The posterior tilt consists of actively rotating the pelvic unit posteriorly while lying supine, in order to temporarily flatten the back and decrease or eliminate the lumbar lordosis (Fig. 7.2B). In someone who presents in alignment but suffers from mechanical back pain, the tilt may be helpful in that it decreases pressure on the lumbar facet joints, opens the foramina, relieves compression pain from the posterior parts of the vertebrae, and decreases pressure within the disc and any tendency of the disc to bulge anteriorly.

Fig. 7.2 Pelvic tilt. (A) The normal resting position showing a hollow (lumbar lordosis). (B) Active posterior rotation of the pelvis flattens the spine.

In someone presenting with malalignment, however, the posterior pelvic tilt may cause more pain.

As we have seen, ‘rotational malalignment’ is often associated with sacral torsion, ‘locking’ of one or other SI joints, pelvic obliquity and a lateral lumbar convexity that reverses at the thoracolumbar junction to give rise to a thoracic curve convex in the opposite direction (Fig. 3.14). Spinal tenderness localizes primarily to the sites of increased stress: the lumbosacral and thoracolumbar junctions.

The posterior tilt aims to flatten the lumbar segment in one plane – the sagittal – in order to decrease the lordosis. This completely ignores the fact that, when malalignment is present, there will also be an accentuated lateral convexity of the lumbar segment to the right or left. In order to create that lumbar curve in the coronal (frontal) plane, the vertebrae must have undergone simultaneous axial rotation into the convexity and side-flexion into the concavity; in other words, simultaneous rotation around the vertical and sagittal axes with movement in the transverse and coronal (frontal) planes, respectively. A left lumbar convexity, for example, results from L1–L4 inclusive side-flexing to the right and rotating to the left, maximal at the apex (Figs 2.42, 4.6, 4.33). There will usually also be an element of extension, in keeping with a residual lumbar lordosis of varying degree (Fig. 3.14A). As a result, facet joint surfaces have been moved closer together on the right and separated on the left side (reverse of L5 findings shown in Fig. 2. 52B).

In someone presenting with malalignment, carrying out the posterior pelvic tilt may, therefore, actually cause more pain (Box 7.1).

Box 7.1 Factors that can cause the ‘posterior tilt’ to be painful

1. trying to flatten a curve in one plane (sagittal), ignoring the fact that the curve exists in two planes (sagittal and coronal) and that the individual vertebrae are rotated in three planes (sagittal, coronal and transverse)

2. further increasing stress on the points of curve reversal (thoracolumbar junction) and the twisted lumbosacral junction

3. increasing the tension on already tender posterior soft tissue structures (e.g. the supra- and interspinous ligaments, and thoracolumbar myofascia) by changing their length-tension ratio

4. stretching the tender posterior pelvic ligaments (e.g. iliolumbar)

5. aggravating the facet joint irritation that results with vertebral rotation by increasing the:

a. joint separation already present on the convex side, further stretching joint capsules, ligaments and their nerve supply

b. joint compression already occurring on the concave side, with a risk of entrapment of these soft tissues and nerve fibres and irritation of the innervated surfaces

Doing the posterior pelvic tilt lying supine on a hard surface also risks putting direct pressure on structures that just may not bear being pressed against that hard surface in the process of attempting the tilt:

1. tender posterior pelvic ligaments (especially those crossing the posterior SI joint (Fig. 2.5)

2. tender PSIS, ischial tuberosity (sacrotuberous insertion, biceps femoris origin; Fig. 2.6), coccyx, coccygeal spicule (see Ch. 4 and Fig. 4.44)

3. protuberant, and particularly stiff, unyielding spinous processes of:

a. rotationally displaced vertebrae, especially the vertebrae around the thoracolumbar junction (see Chs 4, 5; Figs 3.14 C, 5.2).

b. the sacrum and coccyx (Figs 2.80A, 4.44B)

Traction

Traction is unlikely to straighten the curvatures of the spine if these are:

1. part of a compensatory scoliosis, with segmental vertebral rotation in opposing directions (lumbar, thoracic and cervical) attributable to an ‘upslip’ or ‘rotational malalignment’

2. caused by the rotational displacement of one or more isolated vertebrae.

The spine, pelvis and attaching myofascia have to be regarded as a spiral structure that one may not be able to unwind just by pulling on both ends at the same time. Samorodin aptly explained this phenomenon using the analogy of the wound-up telephone cord (Schamberger 2002: 393). Traction alone may precipitate or augment pain by:

1. increasing stress on sites of curve reversal and vertebral rotational displacement

2. further increasing the tension in myofascial and ligamentous structures already tensed-up because of ‘facilitation’, skewing of length-tension ratios and other changes attributable to the malalignment.

However, gentle repetitive traction, aimed at relaxing in particular the paravertebral muscles (e.g. multifidi, extensor spinae), may be a useful adjunct to help achieve and maintain the correction of such a vertebral displacement. Gentle traction can certainly help if carried out immediately preceding and/or following efforts at mobilization, probably by temporarily decreasing the tension in these attaching muscles by:

1. achieving some relaxation through the ‘contract–relax’ mechanism (see Ch. 8)

2. opening up the spaces between the vertebrae and facet joints to relieve compression, reactive muscle tightening and any irritation of exiting nerve roots

3. minimizing or abolishing strain in muscles that have been ‘facilitated’.

Extension exercises and back extensor strengthening

Extension of the back while lying prone, maximal in the ‘cobra’ position (Fig. 7.3), can increase the pressure on facet joint surfaces that are already approximated on one side by vertebral rotation in conjunction with malalignment (Fig. 2.52B). Back extension also causes further stress on the particularly stiff sites of curve reversal, where the adjacent vertebrae rotate in opposite directions (Fig. 3.14B,C).

Fig. 7.3 Hyperextension of the back: the ‘cobra’ position.

This is not to say, however, that one cannot have a person do exercises for the back extensor muscles. Given the frequent involvement of these muscles (e.g. reflex spasm, tenderness, disuse weakness and wasting), a stretching and strengthening programme should be part of rehabilitation – provided a core strengthening programme is well underway to ensure pelvic and spine stability (Figs 7.25–7.29) and alignment is starting to be maintained. Any arching of the back should continue to be limited to the pain-free zone to avoid triggering reflex muscle spasm. A contraction of these muscles, done in a way that avoids excessive back extension, can be initiated in the prone position simply by:

1. extending only the head and neck (no more than 2–3 cm off the surface at first; Fig. 7.4A), progressing to also lifting the shoulders at the same time (Fig. 7.4B)

2. alternately raising the straight right and left leg 1–2 cm off the surface (Fig. 7.4C), and eventually both legs simultaneously:

initially just clearing the bed and then progressing gradually from 5 up to 10–15 cm as the pain decreases and strength increases (Fig. 7.4D).

Fig. 7.25 Exercises: one leg extension with co-contraction of the inner pelvic muscle unit.

(Courtesy of Lee 1999.)

Fig. 7.26 Rise and sit with co-contraction of the inner pelvic muscle unit.

(Courtesy of Lee 1999.)

Fig. 7.27 Exercises: prone over a ball; one leg, one arm extension with co-contraction of the inner pelvic muscle unit (for the posterior obliques).

(Courtesy of Lee 1999.)

Fig. 7.28 Strengthening of one leg extensor in four-point kneeling with a balance challenge on a shuttle MVP.

(Courtesy of Lee 1999.)

Fig. 7.29 Strengthening of the lateral system with co-contraction of the inner unit on a FITTER.

(Courtesy of Lee 1999.)

Fig. 7.4 Progressive strengthening of the back extensor muscles in prone-lying. (A) Extending only the head and neck to a limited degree. (B) Clearing the shoulders 2.5-5 cm off the plinth in addition to extending the head and neck minimally. (C) Alternately raising the right and left straight leg, knee 5–15 cm off the plinth. (D) Simultaneously raising both straight legs, knees 5–15 cm off the plinth; eventually, combining this with (B). (E) All the muscles are completely relaxed between contractions (the head and legs resting on the plinth).

The emphasis is on frequent repetition of contractions that are brief to start with: holding to a slow count of 1 or 2 is adequate, followed by relaxation to allow for a maximum inflow of blood and clearance of waste (Fig. 7.4E).

Initial brief repetitive muscle contractions avoid decreasing or cutting off the entry of blood and the exit of waste for too long, to avoid compounding the problem especially in those muscles along the spine which have already been subjected to the detrimental effects of a chronic increase in tension.

Once the person can do three sets of 10, the duration of each contraction is increased to a slow count of 2 but only for the first set of 10 to start. At this stage, progressively increasing the count is preferable to increasing the degree of extension. Relaxation is improved by tying the contractions in with the regular rhythm of breathing; in this case, contracting on inspiration, relaxing on expiration or vice versa, depending on whatever feels the best way. Once the person can contract to a count of 5 for 2 or 3 sets of 10 and is starting to maintain alignment, the degree of extension may now gradually be increased: first for one set, then two and so on, as tolerated. He or she should preferably be in alignment when carrying out the extension manoeuvres; a good approach is to do the self-assessment and correct any recurrence of malalignment just before the exercises. This simple progressive approach can be used for strengthening any other muscles.

Sit-ups

There seems to be some obsession in our society with doing a sit-up from supine-lying to vertical and, ultimately, perfecting the ‘abdominal crunch’ by touching the nose or the right and left elbow alternately to the opposite knee (Fig. 7.5). Most patients presenting with back pain, whether it be on the basis of malalignment or some other cause, are likely to run into grief with these manoeuvres. Pain often increases as the neck and trunk pass the upright (vertical) position:

1. coming up into sitting leaning slightly forward, at which point the posterior cervical and thoracic paravertebrals and erector spinae, especially, are activated to prevent the trunk from falling forward

2. going back into supine-lying, at which point the anterior neck muscles (e.g. paravertebrals, scalenes and sternocleidomastoid) contract to prevent the head from falling backward.

Fig. 7.5 Risking a recurrence of malalignment doing the abdominal ‘crunch’ with the addition of a torsional component by alternately touching (A) the right elbow to the left knee and (B) the left elbow to the right knee.

Posterior paravertebral contraction effectively increases the pressure on both the disc and the facet joints. In someone with malalignment, the addition of twisting the trunk alternately to right and left has to be viewed as another factor capable of causing:

1. pain

a. from attempted rotation into a restricted range on one side (Fig. 3.5 C) and further compression of the facet joints on the side opposite to the direction of rotation (Fig. 2.52)

b. by increasing the tension on the posterior pelvic ligaments and in the thoracolumbar muscles and fascia

2. a recurrence of malalignment because of the repeated torsion of trunk and pelvis.

The intent is to strengthen the abdominal muscles, especially:

1. transversus abdominis and the obliques, which should respond to core strengthening, and

2. rectus abdominis

In someone with severe back pain, a good contraction primarily of rectus abdominis can be initiated simply by raising the head and neck while lying supine (Fig. 7.6A), then progressing to raising the shoulders just 2–3 cm off the surface (Fig. 7.6B) and possibly incorporating graduated straight-leg raises (especially if activating the neck and shoulder girdle muscles causes discomfort, as it might in someone following a ‘whiplash’ injury). Similar to attempts at strengthening the back extensors, the contractions should initially be of short duration, with the muscles being completely relaxed in-between contraction, carried out within the zone of comfort and avoiding triggering any discomfort or outright pain at all costs. Instructions are for an initial set of 10 contractions daily, increasing to two and then three sets as strength and endurance improve. At that point, either the duration of the contraction and/or the degree of trunk flexion can gradually be increased, following the progression outlined above for the back extensors.

Fig. 7.6 Graduated abdominal muscle strengthening. Simultaneously drawing the umbilicus toward the plinth and tightening up the muscles around the rectum will ensure a strengthening not only of rectus abdominis, but also transversus abdominis and the pelvic floor muscles (see Figs 2.31B, 2.53). (A) Initially only the head is lifted off the plinth. (B) The shoulders clear the plinth, along with the head. (C) Both heels are just clearing the plinth (with the legs held straight).

It cannot be stressed enough that strengthening of the above muscles must be preceded by strengthening of the ‘inner’ and ‘outer’ core and by efforts at realignment, both of which are an intricate part of the overall treatment programme for the ‘malalignment syndrome’ and will be discussed in that context later (Figs 2.28–2.40, 7.25–7.29).

Always consider the possibility of an underlying problem of malalignment when:

1. the standard treatment measures discussed above fail to resolve the pain, or actually worsen it

2. history, examination and investigations do not disclose a disc, facet or other underlying problem.

Manipulation, mobilization and muscle energy techniques

The key to recovery from the ‘malalignment syndrome’ is to relieve the stresses and strains on the skeleton and attaching soft tissues which are attributable to the malalignment.

Realignment using an appropriate manual therapy technique should, therefore, be the first treatment measure and, in combination with core strengthening, remains a mainstay of treatment.

In approximately 80-90% of people presenting with one or more of the three common presentations of malalignment, correction can be achieved quite easily. In a small number of these, 5% at best, realignment is maintained after only one or two treatments, something that is more likely to occur in a younger person. In the majority, correction can be achieved but the malalignment keeps on recurring initially, a reflection of all the changes that the body tissues have undergone in adapting to the malalignment. Realignment is eventually maintained for longer and longer periods of time following each correction as the tissues and joints, and probably also the brain, start to adapt to the more symmetrical postures and biomechanical stresses, the ‘straight’ as opposed to ‘crooked’ you. Within 3–6 months, most of them will finally maintain alignment and require no further correction. However, that is not to say that they may not go out of alignment again at some point in the future and require further treatment, especially if they become symptomatic. Subsequent recurrence of malalignment can usually be linked to a period of increased mental and/or physical stress, excessive lifting (especially with a torsional component) or exertion (e.g. longer than usual participation in a demanding activity) or simply sitting for prolonged periods of time (e.g. when travelling).

In approximately 5-10%, correction cannot be achieved or is quickly lost following each correction. The majority of these people prove to have one or more of the following:

1. instability of one or both SI joints, the pubic symphysis and/or one or more lumbar vertebrae attributable to impaired ‘form’ and ‘force’ closure or neural control (see Ch. 2)

2. a generalized joint hypermobility (e.g. Ehler-Danlos syndrome)

3. persistently increased tension or actual spasm of muscles that are in a position to cause malalignment to recur.

In others, the recurrence may be secondary to some as yet undiagnosed problem, such as a missed central disc protrusion (see ‘Asymmetries that fail to respond’, below).

In addition to the muscle energy technique (MET) and traction, which are the main approaches to realignment discussed in this book, there are numerous other manual therapy techniques that find application in the treatment of malalignment – a number of these are discussed in Chapter 8. They range from the high-velocity, low-amplitude (HVLA) manipulations traditionally associated with chiropractic, the long-lever, low-velocity (LLLV) osteopathic techniques to re-establish joint play and the seemingly more gentle methods (e.g. craniosacral release, zero-balancing, NUCCA technique) which are now being embraced by many chiropractors, osteopaths, physicians and physiotherapists alike because they may be more successful in achieving long-term correction.

In practice, simply achieving lengthening of the tight myofascial tissue and relaxation of muscles can, at times, result in a spontaneous realignment of the bones. In other words, in some cases the problem with malalignment is primarily one of persistent asymmetrical tension and/or contracture of muscle and other soft tissues which:

1. may have led to the bones going out of alignment in the first place

2. are now the cause of recurrences of the malalignment because they continue to exert their detrimental effects, so that realignment can only be maintained temporarily

For example:

1. The myofascial tissue on the concave side of a curve in the spine is put in a relaxed position and will shorten with time (Fig. 2.60). When the curve is decreased or eliminated with realignment, excessive tension in these contracted structures will exert a unilateral force on the vertebrae that can result in a recurrence of the malalignment, unless realignment is combined with a graduated stretching programme to help them regain their normal length.

2. The persistence of a trigger point in the right quadratus lumborum after realignment may perpetuate a general increase in tension in that muscle and cause the recurrence of a ‘right upslip’ (Fig. 2.62).

3. Mobilization may effectively correct the malalignment of the pelvis initially caused by an L1 rotation with resultant ‘facilitation’ of iliopsoas on one side and ‘inhibition’ on the other. The pelvic malalignment is, however, more likely to recur if the L1 rotation, and any persistent asymmetry of tension in right compared with left iliopsoas, is not also attended to after realignment of the pelvis.

Case History 7.2

This 37-year-old female runner presented with symptoms of cervicogenic brachialgia in a left C6 and C7 dermatome referral pattern and frequent headaches following a fall down a flight of stairs. On initial examination, the cervical spine range of motion was reduced in all planes of movement, the deltoid muscle weak (4/5) but the neurological screen otherwise unremarkable. In addition to a postural scoliosis, there was evidence of ‘anterior’ rotation of the left innominate and vertebral rotational displacement at the C2/3, C6/7 and T11/12 levels. Surface electromyography (SEMG) showed increased paravertebral muscle activity readings (the light bars in Fig. 7.7) throughout the spine, worse on the left than the right and at the levels noted to have rotated (e.g. C6/7 and T11), also the lumbosacral region. These SEMG findings were consistent with postural compensation and a reactive increase in paravertebral muscle tension throughout the back.

Fig. 7.7 A surface electromyograph of the paravertebral muscles to detect the tension level (see ‘Case History 7.2’). The light horizontal bars indicate the findings after injury; note the asymmetry and the large number of levels showing an increase in activity. The dark horizontal bars denote the findings after 3 months of treatment, including manual therapy. The asymmetry has significantly decreased in the cervical and thoracic levels, and there are now fewer levels showing increased activity (persisting mainly in the lumbar region).

(Redrawn courtesy of D.J. McCallum, unpublished data 1999.)

After three months of therapy aimed at mobilizing the pelvis and spine and relaxing the paravertebral muscles, the frequency of headaches had significantly decreased and she was otherwise asymptomatic. The neurological screen was now unremarkable. Repeat SEMG (the black bars in Fig. 7.7) still showed some higher readings, now localizing to the left C2–C4 and T7, right L1 and L3 levels, probably indicative of an ongoing attempt to compensate for the changing postural pattern. The muscle tension overall was, however, significantly reduced and more symmetrical than that recorded initially.

Techniques for correction of ‘rotational malalignment’

Some easily-learned manual therapy techniques are particularly useful for treatment of ‘rotational malalignment’ in a clinical setting, at home or even outdoors. It must be stressed at this point that these techniques should not be painful, if at all possible, to avoid any further increases in muscle tone.

A technique may be successful in achieving alignment but the correction is often quickly lost if the procedure has provoked or worsened pain and, with it, a reflex increase in asymmetrical muscle tone.

In most cases, pain can be avoided by a minor modification of the technique being used; often this amounts to no more than simply changing the position (e.g. decreasing the angle of hip and knee flexion; Figs 7.9B, 7.9Ei,ii, 7.13E,F).

Fig. 7.9 Muscle energy technique for the correction of right innominate ‘anterior’ rotation: using gluteus maximus by blocking attempted right hip extension. (A) One-person technique. (B) Two-person technique. (C) To take up any slack as the hip extensors relax on repeated resisted contraction, gradually increase the hip flexion angle (compare to (A) and (B), respectively), provided that this does not cause or aggravate pain. (D) To modify the technique for a painful knee (e.g. osteoarthritis, patellofemoral compartment syndrome), decrease the knee flexion angle: (i) one-person technique – leg resting on chair; (ii) two-person technique – leg resting on assistant’s shoulder. (E) Modified technique resisting hip extension: (i) one-person (note: knee resting over pillow in some flexion, to keep hamstrings relaxed); (ii) pre- or post-partum. (F) Incorrect technique: the effectiveness of a resisted hip extensor contraction is decreased by simultaneous quadriceps contraction, seen here keeping the knee in 90 degrees flexion – the lower leg is held unsupported up in mid-air by rectus femoris which is also capable of exerting a simultaneous, counterproductive anterior rotational force on the innominate bone (see Figs 2.46 C, 2.59, 7.12).

Fig. 7.13 Muscle energy technique for correcting left innominate ‘posterior’ rotation using rectus femoris: blocking attempted extension of the flexed left knee. (A) One-person technique (here using a towel to provide an extension for short arms, in order to avoid any posterior rotational leverage forces that can result with increasing degrees of hip flexion). (B) One-person technique using a sling: (i) as an extension for short arms, (ii) to provide resistance to knee extension at a reduced left hip flexion angle and/or (iii) as a substitute for the arms, to allow sore neck, upper back and shoulder girdle muscles to relax while using this method. (C) Two-person technique: the twisted position of the assistant’s trunk increases the risk of putting himself out of alignment. (D) Improved two-person technique: any torsion is limited and the assistant can offer more counterforce using his body weight to advantage, thereby decreasing any risk to himself. (E) Leg lies on shoulder, assistant again uses his weight to advantage by hanging on to the lower leg to resist knee extension.

Sometimes, however, a patient has such generalized discomfort and soft tissue tenderness that one just cannot use a certain approach, such as the ‘muscle energy technique’ (MET), during the initial stages of treatment. In that case, an even more gentle and less ‘invasive’ method, one that requires less effort on the part of the patient or involves working at sites distal to where pelvic and spine instability and pain are most severe, may be more appropriate (e.g. craniosacral release or the NUCCA technique; see Ch. 8). One can then try reintroducing MET, possibly in conjunction with some of the complementary methods of treatment at a later date, once the patient’s condition has started to improve. However, the ‘more gentle’ techniques of realignment, or even just limiting initial treatment to core muscle strengthening may fail, especially if there is a problem such as soft tissue or joint inflammation and pain, or joint instability secondary to ligament laxity or joint degeneration. In that case, attempts at trying to achieve stability and realignment may have to be discontinued until the inflammation has settled down and/or the ligaments have been strengthened (see ‘anti-inflammatories’ and ‘prolotherapy’, below) to allow the patient to finally get on with a progressive core strengthening, realignment and postural retraining programme.

Muscle Energy Technique (MET)

Muscle energy technique is one method of mobilization particularly useful for correcting a ‘rotational malalignment’ by harnessing the person’s own muscles to generate a rotational force on a specific structure.

MET allows for correction of malalignment using the person’s own muscle power to rotate a bone or bones back into their proper position. Take the example of a person presenting with an ‘anterior’ rotation of the right and a compensatory ‘posterior’ rotation of the left innominate.

Right innominate: ‘anterior’ rotation

A resisted active contraction of the right gluteus maximus can be harnessed to create a posterior rotational force on the right innominate in order to correct the ‘anterior’ rotation (Figs 2.5B, 2.36, 2.37, 7.8Ai). Essentially, gluteus maximus originates from the posterior iliac crest, along the posterior gluteal line, and inserts primarily into the greater trochanter (Figs 2.5B, 7.8Ai,ii). One of its actions is to extend the hip joint when the thigh is free to move (Fig. 7.8Aiii). However, by resisting right hip extension, and hence any movement of the femur, one effectively reverses the muscle origin and insertion (Fig. 7.8C). Gluteus maximus will now exert a posterior rotational force on the right innominate, which is still free to move. The person attempts to extend the hip but this movement is prevented by having him or her:

1. hold on to the thigh or shin, with the hip and knee flexed (Figs 7.8C,D, 7.9)

2. push against another person or an object that serves to provide the resistance needed (Figs 7.8, 7.9).

Fig. 7.8 Muscle energy technique to correct a ‘rotational malalignment’. (A-C) The biomechanics of using gluteus maximus (Fig. 2.5B) to correct a right innominate ‘anterior’ rotation (B). (A) The muscle acts as a hip extensor when the leg is free to move. (C) Blocking right hip extension reverses the muscle origin and insertion, creating a posterior rotational force on the innominate. (D) Muscle energy techniques can be used in a variety of positions

(Courtesy of DonTigny 1997.)

Following each contraction, a muscle usually relaxes and will lengthen a bit more. In the case of gluteus maximus, one can take up the slack each time by letting the thigh drop down toward the person’s chest and, if tolerated, even toward the opposite shoulder (given that gluteus maximus is oriented somewhat diagonally across the buttock) before attempting the next resisted contraction (Fig. 7.9C). The repeated contraction and relaxation of gluteus maximus in this manner will successfully correct an ‘anterior’ rotation in 80-90% of people. For those who have pain on knee flexion (e.g. aggravation of osteoarthritic pain; patello-femoral syndrome), the procedure can be modified by supporting the lower leg (calf) on the assistant’s shoulder or on a chair to decrease the knee flexion angle (Fig. 7.9D). Similarly, if there is hip or groin pain, one may find a position of comfort either by abducting or adducting the femur slightly or by decreasing the hip flexion angle.

Left innominate: ‘posterior’ rotation

Two different sets of muscles can be harnessed in order to correct a ‘posterior’ rotation of the left innominate.

Iliacus

Iliacus originates primarily from the anterior iliac crest and upper iliac fossa, inserting into the tendon of psoas major and directly into the lesser trochanter (Figs 2.46B,C, 4.2, 7.10A). If the thigh is free to move, the primary action of iliacus is to flex the hip joint (Fig. 7.10Aii). By resisting left hip flexion, one effectively reverses the origin and insertion and creates a force that will rotate the left innominate anteriorly (Fig. 7.10C). When sitting or lying supine, the person attempts to flex the hip, but any movement is again blocked.

Fig. 7.10 Muscle energy technique versus innominate ‘posterior’ rotation (B). (A) Iliacus acts as a hip flexor when the thigh is free to move (see Fig. 2.46). (C) Blocking hip flexion reverses the muscle origin and insertion, creating an anterior rotational force.

One-person technique

1. the counterforce is provided by the arms/overlapping hands pushing against the anterior aspect of the left thigh (Figs 7.10C, 7.11A,B)

2. the elbows are preferably locked in extension so that, when lying supine, the force goes straight up to the shoulder girdle and through to the surface he or she is lying on

a. there is, therefore, no need for contraction of any of the neck, shoulder girdle or arm muscles, a point to consider especially when a patient has, for example, suffered a whiplash’ or a shoulder injury (Figs 7.10C, 7.11A)

b. the only muscle working is iliacus.

Fig. 7.11 Muscle energy technique for correcting left innominate ‘posterior’ rotation: using iliacus and/or rectus femoris by blocking attempted hip flexion or knee extension, respectively. (A) One-person technique. (B) Two-person technique. (C) Modification for a painful left knee; using primarily iliacus;. (D) Modification for short arms and/or an inability to flex the hip: the pillow helps to fill the gap. Note: Should it prove difficult or painful to maintain the hip at 90 degrees flexion, try decreasing the angle: (E) one-person technique – the fixed belt resists the attempted hip flexion; (F) two-person technique during pregnancy or post-partum, activating both iliacus and rectus femoris. A pillow (E) or hand-support (F) under the popliteal fossa maintains the knee in partial flexion, to ensure hamstring relaxation.

Two-person technique

An assistant provides the resistance needed to prevent any movement on attempted hip flexion (Fig. 7.11B,C,F).

Rectus femoris

Rectus femoris originates from the anterior inferior iliac spine and anterior rim of the acetabulum; it inserts indirectly into the tibial tubercle by way of the patellar tendon (Figs 2.46 C, 2.59, 7.12Ai). It is the only muscle of the quadriceps complex that crosses both the hip and knee joint so that, in addition to extending the knee, it can also flex the hip joint when the knee is in full extension (Fig. 7.12Aii, Cii). This muscle can, therefore, be effectively used to create an anterior rotational force on the ‘posteriorly’ rotated left innominate (Fig. 7.12B) by:

1. blocking attempted extension of the left knee when that knee is flexed (Fig. 7.12 Ci)

2. blocking attempted left hip flexion when that knee is straight (which actually also engages iliacus; Fig. 7.12Cii).