Scalenes, the Dynamic Duo + 1

The Scalenes are an important neck muscle comprised of three parts, the anterior, the middle, and the posterior. The anterior and the middle will be the subject of this post because the posterior is mostly involved as a synergist for the upper trapezius. The brachial plexus passes through an opening between the anterior and middle scalenes, making it subject to dysfunction if the scalenes are hypertonic. The scalenes are also accessory muscles of respiration and can cause breathing imbalances if one is a chest breather. The scalenes are also involved in the kinetic chain of the arm as well as the front line and lateral line. We will examine all of these relationships to reveal just how dynamic these muscles truly are.

In cervical dysfunction the scalenes can be either facilitated or inhibited. If the sternocleidomastoid muscle is inhibited, the scalenes may compensate to stabilize neck flexion. In the case of whiplash, the scalenes may become inhibited by facilitated neck extensors. I find it very important to release the scalenes indirectly by stabilizing the first and second ribs while performing a myofascial stretch. I have found that working directly on the scalenes can cause them to rebound and tighten up even further. To strengthen the scalenes, resist at the forehead while nodding towards the ipsilateral shoulder. The scalenes also ipsilaterally flex the neck, and therefore can become inhibited by either the ipsilateral or contralateral upper trapezius. The scalenes produce ipsilateral rotation of the cervical spine, and can become facilitated by an inhibited contralateral sternocleidomastoid or an ipsilateral longus colli.

Because the brachial plexus passes through an opening between the anterior and middle scalenes, hypertonicity, whether caused by facilitation or inhibition, must be addressed. The extra pressure on the brachial plexus caused by hypertonic scalenes can result in Thoracic Outlet Syndrome. Symptoms include numbness and tingling in the arms and hands, as well as loss of strength in both the arms and hands. I have found the scalenes to be compensating for 13 different functions in the arm line with someone who had TOS. Reestablishing the proper relationship between the scalenes and these 13 different functions was crucial in the resolution of the TOS.

The scalenes are an important part of the front line kinetic chain. It is not unusual for the scalenes to be facilitated for an inhibited ipsilateral psoas and adductors. They may also be facilitated for an inhibited contralateral TFL and adductors. Even dysfunction of the extensor hallucis longus can be compensated for by the ipsilateral scalenes.In the lateral line, the scalenes oftentimes become facilitated in combination with the peroneals in cases of over pronation or ankle sprains. The most likely inhibited muscle in this scenario is the TFL. The scalenes can also be dynamically involved with the obliques and the quadratus lumborum.

The scalenes are also accessory muscles of respiration. They elevate the first and second ribs, and in chest breathers, they can become,along with the pectoralis minor, dominant muscles of respiration. In this situation they can become facilitated for inhibition of the muscles that depress the rib cage, such as the quadratus lumborum and the obliques. Resolution of these dynamic muscular relationships along with restoration of proper breathing patterns can go a long way to resolving this issue.

The scalenes are important to consider in cervical dysfunction, Thoracic Outlet Syndrome, problems with the arms and hands, dysfunction of the muscles of the front line, dysfunction of the muscles of the lateral line, and improper breathing patterns. Remember to treat these muscles with respect and they will reward you with outstanding therapeutic outcomes.

Pectoralis Minor, King of Compensation

The pectoralis minor is a muscle that becomes easily shortened and tight due to many factors, including rounded shoulder posture, glenohumeral joint dysfunction,breathing dysfunction, and a variety of compensation patterns. It sits on top of the brachial plexus, and can therefore contribute to Thoracic Outlet Syndrome. The pectoralis minor is located in an area of the shoulder with many other muscles, including the pectoralis major, biceps, deltoids, coracobrachialis, subscapularis, serratus anterior, and the latissimus dorsi. I find that clusters of muscles like this often can become dysfunctional due to poor biomechanics. This can lead to adhesions, facilitation/inhibition, and synergistic dominance. The pectoralis minor is often the overactive muscle in these compensation patterns.

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Popliteus, the Tiny Muscle of Knee Pain


The popliteus tendon originates on the lateral surface of the lateral femoral condyle (in front of and below the lateral collateral ligament origin) and also from the fibular head. It also has an origin stemming from the posterior horn of the lateral meniscus. The tendon then courses under the lateral collateral ligament, descends into the ‘popliteal hiatus’, and becomes extra-articular (outside the knee joint) before joining its muscle belly. It inserts into the tibia above the popliteal line. It is therefore a relatively horizontal muscle lying deep in the back part of the knee.


The popliteus is believed to have a number of functions, made possible by its unique ability to reverse its origin and insertion, depending on whether the femur or the tibia is fixed.

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Often Overlooked Tensor Fascia Lata

The Tensor Fascia Lata (TFL) is a muscle with many different functions. It is an abductor, and internal rotator of the hip, and a hip flexor. Having so many functions, the TFL can be involved in many dysfunctional movement patterns throughout the body. We will explore its role in each of the aforementioned functions, assessing the resultant dysfunctions based on whether it is facilitated or inhibited. The TFL is most commonly associated with the IlioTibial Band, which unfortunately has led to its being treated as one unit. The usual treatment for this unit is myofascial release or foam rolling without assessing whether or not it is facilitated or inhibited. This can lead to further biomechanical complications and unnecessary pain and discomfort.

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Piriformis is a Real Pain in the Ass

The piriformis muscle is the most superior of the deep external rotators of the hip. The sciatic nerve passes underneath it and sometimes through it. Hypertonicity of the piriformis can contribute to many kinds of Low Back Pain, also known as Piriformis Syndrome. We will examine the factors that make for a hypertonic piriformis muscle so that we can have an effective treatment strategy. The most common imbalance associated with this condition is a facilitated piriformis inhibiting the ipsilateral hip internal rotators. These muscles, such as the gluteus medius, gluteus minimus, and the tensor fascia lata are prone to inhibition. This balance can easily be ascertained through the manual muscle testing protocol employed by NeuroKinetic Therapy. Release of the piriformis muscle is immediately followed by activation of the internal rotators to reprogram the dysfunctional movement pattern that has been stored in the motor control center. This change is first stored in short-term memory, so it becomes imperative for the client to perform their homework twice a day in order to convert this new functional movement pattern into long-term memory.

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Temporomandibular Joint Dysfunction

Temporomandibular Joint Dysfunction or TMJD is a common malady affecting millions throughout the world. According to statistics most sufferers are women. I believe the reason for this is, that in many cultures women are not allowed to express their anger, and as a consequence, it somatizes in the jaw. We do know that suppressed anger and stress contribute greatly to TMJD. Most jaw clenching occurs at night but can also happen on an unconscious level throughout the day. In my experience, treatments like EMDR, are very effective for the psychological aspects of  TMJD. The physical causes include malocclusion, improper orthodontia, cranial trauma at birth, whiplash, and of course any blows to the jaw. Standard treatments include night guards, oral appliances, adjusting tooth height, orthodontia, cranial osteopathy, physical therapy, and chiropractic. It is my contention and experience that these treatments would be more effective if they included a method to make  the jaw muscles less facilitated/reactive to other muscles and functions throughout the body.

Symptoms of  TMJD include jaw pain, headaches (especially around the eyes), neck pain, and tinnitus (ringing in the ears). Tinnitus often is caused by a hyperactive lateral pterygoid muscle which has fibers that connect to the inner ear. But to treat the jaw as if it existed without any connection to the rest of the body is to do it a great injustice. Let’s explore some of the basic and more complex relationships. Mastication is a very complex movement. It involves movement superiorly, inferiorly, anteriorly, posteriorly, medially and laterally. All of these planes of motion affect other muscles throughout the body creating similar planes of motion. Jaw opening creates superior, inferior, anterior, and posterior movement. Chewing adds the medial and lateral components. I will first address the four major muscles of mastication: the temporalis, the masseters, the medial pterygoid, and the lateral pterygoid.

NeuroKinetic Therapy views the jaw muscles as a default mechanism for overcompensation. In other words, the jaw muscles can become facilitated for other inhibited muscles throughout the body. The temporalis muscle can compensate for muscles along the Front Line, including the neck flexors, pectorals, abdominals, hip flexors, and dorsiflexors. Due to its interesting configuration, the temporalis muscle can also compensate for muscles along the Back Line. These include the spinal muscles, the gluteals, the hamstrings, and the plantarflexors. The masseters, the strongest muscle in the body for its size, affects the Front Line and Back Line in a similar fashion. This muscle is capable of medial and lateral translation of the jaw, creating ipsilateral lateral movement. Thus it can affect muscles that side bend the neck, side bend the torso, hip abductors, and the peroneals. Both the medial and lateral pterygoids create contralateral lateral movement of the jaw. Therefore they can affect the same muscles as the masseters, only on the opposite side.

Some good examples of these relationships are as follows. The temporalis often compensates for inhibited neck flexors and gluteals. The masseters often inhibit those same muscles and the hip flexors. The pterygoids often inhibit the scalenes, the latissimus dorsi, the obliques, the quadratus lumborum, and the hip abductors. If these relationships are left unattended the tension in the jaw muscles increases tremendously resulting in the aforementioned symptoms. Remember that the tension in these muscles is a result of a faulty relationship with other muscles/functions. To simply release these muscles without first figuring out what they are compensating for, could result in destabilizing functional integrity. Treat the cause not the symptoms.

The muscles of the floor of the mouth can also compensate globally, but I find them most involved in bracing with the diaphragm and the pelvic floor muscles, similar to the Valsalva maneuver. This kind of “bearing down” is a very common compensation pattern often involved with emotional issues. When treating the muscles of the floor of the mouth, it is important to consider the diaphragm and pelvic floor muscles. Clenching, breath holding, and anal tightening are common reactions to stressful situations which can result in developing dysfunctional movement patterns. These can often be the missing pieces to solving long-standing puzzles.

Successful treatment of  TMJD  must include a consideration of the global relationships between the jaw muscles and the rest of the body.

Hip Joint Jam

Hip joint impingement or Femoroacetabular impingement is a common malady affecting millions of people. If left untreated, this condition will result in osteoarthritis, hip replacement, severe groin and buttock pain, and limited and painful range of motion. FAI can result from playing sports or sitting too much. A student of mine brought his client to me who was suffering for years from severe buttock pain. She had had several MRIs as the doctors suspected she had sciatica resulting from some impingement in her lower lumbar spine. The MRIs were of course negative. She also received anti-inflammatory injections in her lumbar spine which did nothing. After getting her history I put her through some range of motion testing which included her hip joint. I found her hip joint to be very jammed. After balancing the muscles around her hip joint, I applied light traction to her leg, and voila, there was an audible pop, and while weeping, she reported that her pain was completely gone.

Let’s go over the important muscular components of FAI. First and foremost are the obturator internus and externus. These two muscles suspend the femur in the hip joint. If they become too tight the femur jams into the acetabulum. The question then becomes why are they tight? A very common compensation pattern that I see is the obturator muscles inhibiting the gluteus maximus. This is something that happens from sitting too much. The obturator muscles can also inhibit the psoas. Again, this is due to sitting and sometimes athletics. The obturator muscles, just like the rotator cuff muscles, are not meant to do motions that require load bearing. So when there is a dysfunctional movement pattern, and they are required to compensate, naturally they tighten up. The result of all of this is a painful hip joint. I know about this from personal experience. From doing a lot of mountain biking, my hip joint became increasingly painful, to the point where when I sat with the soles of my feet together, my one knee was much higher than the other. I tried stretching my  adductors to no avail. Finally I learned about the obturator muscles, and was able to resolve my problem.

I use the standard range of motion tests to determine if FAI exists. I have the client perform internal and external rotation of the hip via the foot, knee to chest, cross one leg over the other, put the soles of the feet together, and do a circular range of motion. Often times many of these are restricted, and depending on the severity, sometimes only one is restricted. After balancing the obturators, the next thing I check is strength in the rectus femoris. With FAI, this is often inhibited. This muscle is also inhibited after hip joint replacement, and it’s facilitation is crucial in postsurgical recovery. What I find commonly facilitated is the iliacus. Naturally, the adductors can be facilitated and inhibit the rectus femoris. Dysfunction of the hip joint commonly can lead to lower back pain via antagonistic relationships, neck pain due to kinetic chain compensation, and knee pain also due to kinetic chain compensation. Only after all of these relationships have been resolved, will I gently traction the leg to facilitate a release of the hip joint.

Of course, if there has been too much degeneration in the joint, I will recommend a hip replacement. Optimally, if there hasn’t been too much damage, a hip resurfacing procedure can be done. Let’s remember that hip joint replacement is amongst the most successful of surgeries. I have seen people’s lives changed dramatically from such a procedure. Remember to be a pragmatist not a fanatic. Conservative management of FAI is very successful if you understand its components and how to resolve the specific dysfunctional movement patterns.

Diaphragm and its Global Relationships

The diaphragm, being a centrally located muscle, when it becomes facilitated, its effects can be felt throughout the entire body. There are many reasons why the diaphragm becomes facilitated. One of these is emotional stress which causes the diaphragm to contract. Another is poor breathing habits. This results in chest breathing with the scalenes,serratus posterior inferior, quadratus lumborum, and the intercostals becoming overburdened. Regardless of the cause, let’s examine the effects of a facilitated diaphragm. The diaphragm, along with the upper trapezius, neck extensors, pectoralis minor,iliacus, and the jaw muscles, has the potential to be one of the most facilitated muscles in the body.

A great example of this is a client who played water polo and had a chronically tight diaphragm. Her parents took her to every respiratory expert in the area. No one could determine the exact cause of her discomfort. I examined her diaphragm with palpation and found it to be extremely tight and painful. I then began using the NeuroKinetic Therapy protocol to assess for muscle/function imbalance. I performed the manual muscle tests first by having her hold her breath and secondly with her breathing out. The muscles that were inhibited included the neck flexors, pectoralis major bilaterally, humeral flexors and extensors bilaterally, psoas bilaterally, rectus femoris bilaterally, gluteus maximus bilaterally, and several gait patterns which I will describe later. As you can see, the diaphragm was extremely overburdened. We then began the process of releasing her diaphragm and retesting all of the above muscles/functions. Over a process of several weeks the diaphragm progressively released and the inhibited muscles/functions became available. She was able to go back to playing water polo at a competitive level.

Because of the motions involved in playing water polo, I had to get creative with gait patterns. Not only were the normal gait patterns investigated, such as flexion and extension of the contralateral humeral and hip flexors and extensors, but also abduction and adduction of the humerus and femur. Rotational patterns were also examined such as bringing the right arm towards the left knee. Cleaning these up really helped to solidify the changes we were making in the motor control system. Of course after each session she was given exercises to do which mimicked what we did. Due to her discipline and hard work she was able to return to competition quickly.

The diaphragm, with its connections to the thoracic and lumbar erectors, quadratus lumborum, and the psoas, is considered a core muscle. It is also connected to the jaw muscles, abdominals, and the pelvic floor through the Valsalva maneuver. These are also considerations for inhibition when dealing with a facilitated diaphragm. It is most likely that the abdominals,psoas, and the pelvic floor muscles will be inhibited.

The diaphragm must be considered as a possible source of facilitation when dealing with global inhibition. Release of the diaphragm and reestablishing the neural pathways to the inhibited muscles/functions is critical in rehabilitation.

Pelvic Floor-Overactive or Underactive?

Weakness of the pelvic floor muscles is associated with lower back pain, incontinence, constipation, and sexual dysfunction. The use of Kegel exercises to correct this is commonplace and widely utilized by physical therapists and Pilates instructors. When employed correctly these exercises can strengthen the core, the lower back, and the pelvic organs. Problems occur when these muscles are overactive and are inhibiting associated core and lower back muscles. Asking overactive pelvic floor muscles to perform Kegel exercises can lead to pelvic floor pain and irritation of the pudendal nerve. The question is then how do we determine if the pelvic floor muscles are overactive or underactive?

A simple way to determine this is to use manual muscle testing. For example, if the pelvic floor muscles are weak, other associated muscles will have to compensate and thus become tight and painful. Let’s say the obturator internus remains tight and painful despite your best efforts to release it. Have your client do some Kegels and then reevaluate the obturator internus. If the OI has become more pliable you know you’re on the right track. This technique can be applied to the psoas, quadratus lumborum, gluteus maximus, sacroiliac area, and the hip joints.

But what to do if the pelvic floor is overactive? Start by evaluating the core and lower back muscles for weakness. For example, if the psoas tests weak have the client tighten the pelvic floor and retest. If the psoas now tests strong you know it is being inhibited by the pelvic floor muscles. This process can be applied to all associated muscles. If you are familiar with manual release of the pelvic floor it would be appropriate to do that. If you’re not there is a simple way to release the pelvic floor muscles. With the client supine, have them bend their knees and turn them out at a 45° angle so that the soles of their feet are touching. Then have them place their hands on their knees. Release of the pelvic floor muscles occurs when the hands resist a superior/diagonal movement of the knees. It is important that only light resistance is applied. This technique works very well as a home exercise program which would include this movement first followed by strengthening of the inhibited muscle.

Determining if the pelvic floor muscles are overactive or underactive is crucial in their treatment. Exercising an overactive pelvic floor can lead to serious pain and nerve irritation. Exercising an underactive pelvic floor can lead to vast improvements in core strength and lower back, sacroiliac, and hip joint function. It is truly a double-edged sword.

Importance of Functional Lats

There are very few muscles in the body whose functionality is as important as the lats. Because it connects the thoracolumbar fascia to the humerus, inhibition of the latissimus dorsi can cause compensations in the neck, shoulder, elbow, lower back, and gait. This article will detail these compensation patterns and how to resolve them. This information is important for all massage therapists, Pilates instructors, personal trainers, physical therapists, etc. because inhibition of a muscle that is centrally located causes global responses. Understanding how these patterns are formed and relate to each other  is essential in resolving long-standing and difficult presentations.

First, let’s start with the neck and shoulder. The lat via its attachment to the humerus is capable of scapular depression. It is opposed by the elevators of the scapula including the upper trapezius and the levator scapula. After palpating tight spots in the neck extensors, upper traps, and levator scapula I will then test the function of the lat by asking the client to hold their palm against their hip. If this is a weak test I then therapy localize tender spots on the aforementioned muscles while testing the lat  to see if they strengthen the test. Whichever one makes the tests the strongest is the one I release first. If that does not completely resolve I then proceed to the next tenderest spot and continue on until the test is strong. If the lat tests strong to begin with, I will challenge it by having the client shrug their shoulder or turn their head to the opposite side. One of these will usually inhibit the lat. When the lat tests strong and can withstand the challenges, I consider that a reprogramming of the motor control system. I will then assign a home program of  first stretching the neck/shoulder muscles followed by strengthening of the lat. It is crucial that the client follows this protocol exactly in order to successfully reprogram the motor control system. When the reprogramming occurs it is stored in the short-term memory. By constant repetition the reprogramming is then shifted to long-term memory.

Now let’s talk about the elbow. When the body perceives an instability in a joint it will very often either compress that joint or a nearby joint. I find very often with difficult to resolve cases of medial or lateral epicondylitis that the elbow is compressing to stabilize for the shoulder joint. Inhibition of the lat will often result in either of these situations. I will test the lat by having the client either holding their pinky against their hip with the palm up for medial epicondylitis or with the thumb against the hip with the palm down for lateral epicondylitis. If the test is weak I will then therapy localize spots around the epicondyles and then proceed with the NeuroKinetic Therapy protocol. A home program would be releasing the areas around the epicondyle followed by strengthening of the lat.

Finally the lower back. The latissimus dorsi  is contiguous with the thoracolumbar  fascia. Any inhibition of the lat will cause muscles/functions in that area to compensate. These include the ipsilateral erector spinae group, the quadratus lumborum, the gluteus maximus, and the gluteus medius.  This may also cause a contralateral rotational compensation, including the piriformis. Follow the NKT protocol, identify the facilitated muscles/functions using therapy localization, challenge the reprogramming, and assign the appropriate home program.

Gait can also be affected by inhibition of the lat. The lat is also an extensor of the humerus. Start by testing humeral extension with contralateral straight leg hip extension. If the extension of the humerus is inhibited check for tender spots in the opposite glute, hamstring, calf, and plantar foot muscles. Use the NKT protocol. Extension of the humerus may also be tested against flexion of the opposite humerus or flexion of the ipsilateral leg.

Functionality of muscles/functions that are centrally located are essential in maintaining healthy global relationships. The latissimus dorsi with its attachments to both the upper body and lower body is a muscle whose function is crucial in maintaining balance. A strong functional lat =  a happy body.