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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5548_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 6 The Fundamentals—Breath and Support 85
of the pectoralis major muscle. Avoid the breast tissue
when working on a woman.
Connective Tissue Therapy
Perform the fanning stroke on the upper portion of the chest.
Begin with the sides of the thumbs touching each other. The
tips of the fingers of both hands may be used as an alternative
to the thumbs. Slowly spread them apart, stretching the tissues.
Keep the strokes small, spreading the thumbs or fingers 2 or
3 inches apart with each stroke.
Start at the midline of the chest over the sternum, just
above the level of the breasts. The fanning strokes move
upward toward the clavicles. Repeat the stroke a number of
times, covering the entire upper segment of the chest. The
intention is to free the fascia of the upper thorax, creating a
sense of lift in the chest.
SESSION IMPRESSION
THE CHEST
he client is a 10-year-old boy named Joey, who has
asthma. He has been picked on in school because of
T
his small stature, and because he cannot participate fully
in sports activities. His mother wants him to receive inte-
grated deep tissue therapy to help alleviate the condition
and possibly boost his self-esteem.
is severely constricted. There are noticeable hollow areas
under the clavicles and along the borders of the anterior
deltoids, indicating that the pectoralis minor muscles are
extremely contracted. The central sternal region of the
chest is lifted, but in a strained manner. This position of
the chest may also partly be a consequence of struggling
to breathe during asthma attacks.
The focus of the session was to relieve tension in the
chest and ease restrictions in the breathing muscles.
Because Joey was a minor, his mother sat in on the session. Based on observation and the information gathered
about his asthmatic condition, the areas chosen to focus
on included the pectoralis major and minor, subclavius,
scalenes, intercostals, and diaphragm. A connective tissue
approach to these muscles was mandated because of the
child’s sensitivity to touch in the chest area.
Joey responded well to the front to back polarity contact
on his sternum and upper back. He visibly relaxed, and his
breath deepened. Swedish massage strokes were used to
warm up the muscles thoroughly before the deep tissue/
connective tissue strokes were applied. The integrated
deep tissue protocol was followed, but with full attention
given to sensing a melting of the tissues before applying
any further pressure or moving through the muscle fibers.
Deep Tissue/Neuromuscular Therapy
SEQUENCE
1. Pectoralis major (attachments and belly)
2. Subclavius
3. Intercostal muscles (from supine and side position)
4. Diaphragm
5. Back muscles (serratus posterior superior and inferior)
It is likely that the chest muscles will be restricted in many areas, because the breathing
mechanism is compromised in the majority of
the adult population as a result of stress and the lack of
encouragement of full expression of feeling and sensation. The reductions of trigger points not only assist in
opening up the breathing but also are instrumental in
rebalancing the shoulder girdle and freeing the ribs.
The chest muscles were addressed
in layers, from superficial to deep.
Many trigger points were encountered
in the intercostal muscles. As a trigger point
was pressed, Joey was encouraged to breathe
deeply and imagine the point melting. He enjoyed participating in the process and felt a sense
of accomplishment when the uncomfortable feelings
generated by the trigger points dissolved. The diaphragm
was contacted and massaged very carefully.
The session was concluded with long, Swedish strokes
along the erector spinae and with fingertip raking into the
intercostal spaces between the ribs in the back to balance
the work performed on the front of the chest cavity. After
the session, Joey’s mood was much lighter. He was thrilled
to be able to take fuller breaths without struggling, and he
commented to his mother how much broader his chest and
shoulders felt. He was extremely proud of himself. Joey was
shown the door frame stretches for the chest muscles, and it
was suggested that he practice them every day to maintain the
newfound length in his pectoralis major and minor muscles.
Topics for Discussion
1.
Give at least three reasons for beginning a series of deep
tissue sessions with chest work.
2. Describe several possible manifestations of chest con-
striction along with the muscles involved.
3. What precautions should be taken when performing
deep tissue therapy on the diaphragm muscle?
4.
How might restricted breathing patterns be revealed
by observing a client’s thorax?
5.
Where are the most likely areas for trigger points to
form in the thoracic region, and why?
¢
86 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
Pectoralis Major (Attachments and Belly)
Origin:
Clavicular—medial half of the clavicle.
Sternal—sternum to the seventh rib, cartilages of upper
six ribs.
Insertion: Lateral lip of the bicipital groove of the humerus.
Action: Adduction of shoulder. Medial rotation of shoulder.
Clavicular—shoulder flexion, medial rotation of shoul-
der, horizontal adduction of humerus.
Sternal—adduction of humerus diagonally downward,
anterior shoulder stabilizer.
Pectoralis Major (Origin)
Strokes
r Elongation stroke on the sternum, just lateral to the mid-
line, from the xiphoid process to the manubrium, using
the fingers or the thumb (Fig. 6-8).
r Elongation stroke along the inferior border of the medial
half of the clavicle, using the fingers or the thumb. Move
medial to lateral. Feel for small knots and stringy fibers. If
they are tender or refer pain, work on them with cross-fiber
strokes and direct compression.
FIGURE 6-9 Contacting the attachment of the pectoralis major on
the lateral lip of the bicipital groove of the humerus.
Insertion of the pectoralis major. Perform the side-to-side
r
stroke and static compression with the fingers on the lateral
lip of the bicipital groove of the humerus (Fig. 6-9). To
locate it, take the client’s arm to an abducted position.
Slide your fingers along the border of the pectoralis major
and the anterior deltoid to reach the point of attachment
on the humerus. It is superior to the deltoid tuberosity on
the lateral lip of the bicipital groove. Check for trigger
points. If any are found, pause there for several seconds
while checking with the client about the level of pain
reduction.
B
A
FIGURE 6-8 Directions of elongation strokes on the sternal and
clavicular attachments of the pectoralis major.
Pectoralis Major (Belly)
The pectoralis major muscle has three major
segments. They are named after their sites of
origin: clavicular, sternal, and costal. Trigger
points in the upper or clavicular portion may be found
along the lateral border, underneath the edge of the
anterior deltoid muscle. They refer pain throughout the
anterior deltoid and into the area of the pectoralis major
near the trigger point.
Trigger points in the sternal section tend to accumulate in the medial and lateral portions between ribs 3,
4, and 5, near the insertion points of pectoralis minor.
Check along the inferior border of the costal section of
the muscle for trigger points. The pain pattern is into the
front of the chest and down the arm.
Trigger points in the lower section of the muscle tend
to form along the lateral border. They refer pain into the
breast and nipple.
Heavy lifting, prolonged holding of the arms in an
abducted position, and postural changes related to
emotional stress may all contribute to the formation of
trigger points in this muscle.
Strokes
r The client’s arm is still in the abducted position. Using
your knuckles, perform the elongation stroke from the
sternum to the insertion on the humerus in several
strips (Fig. 6-10). Begin the first strip just inferior to the
clavicle. Begin the last strip across the muscle at the
xiphoid process.
r With a female client, the knuckle stroke should only be
done on the upper chest, superior to the breast tissue. At
the level of the breast, stroke outward, using the fingers or
thumb, from the sternum to the medial border of the breast.
Subclavius (Fig. 6-11)
Origin: Upper border of the first rib.
Insertion: Groove on the inferior surface of the clavicle.
Action: Depresses and moves the clavicle forward. Stabi-
lizes the clavicle during shoulder movements.
A commonly occurring trigger point is found
on the medial side of the subclavius, near the
manubrium. Its referral zone is along the inferior border of the clavicle and down the arm into the
thumb side of the hand.
Strokes
r
Stand at the side of the table, and face the inferior
border of the client’s clavicle. The client’s arm is flexed
at 90°. Hold it slightly inferior to the elbow. Drawing
the clavicle slightly away from the chest wall for easier
access to the subclavius muscle, traction the arm toward
the ceiling.
r
Using the pads of the index and middle fingers or the
pad of the thumb, stroke under the inferior border of the
clavicle from the medial to the lateral end.
Chapter 6 The Fundamentals—Breath and Support 87
FIGURE 6-11 Accessing the subclavius.
Intercostal Muscles
Origin:
External—from the lower border of each of the upper
11 ribs.
Internal—from the cartilages to the angles of the upper
11 ribs.
Insertion:
External—superior border of the rib below the origin.
Internal—superior border of the rib below the origin.
Action:
External—elevation of ribs during inspiration.
Internal—depression of ribs during exhalation.
Intercostals (Supine Position)
DAR
FIGURE 6-10 Elongation stroke on the clavicular, sternal, and
costal sections of the pectoralis major.
Trigger points are likely to be found in concentration along the borders of the ribs where the
intercostal muscles attach. Contracted muscles
related to inhibited breathing are the probable cause of
their formation.
Strokes
r Begin at the base of the rib cage, in the rib space between
the 10th and 9th ribs. Place your fingers between the two
ribs. Allow the fingers to sink into the tissues until resistance
is met (Fig. 6-12).
r Perform a short, side-to-side stroke, feeling for deviations
in the tissues (i.e., stringy fibers, tiny knots). Hold with
static compression on tender points until pain diminishes.
The thumbs may be used instead of the fingers if more
pressure is required.
r
Continue with this procedure, working between each pair
of ribs, to the clavicle. Be thorough.
88 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
Strokes
8JUIUIFQBMNTVQJOBUFETMJEFZPVS GJOHFST VOEFSUIF
r
CPSEFSPGUIFDPTUBMDBSUJMBHFPGSJCTmKVTUMBUFSBMUP
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JOUPUIFVOEFSMZJOHPSHBOT5BLFUJNFUP MFU UIFGJOHFST
TJOLJOUPUIFUJTTVFT'JH
Avoid pressing directly on the xyphoid process,
because it is not well supported.
r
%PTIPSUTJEFUPTJEFNPUJPOTXJUIZPVSGJOHFSTGFFMJOHGPS
UJHIUOFTTBOEUSJHHFSQPJOUBDUJWJUZ.PWFMBUFSBMMZBMPOH
UIFCPSEFS1MBDFUIFQBMNPGZPVSOPOXPSLJOHIBOEPWFS
UIFMPXFSSJCTUPHJWFBEEJUJPOBMTVQQPSUUPUIFVQXBSE
FIGURE 6-12 Working with the intercostals.
Intercostals (Side Posture)
Position
r 5IFDMJFOUJTQVUJOTJEFQPTUVSFXJUIUIFLOFFTGMFYFEBOE
QSFTTVSFPGZPVSXPSLJOHIBOE
r
8PSLXJUIUIFDMJFOUTCSFBUI0OUIFFYIBMBUJPOTJOLJOUP
UIFUJTTVFTXJUIZPVSGJOHFSTVOUJMSFTJTUBODFJTGFMU0OUIF
JOIBMBUJPOBMMPXUIFDMJFOUTBCEPNFOUPQVTIZPVSGJOHFST
PVUGSPNVOEFSUIFSJCT
BQJMMPXQMBDFECFUXFFOUIFN5IFUPQBSNJTQPTJUJPOFEJO
GSPOUPGUIFDMJFOUBMMPXJOHBDDFTTUPUIFTJEFPGUIFDIFTU"
QJMMPXNBZCFQMBDFEVOEFSUIFTJEFPGUIFIFBEGPSDPNGPSU
r 5IFUIFSBQJTUTUBOETCFIJOEUIFDMJFOU
Strokes
r
1FSGPSNGBOOJOHTUSPLFTXJUIUIFGJOHFSTPSIFFMTPGUIFIBOE
JOBTVQFSJPSEJSFDUJPOPOUIFTJEFPGUIFDIFTUGSPNUIF
CBTFPGUIFSJCDBHFUPUIFBYJMMBUPTPGUFOUIFTVQFSGJDJBM
GBTDJBBOEQSFQBSFUIFUJTTVFTGPSEFFQFSXPSL
r 'JOEUIFTQBDFCFUXFFOSJCTBOE 'JH4JOL
UIFGJOHFSTJOUPUIFUJTTVFTVOUJM SFTJTUBODFJTNFU BOE
Back Muscles
Position
r 5IFDMJFOUJTMZJOHTVQJOF
r 5IFUIFSBQJTUJTTUBOEJOHPSTJUUJOHBUUIFTJEFPGUIFUBCMF
Serratus Posterior Superior
Origin:4QJOPVTQSPDFTTFTPGUIF$BOEUIF5m5WFSUF
CSBF-JHBNFOUVNOVDIBF
Insertion:6QQFSCPSEFSTPGSJCTmKVTUMBUFSBMUPUIFJSBOHMFT
Action:&MFWBUFTVQQFSSJCT1PTTJCMFBTTJTUBODFJOJOTQJSBUJPO
CFHJOTIPSUTJEFUPTJEFTUSPLFTXPSLJOHUIFJOUFSDPTUBMTJO
TFDUJPOT$POUJOVFXPSLJOHJOFBDISJCTQBDFUPUIFUPQ
PGUIFBYJMMBUPSFBDIUIFTQBDFTCFUXFFOUIFVQQFSSJCT
Diaphragm
deep, under the upper portion of the scapula. It can also
extend over the posterior deltoid and down the triceps.
This muscle may house a trigger point just medial to the superior angle of the scapula. It is a
common cause of shoulder pain. The pain is felt
Origin:
Sternal partJOOFSTVSGBDFPGUIFYJQIPJEQSPDFTT$PT
UBMQBSUJOOFSTVSGBDFT PGUIFDBSUJMBHFTPGSJCTm
Lumbar part-m-WFSUFCSBF
Insertion:$FOUSBMUFOEPO
Action:*ODSFBTFTWPMVNFPGUIFUIPSBDJDDBWJUZEVSJOHJO
IBMBUJPOCZESBXJOHUIFDFOUSBMUFOEPOEPXO
DAR
An active trigger point along the diaphragm
attachment on the underside of the costal cartilage may be found approximately 1-inch lateral
to the xiphoid process.
Position
r
5IFDMJFOUJTQMBDFECBDLJOBTVQJOFQPTJUJPOXJUIBCPMTUFS
VOEFSUIFLOFFT
r
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UIFDMJFOUTSJCDBHF
FIGURE 6-13 Working with the intercostals from side-lying position.
Chapter 6 The Fundamentals—Breath and Support 89
Strokes
4MJEFZPVSIBOETVOEFSUIFDMJFOUTCBDLBUUIFMFWFMPGUIF
r
MPXFSUIPSBDJDBOEVQQFSMVNCBSWFSUFCSBF5m5BOE
-m-*G UIFDMJFOUJTUPPMBSHFPSIFBWZUPTMJEFZPVS
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UIFDMJFOUJOTJEFQPTUVSFUPBEESFTTUIFTFSSBUVTQPTUFSJPS
TVQFSJPSBOEJOGFSJPSNVTDMFT#FHJOOJOHBUUIFTQJOPVT
QSPDFTTFTQFSGPSNTIPSUCBDLBOEGPSUINPUJPOTXJUIZPVS
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NVTDMFTJOTFSUJPOPO UIF JOGFSJPSCPSEFST PGSJCTm
'JH
When performing the strokes on ribs 11 and 12, be
careful to contact only the inferior edge of the ribs.
Do not press down on the body of the ribs, because they
have little support underneath them.
r )PMEXJUITUBUJDDPNQSFTTJPOPWFSTFOTJUJWFQPJOUTBTUIF
DMJFOUCSFBUIFTEFFQMZ
r "TBOBMUFSOBUJWFQSPDFEVSFVTFUIFLOVDLMFTJOTUFBEPG
UIFGJOHFST
STRETCH
FIGURE 6-14 Working with the diaphragm.
Strokes
r
4MJEFZPVSIBOETVOEFSUIFDMJFOUTCBDLBUUIFMFWFMPGUIF
VQQFSUIPSBDJDTQJOF5m5#FHJOOJOHBUUIFTQJOPVT
QSPDFTTFTQFSGPSNTIPSUCBDLBOEGPSUINPUJPOT XJUI
ZPVSGJOHFSQBETNPWJOHUPXBSEUIFWFSUFCSBM CPSEFS PG
UIFTDBQVMB
r
)PMETUBUJDDPNQSFTTJPOPWFSTFOTJUJWFQPJOUTBTUIFDMJFOU
CSFBUIFTEFFQMZ
"TBOBMUFSOBUJWFNPWFVTFUIF LOVDLMFTJOTUFBEPGUIF
r
GJOHFST
Serratus Posterior Inferior
Origin:4QJOPVTQSPDFTTFTPG5m5BOE-m-
WFSUFCSBF
Insertion:*OGFSJPSCPSEFSTPGSJCTmMBUFSBMUPUIFJS
BOHMFT
Action:%FQSFTTFTMPXFSSJCTBOENPWFTUIFNEPSTBMMZ1PT-
TJCMFBTTJTUBODFJOFYQJSBUJPO
5IFUIFSBQJTUTUBOETBUUIFIFBEPGUIFUBCMF5IFDMJFOU
FYUFOETIJTPSIFSBSNTPWFSIFBEUPXBSEUIFUIFSBQJTU
5BLFIPMEPGUIFDMJFOUTBSNTTMJHIUMZTVQFSJPSUPUIFFMCPX
KPJOUT1VMMUIFBSNTUPXBSEZPVBOETMJHIUMZEPXOXBSE
XIJMFUIFDMJFOUUBLFTGVMMCSFBUITGPDVTJOHPOFYQBOEJOH
UIFDIFTU'JH
5IFDMJFOUUVSOTPOUPIJTPS IFS TJEFXJUIUIFLOFFT
GMFYFE5IFDMJFOUTTUSBJHIUFOFETVQFSJPSBSNSFBDIFT
CFIJOEIJN5IFUIFSBQJTUTUBOETCFIJOEUIFDMJFOUT
To locate trigger points, examine the serratus
posterior inferior’s attachments along the inferior borders of ribs 9–12. The pain pattern is
throughout the muscle itself and over the lower ribs.
FIGURE 6-15 Accessing the serratus posterior inferior along
ribs 9-12.
90 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
shoulder. Hold the extended arm, and slowly increase
the stretch while your fist is placed against the client’s
scapula to prevent the client from rolling backward too
far (Fig. 6-17). This position stretches the pectoralis
major muscle.
ACCESSORY WORK
1. Perform an elongation stroke on the erector spinae
and paraspinal muscles. Using the forearm, begin the
stroke between the scapula and spinous processes on
one side of the back. The forearm is parallel to the
spine until you clear the inferior angle of the scapula.
Then, it is rotated perpendicular to the spine to make
contact with a broader section of the back. Continue
the stroke to the iliac crest of the pelvis (Fig. 6-18).
Repeat on the other side of the back. Press points
along the inferior border of the 12th rib, which is near
the attachment of the diaphragm muscle (Fig. 6-19).
Both sides may be palpated simultaneously. Begin
with the thumbs on either side of T12, and move
FIGURE 6-16 Thoracic stretch with the client supine.
them apart laterally.
FIGURE 6-17 Pectoralis
major stretch from side-lying
position.
FIGURE 6-18 Elongation stroke for the erector spinae muscles.
Chapter 6 The Fundamentals—Breath and Support 91
FIGURE 6-20 Reflex zone for the diaphragm.
FIGURE 6-19 Pressure points for the diaphragm.
2. Concentrate on diaphragm reflex points on the foot
(Fig. 6-20). Press points along the diaphragm line
on the plantar surface of the foot, moving medial
to lateral. The line is located slightly inferior to the
metatarsal bones, and it runs all the way across the
surface of the foot. It is easy to distinguish, because
the color of the skin is darker above the diaphragm
line and lighter below it.
CLOSING
Sitting at the foot of the table, lightly hold the heels of the
client’s feet in your hands for 30 to 60 seconds. Remove your
hands slowly.
92 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
The Back and Spine
◗ GENERAL CONCEPTS
The spine acts as the primary support structure for the entire
body. Functional alignment of the spine is essential so that
it can carry the three major weights that are connected to it
(the head, rib cage, and pelvis) without adding unnecessary
stress in the muscles of the trunk. A poised, balanced spine
results in the effortless elongation of the trunk that is associated
with healthy posture. The muscles attached to the spine must
be free of restrictions so they can achieve the equalization
of forces along the spinal column that allows a balanced
relationship between its components. This is the next goal
in the integrated deep tissue series.
The spine is constructed so that many muscles and ligaments
attach to it in a lattice-like pattern, allowing a great deal of
mobility and flexibility along with stability. The spinal column
is capable of forward and side flexion, extension, and rotation.
◗ MUSCULOSKELETAL ANATOMY
AND FUNCTION
Spinal Column
The spinal column consists of 33 bones: 7 cervical vertebrae,
12 thoracic vertebrae, 5 lumbar vertebrae, and at birth, 5
modified sacral vertebrae and 4 small vertebral remnants
forming the coccyx. The bones of both the sacrum and the
coccyx fuse later in life, leaving 24 functional vertebrae in
the adult. Twenty-three intervertebral discs are sandwiched
between the vertebral bones (Essential Anatomy Box 6-3
and Fig. 6-21).
All vertebrae except C1 are composed of two parts: a
rounded body on the anterior side, and a posterior segment,
called the vertebral arch. The vertebral arch is a complex
structure with several landmarks. The spinous and transverse
processes are on the vertebral arch; these provide attachment
sites for many muscles and ligaments. The opening between
the vertebral body and arch is called the vertebral foramen.
Lined up within the spinal column, the foramen form a tunnel, called the vertebral canal, within which the spinal cord
is located. See Figure 6-21A for an illustration of a vertebra.
Stacked vertebrae also create bilateral holes on the horizontal plane. These are called the intervertebral foramina,
and they allow the spinal nerves to exit the central nervous
system and become part of the peripheral nervous system.
The vertebral bodies are separated by cartilaginous discs.
The two components of the disc are a central, compressed
fluid core, called the nucleus pulposus, and a tough fibrous
covering, called the annulus fibrosus. The discs act as cushions,
helping to transfer weight evenly between the vertebrae, and
absorbing the shock of the vertical and shearing pressures
that occur when we walk, run, bounce, and twist. The discs
in the lumbar and cervical segments of the spine are thicker
in relation to the height of the vertebrae, allowing greater
movement between the individual vertebrae, but the discs
in the thoracic segment are smaller, decreasing the amount
of possible motion. When adjacent vertebrae are properly
aligned, compression on the intervertebral disc is distributed
evenly, allowing a smooth downward transfer of weight.
One of the spinal column’s primary functions is to provide
an anchor of support and stability for the cranium, thorax,
and pelvis. The spinal column has a series of four opposing
curves that offset the uneven size and placement of these
three weights (Fig. 6-22). The cervical and lumbar curves
are concave, while the thoracic and sacral curves are convex.
This design creates continuity of weight transfer and shock
absorption throughout the spinal column. The vertebral joints
where the curves change (C7–T1, T12–L1, and L5–S1) bear
the greatest weight load, and must be in best alignment for
the spine to be an integrated, stress-free unit.
BOX 6-3 ESSENTIAL ANATOMY | The Back/Spinal Column Routine
MUSCLES
Trapezius
Latissimus dorsi
Erector spinae
Rhomboid minor
Rhomboid major
Intercostals
Quadratus lumborum
Sacral ligaments
BONES AND LANDMARKS
Vertebral column
Spinous processes
Transverse processes
Lamina groove
Scapula
Ribs
Iliac crest
Sacrum
Coccyx
Chapter 6 The Fundamentals—Breath and Support 93
Superior View
Lamina
Pedicle
Vertebral
foramen
A
POSTERIOR
Spinous process
ANTERIOR
Superior ar
facet
Transverse
process
Body
ticular
Middle trapezius
Deltoid
Teres major
Triceps brachii
Inferior trapezius
External oblique
B
Sternocleidomastoid
Superior trapezius
Latissimus dorsi
David Rini
Thoracolumbar
fascia
FIGURE 6-21 A. Superior view of lumbar
vertebra. B. Superficial muscles of the
back with areas of possible trigger point
formation. C. Middle layer of back muscles.
D. Deep layer of back muscles. E. Sacral
ligaments.
94 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
Semispinalis capitis
Longissimus capitis
Longissimus cervicis
Iliocostalis cervicis
Iliocostalis thoracis
Longissimus thoracis
Spinalis thoracis
Longissimus lumborum
Iliocostalis lumborum
Semispinalis
capitis
Multifidus
Rotatores
C
Posterior
superior
iliac spine
Greater
sciatic
ramen
fo
Ischiofemoral
ligament
E
Erector spinae
Supraspinous
ligament
Sacrotuberous
ligament
RIni
after Mader
Posterior
sacrococcygeal
ligaments
DAR
Lesser
sciatic
foramen
DAR
D
Iliolumbar
ligament
Posterior
sacroiliac
ligament
Sacrospinous
ligament/
Ischial spine
Ischial
tuberosity
FIGURE 6-21 (continued)