tl'mpmll1:Y adjusnncnts;tin unbalanced spine requires drdial1ni t ig/;mess ill t h e p i ri fo rm i r.

80 MaN:I)! April 1!)9S


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Figure 11: The carl'srructuresfrom the front reveals a diffirent relationship betweenthe psoas and the piriformis than does Figure 5. the Sf/me area from the side.

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flexor. and most agree that it produces lat-eral rotation. though arguments can bemade (with which this author disagrees)that it could produce medial rotation of thefemur. It is axiomatic that the psoas pro-duces extension and hyperextension in thelumbars, but we can also open that to ques-tion. in the manner described in the follow-ing paragraph.The psoas isa triangular muscle. like, say,

the deltoid. The insertion is practically apoint-the lesser trochanter-but the ori-gin stretches from the fifth lumbar to the12th thoracic. Fibers from the bodies andthe transverse processes of each of these ver-tebrae head directly toward the insertion onthe femur. The human psoas does not looklike a triangular muscle in the booksbecause, in standing up, the longest fiberscover the shorter ones, so it appears to be(and feels like) a fusiform muscle. Look atthe accompanying diagram (Figure 5) of the82 Marchi April 1998

psoas in a quadruped (like a cow, where itforms the round steaks of the filet mignon)and its triangular nature is much clearer. A swith the deltoid. one edge of a triangularmuscle can make different movements fromthe other edge. "What ifthis were true for thepsoas as well?The lower fibers of the psoasclearly are going to pull L5 and L4 anteri-orly and create lumbar hyperextension(Figure 5). The upper fibers of the psoas(and the muscular fibers of psoas minor, ifpresent) are going to pull T12 and L1toward the groin. which could conceivablypush the middle and lower lumbars back.posteriorly. into lumbar flexion. Whetherthis will happen depends on the placementof the mechanical axis of the lurnbars andwhere the upper lumbars are held relative tothe hip joint. If it is true. we are led to thesurprising proposition that the different seg-ments of the psoas could counterbalanceeach other. supporting the lurnbars in their

proper curvature. (eaving surrounding mus-cles free tor movement.[Author's note: the preceding paragraph is

pure speculation. subject to experiment;however, this theory has worked well for theauthor clinically. in certain postural pat-terns. The author believes that this argu-ment should be tested. because it hasprofound and practical implications forclinical treatment of lumbar lordosis orreverse lumbar curvature and the host ofrelated ills that accompany either of thosepostural disrorrions.]But for the rest of this article. let us

assume the psoas as a whole-s-or at least thelower (and more medial) fibers-is produc-ing a flexion. a forward-pulling of the lowerlumbars, and thus dragging the sacrumalong with it. Thus the psoas. like the piri-formis. also affects the SI joint indepen-dently of the hip bone position.We should say a few words here about the

pelvic floor in this regard (Netter plates 337,338). The levator ani consists of threesmaller muscles. all of which pull forwardon the lower end of the sacrum. as we haveseen in the piriformis-though these threepull on the sacrum by way of the lessstablecoccyx. Bur their role in keeping the sacrumin place. or contributing to a locked S1jointthrough hypertension. should not beignored.ApplicationSo let us summarize the picture we have

presented here: To line up the pelvis. chestand head in gravity, humans must achievefull extension in the hip joint. This requiresbringing the back of the femur and the backof the pelvis closer together. Hamstrings.adductor magnus. and the lateral rotators,most notably the quadratus femoris and theobturarur intern us-all of these act toextend the hip bone on the femur. Only thepiriformis and the pelvicfloor act to pull thesacrum in a similar direction. calledcounter-nutation.This extension of the hip is opposed by

the iliacus, pectineus, and all the other hipflexors. which must release to allow fullopening and the complete extension neces-sary to easy. upright poise. But only rhepsoas goes directly to the spine to opposethe piriformis. Only these two musclesjump from femur to spine.\Ve do not offer techniques in Body3, we

offer strategies. and invite you to matchyour bag of techniques to the strategies.Whether you use facilitated stretching, posi-


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rional release, trigger points, deep tissuework or crystal vibrat ions, (he srrategy is thesame:1.Open the monarticular hip flexors, likethe pectineus, iliacus and the anterioradductors:

2. Make sure the multi-articular hip flexors(the TFL, sartorius, rectus femoris) arealso supple;3. Seek balanced tone among the hip exten-sors (the hamstrings and lower lateralrotators);

4. In lordotic cases, ease the rhoracico-lurn-bar fascia and lower deep trausver-sospinalis muscles;

5. Free the psoas, especially [he medialfibers=-carefully, sensitively, bur fully;

6. Seek ease in the piriformis, and see if itmight not stick around a bit longer thanusual;

7. Educate your clients about the front-backbalance, and call their attention to themovements within the pelvis, so that theycan reinforce your work with every stepthey rake.Poise? It's still elusive. As this balance

becomes hlmiliar (0 your clients, with thesacrum poised over the legs, well, they maynot all become supermodels or Fred Asraire,but YOll can look for a more fluid confidencethat comes from being poised "on top oftheir world. n v\1

Footnotes :1. In th e interests o f sp ace an d sim plicity w e o re

leav ing o ut o f th is article a fou r th co mpo nent o fless-th an-o ptim al stru ctu re in th is area: ro tatio n

and to rque. W e co nsider sagittal issu es: flexio n-e xt en sio n i n t h e h ip s. n ut ot io n a nd c ou nt er -n ut oti oni n t he s oc ro il ia c j oin ts , f le xi on a nd h yp er ex te ns io nin th e lu mb ar s pin e.

Th ese issues o re o ften fu rth er co mplicated byro to tio nal issu es pro ceeding fro m fu nctio no llysh ort legs o r trau matic sequ elae th at lead to m ed i-a lly o r late ra lly ro tate d f em urs , s ep ara te p atte rn so f tilt, f la re o r to rqu e in th e inn om in ates, and ro ta-tio nal co mp on en ts in th e sacro lu mbar ju nctio n, inth e lu mb ars th em selv es as allo wed , and in th e th o-r oc ic o- lu rn bo r j un ct io n . W e w il l d ea l w it h r o ta tio n sin the lum bers in th e next issue, bu t pelv ic to rqu ew ill rem ain beyo nd th e sco pe o f th is series.

2. K en dall, F lo rence; an d M cR eary , E lizab eth .M u s cl es , T e st in g 6- Func t ion, th ir d e ditio n, 1 98 3,Williams & Wi lk in s , B a lt im o r e, Ma r yl an d .

3. So mebo dy th ou gh t it lo oked like an "ear ."4. G orm an, D . T he B ody M oveable, V ol. III, pg.

53, 1981, A mpersand P ress, G uelph , O ntario ,Canada .

5. A lth ou gh it is o ften co mb ined w ith th e iliacu sas the "ilio pso as: th is au th or is adam ant in sepa-r atin g th e f un ctio ns o f th e tw o m us cles . T he d is cu s-sion here refers o nly to th e actio ns o f the psoasm aj or m u sc le , e xc ep t w h er e o th er wi se d es ig na te d.

Thomas Myers is a Rolfin:t' practitionerand anatomy instructor who co-presentswork-shops with specialists of other types of body-work, movement therapies and yogaworldwide. He has trained with Ida Rolf andMoshe Feldcnkrais,and servedfi-orn 1992-95as the chair of the Rolf Institute's anatomydepartment. Myersmaintains private practicesin Boston fl11dPortland. Maine. in which hecombines structural integmtion, visceralmanipulation, craniosacralthempy and move-ment therapy.

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