The client came in today reporting radiating pain (px) that originated on the L side just under the rib cage. She felt it was in the diaphragm. She stated the px radiated across to the right side of diaphragm and became worse as the day progressed. Her activities of daily living (picking up her toddler, doing dishes, walking the dog, putting on her shoes, exercising) were all limited and significantly reduced or eliminated due to px along the diaphragm. She had consulted with her midwives, chiropractor, and acupuncturist. No one was overly concerned, but she was not getting relief from any of the therapies offered by those practitioners. The client voiced concern that her mother and grandmother had suffered a hiatal hernia during their pregnancies. She was worried she was experiencing the same thing. She is in the 3rd trimester of her pregnancy. She agreed that we would work slowly and gently along the area where she was experiencing the px and try to see if relief could be found with soft tissue work.
So, off we went into the wilds of the pregnant abdominal tissue. First we did a little Belly Mapping(trademarked) and Leopold's to determine where baby was hanging out this morning. Baby was L(eft)O(cciput)P(osterior) and very disorganized.
Image used with express permission from Gail Tully of Spinning Babies
What does disorganized mean? It means baby's limbs were literally all over the place. Baby's bum was right in the area where mama was experiencing her debilitating px. She reported baby would often kick her there as well. A light fascial palpation along the inferior border of the rib showed congestion and threadiness in the tissues. The abdominal muscles were pulling against the lower anterior rib and formed a band of bunched up muscle fibers. We followed the fibers toward the navel and about 1/5 of the way there, the client exclaimed, "That's it! That is making my diaphragm hurt!". So here we have a classic trigger point in the upper external obliques of the abdomen. The nodule was quite large and deep.
Baby became very responsive to the touch and was interacting with us as we worked through the trigger point (TrP). Now, be aware, one cannot use traditional Cyriax and Travell method to release a TrP on a pregnant belly. The technique must be slowed way down, there is no Optimal Tolerance (OT - means right on the edge of pain, an "it hurts so good feeling") work, you must work well below OT and in comfort of your client. Yes, this takes longer, but the reward is greater for your client, and it gives you time to really get into the flow of the tissue. The TrP was mostly freed up but there was a residual tension in the abdomen that both of us noticed.
So, therapist pulls out the detective hat....let us go for the most obvious first, take a look at the superficial fascial line (according to the teachings of Tom Myers - inventor of the Anatomy Trains).
Photo by Adrienne Caldwell
Image used with permission of the model
Image used with permission of the model
Indeed the right hip was tight and restricted. The fascial line that was restricted goes at a diagonal from the Left shoulder to the Right hip. There is a match on the opposite sides as well. So, if you were to look at the human body with only the superficial fascial line it would look like a large "X" over the torso. It is my experience that injury, overuse, and compensation will restrict this line. This means, when you have a significant dysfunction anywhere along these lines, in order to fully release and gain full function of the soft tissues, you must follow the lines to where the next most restricted area is, and release it. This does mean that sometimes it takes more than one session to fully open these lines in pregnancy. So what did we release? The tensor fascia latae (TFL), attachments at the anterior superior iliac spine (ASIS), attachments at the anterior inferior iliac spine (AIIS), the quadriceps group, the iliotibial (IT) band, and the gluteus maximus. The techniques to release the structures are varied. Primarily, fascial release is the mainstay of my practice.
As soon as the right hip was released the client reported she could feel more space in her left upper abdomen. She also stated she felt like baby was in a different position. First we checked the TrP area, the TrP was gone - no more referral px along the diaphragm, and then we rechecked baby's position. Baby was still LOP but their limbs were more organized and closer to the right side of mom's belly. Baby's back was more upright and the head was more centered.
When the client stood up from the table she stated how much better she felt. She stated she felt like she had room to breathe. She could feel that baby was lying differently in her pelvis.
So, this scenario of a place of pain not being the source of pain is incredibly common in my practice. I hope you enjoyed this little case study and it helps you on your journey of pregnancy, bodywork, or just understanding the mystery of the human form.
Join myself, Deb McLaughlin, and Marcello Windolph in July to learn our techniques and philosophy around prenatal, labor, birth, and postpartum care. We are presenting in Minneapolis, MN in July. Here is the link to the conference web site. It will be a unique blend of disciplines with the Spinning Babies paradigm leading the way!
All the best!
None of the information presented in this blog is instructional. If you have a specific medical concern please consult your primary physician. All thoughts and ideas presented are those of Adrienne, and are not advice on practice or medicine.