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Dear Cara – or -The Problem of Wiberg

Dear Cara,

My book, Save Your Hips, does talk about dysplasia, a concept first put forth in 1939 by Gunnar Wiberg. By this time, radiology was well established and the practice of orthopedics focused primarily on bones. Throughout the previous century a deep level of understanding had been centered on imbalances in the soft tissues surrounding the joint as the initial, fundamental pathology in common hip disease.

I believe The Problem of Wiberg (I just coined this phrase) to be the tipping point in changing current understanding of chronic hip disease.

Center Edge Angle of Wiberg

Center Edge Angle of Wiberg

Wiberg saw on AP radiograph that some acetabulae provide less coverage to the femoral head than others. Working with impressive 2D images that were easy to manipulate mathematically, he produced a theory stating that at a certain point in his diagnostic parameter, called the center edge angle of Wiberg (CEA), a hip could be considered dysplastic or not.

The CEA contains a large margin of error, however, because it does not take into account the major musculoskeletal movement that positions the acetabular roof over the femoral head which is, of course, sacral nutation (i.e. lordosis). When we lie supine for a standard AP radiograph, the femoral head moves slightly up and out of its socket. When we stand up, the femoral head moves down and medially. The hip joint follows the sacrum in this movement. Therefore, none of the images Wiberg was working with gave a true representation of how much of the weight-bearing joint was actually covered by the acetabular roof. No doubt he saw some very abnormal joints. But his parameter is largely erroneous because it measures spacial relationships in a non-weight-bearing position. This wouldn’t be a problem if the joint didn’t radically change from supine to standing…but it does! Wiberg and all the diagnosticians after him never really knew from an AP radiograph which hips were going to be covered-enough as the lumbar spine extended with standing. There are other imaging technologies today, but no one has wanted to confront The Problem of Wiberg. Therefore the images are digitally manipulated to give a standard AP view of the pelvis (“anterior pelvic plane”).

Crazy, but true. This is what Save Your Hips is all about.

But what were Wiberg and others through the century seeing in a dysplastic acetabulum? That it is “shallow” and “oval-shaped”, instead of more circular (it is actually a spiral, which my daughter, who is also my artist, and I realized at the same moment).

Dysplastic Acetabulum

Normal Acetabulum

The only possible gravitational dynamic capable of creating such an acetabular shape is bearing the center of mass on the front aspect of the joint. One bears the COM in this way by flattening lumbar curvature while weight-bearing. The degree to which the lumbar spine is flattened from its natural, wide-radius curvature, is the same degree the femoral head is moved up and laterally.

It is also true that there is another, far less common, condition where the femoral head has been held slightly out of the joint from birth or early childhood. Thus, we have a true developmental dysplasia, and also an acquired (degenerate) condition. Spinal and/or pelvic obliquity (scoliosis) can also cause the hip joint to twist and elongate.

So how should a thirty or forty-year-old who has new-onset or slowly progressing hip pain with radiologic signs of dysplasia be categorized? You would not be able to determine (other than by history) which hip dysplasia was acquired and which was developmental. The trained eye, however, would be able to tell by subtle differences in the bones themselves. But this distinction is not studied and therefore not mentioned in orthopedic literature. It is all classified as developmental.

Acquired dysplasia causes the anterior aspect of the symmetrical, arched acetabular roof to (1) stretch – as gravity pulls the joint downward, elongating the acetabulum like taffy, and (2) apply bone to what becomes the anterior-superior aspect of the acetabulum in the counternutated position (lumbar curve flattened). This area becomes thickened and protruding as it tries to cover and protect the joint.

Normal Acetabulum

Dysplastic Acetabulum

The process of stretching and bone deposition at the anterior-superior aspect of the joint is probably largely responsible for other popular orthopedic theories, acetabular retroversion and pincer FAI, which describe the same architectural characteristics. This is why I describe in my book how orthopedics creates new diseases out of thin air.

To convolute matters further, the practice of orthopedics believes this dysplastic area to be the weight-bearing roof of the normal acetabulum, due to a 500 year-old misconception of pelvic orientation in the bipedal position.

Orthopedics has used flawed, circular logic to justify the mutilation of millions of hips.

Which kind of dysplasia do you believe you have, Cara?

Wishing you well,
Christine

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PAO – A Devastating Operation

Reciting the words spoken by William Harris in 1986, orthopedic surgeons persist in their assertions that “Primary hip osteoarthritis (OA) is extremely rare.”1 These doctors continue to claim that “Up to 90% of young patients (<50 years of age) that develop OA of the hip have an underlying structural problem, which in half the cases is dysplasia.”2

A diagnosis of developmental dysplasia of the hip (DDH) is based on the center edge angle of Wiberg3, which is calculated from standard anterior-posterior (AP) radiographs. To obtain the CE angle, a vertical line is drawn through the center of the femoral head, and another to the lateral edge of the ‘sourcil’. (Figure 1)
Figure 1

The sourcil, a French term meaning ‘eyebrow’, is a projection of the anterior-superior acetabular wall. It is a 2-dimensional contrived parameter that the practice of orthopedics actually believes to be the load-bearing aspect of the acetabulum. In reality, the sourcil does not exist as reflected on pelvic x-rays. Its lateral edge, often used to diagnose ‘pincer impingement’, is subject to change with the slightest rotation of the pelvis, as more of the arched acetabular roof comes into view. (Figure 2)
Figure 2

Moreover, the entire AP radiograph, taken in the supine position, is a faulty representation of how the femoral heads are actually contained within the acetabulum. When supine, lumbar curvature flattens and the femoral heads move slightly up and laterally. When standing with lumbar curve in place, the femoral heads move down and medially. There is no way to calculate to what extent individual pelvic rotation will change the CE angle, a configuration derived strictly from the supine x-ray. Yet, it does not matter because orthopedic surgeons are only interested in treating DDH surgically.

After a decade of disastrous results treating dysplasia with arthroscopic surgery to “repair” labral tears4, the standard of care has become the periacetabular osteotomy (PAO). Surgeons believe the goal of treatment “should be the restoration of hip anatomy as close to normal as possible.”5 PAO is the preferred technique “because of its balance between minimal exposure, complications, and ability to provide optimal correction.”6

In reality, orthopedics has an extremely inaccurate view of pelvic orientation, and rather than restoring normal anatomy, PAO changes the pelvis to a configuration that does not occur in nature. Drawn from centuries of misperception, orthopedics believes “Two strong osseous columns of bone surround the acetabulum, transmitting the stresses between the trunk and lower extremities.”7 (Figure 3)

Figure 3 The most current orthopedic literature proclaims that PAO “preserves the posterior column of the acetabulum and therefore allows early weight-bearing post-operatively.”8

Actually, in the standing body the pelvic inlet is in a vertical position, and the so-called bony “columns” are horizontal, not vertical. In 1955 it was recognized that gravitational forces are carried around the linea terminalis (circular pelvic inlet) and distributed onto the femoral heads.9 (Figure 4)
Figure 4

Surgeons contend, “The pelvic ring and outlet are not disrupted by PAO”10, yet anyone who has ever seen a post-PAO x-ray knows the fallaciousness of such statements. Another selling point of the PAO is that, “It can be performed through one incision without violation of the abductors, thus enhancing recovery.”11 The following summary of the steps in the soft-tissue dissection and exposure prior to the actual osteotomy illuminates the devastating and irreversible trauma that accompanies PAO.12

  1. External oblique incision and exposure of iliac crest.
  2. Subperiosteal iliacus dissection.
  3. Detachment of sartorius origin and inguinal ligament attachment through anterior superior iliac spine osteotomy.
  4. Incise fascia of tensor fascia lata muscle.
  5. Dissect tensor fascia lata from intermuscular septum.
  6. Exposure of lateral rectus femoris muscle belly and medial retraction to identify distal hip capsule.
  7. Release reflected head and direct head of rectus femoris.
  8. Incise fascia of capsular extension of iliacus muscle and dissect muscle exposing entire anterior hip capsule.
  9. Subperiosteal dissection of pubic root and entrance into iliopectineal bursa.
  10. Insert Hohmann retractor into pubis, flex hip, and retract psoas muscle. Overly vigorous traction may injure femoral nerve.
  11. Complete dissection of anterior hip capsule and interval between psoas tendon sheath and hip capsule.
  12. Incise periosteum of pubis and perform subperiosteal anterior and posterior pubic dissection reflecting the obturator membrane from the inferior pubis.
  13. Reflect iliopectineal fascia from iliopectineal line.
  14. The iliac nutrient artery located anterior to the distal sacroiliac joint should be cauterized and sealed with bone wax.

The next step is the osteotomy itself, whereby the acetabulum is sawn in three places and rotated with the intention of better covering the femoral head by the acetabular roof. The established maneuver in PAO is to turn the acetabular fragment into flexion, lateral tilt, and medial rotation. (Figure 5)
Figure 5

“Every effort should be made to orient the acetabular sourcil in a horizontal position relative to the weight-bearing zone of the femoral head. The anterior and posterior walls of the acetabulum should be positioned so that the posterior wall is lateral to the anterior wall.”13

One of the great medical outrages of the 21st century is that what these surgeons are trying to reproduce is not normal anatomy, but the misconstrued reflection of the 2D pelvic x-ray. In the flesh-and-blood standing pelvis, the posterior wall is medial to the anterior wall, due to the oblique nature of the pelvis from the wide anterior superior iliac spines in front, to the more narrow ischial tuberosities in back. (Figure 6)

Figure 6

It is also a tragic irony that the goal of PAO is to get the “femoral head centered under the acetabular roof”14 when this is the natural biomechanical result of sitting, standing, walking, and running with a wide-radius lumbar curvature.

Reinhold Ganz, the orthopedic surgeon who popularized the PAO, recently reported that a 10-year follow-up revealed one-third of his PAO patients had developed femoroacetabular impingement (FAI) as a result of the operation.15 It is logical to assume this would cause orthopedic surgeons to pause and reconsider the long-term benefits of the surgery. Instead, the prevalence of PAO is increasing exponentially. Only now, FAI surgery is being routinely added as an adjunct to the PAO operation. “[Hips] are routinely examined intraoperatively and a femoral neck plasty is performed to maintain or enhance motion and to prevent post-PAO acetabulofemoral impingement.”16

Another recent source tells us, “The longest follow up of PAO to date shows a survivorship, defined as not yet requiring THR or arthrodesis, of 60% at 20 years.”17 These are terrible odds, yet even post-PAO patients seem to be in denial about the realities of the surgery, often encouraging others to submit to the operation. Online support groups serve as funnels, delivering scores of naive victims into the hands of orthopedic hip surgeons.

The theory of acetabular dysplasia has not been challenged since Gunnar Wiberg published his dissertation on the subject in 1939. No one questions that a rudimentary geometric angle drawn onto a 2D x-ray may have no correlation with the reality of the standing body. Or worse, that the natural depression in the front acetabular rim (Figure 7)

Figure 7 is often mistaken for dysplasia and reduced coverage of the femoral head.18 There is no consensus among orthopedic surgeons whether patients with dysplasia benefit from arthroscopy, and what the exact indications for labral repair should be.19

Too often the progression of surgically managed dysplasia is arthroscopy > PAO > THR. Young age is a major risk factor for revision THR, yet untold numbers of post-PAO patients in their teens and twenties are receiving total hips. Many of these surgeries are being conducted in out-patient settings, for which no public records are required to be kept.

The periacetabular osteotomy should be considered a rescue operation to be utilized in the most severe cases of disease and birth defect. The natural history of mild and moderate hip dysplasia has yet to be defined. Moreover, surgeons know “It does seem possible to live a long and asymptomatic life with mild or moderate hip dysplasia.”20


Notes:

1 Perry K Trousdale R Sierra R Hip dysplasia in the young adult. The Bone and Joint Journal 95-B(11):21-25 2013
2 Ibid
3 Zou Z et al Optimization of the position of the acetabulum in a Ganz periacetabular osteotomy by finite element analysis. Journal of Orthopaedic Research 31: 472-479 2013
4 Jackson T Watson J LaReau J Domb B Periacetabular osteotomy and arthroscopic labral repair after failed hip arthroscopy due to iatrogenic aggravation of hip dysplasia. Knee Surgery, Sports Traumatology, Arthroscopy June 13 2013 [Epub ahead of print]
5 Perry 2013
6 Ibid
7 Callaghan J Rosenberg A Rubash H The Adult Hip Lippincott-Raven 1998 p.57
8 Perry 2013
9 Davies JW Man’s assumption of the erect posture, its effect on the position of the pelvis. American Journal of Obstetrics and Gynecology 70(5): 1012-1020 1955
10 Perry 2013
11 Ibid
12 Zaltz I How to properly correct and to assess acetabular position: an evidence-based approach. Journal of Pediatric Orthopedics 33(1): S21-S28 2013
13 Ibid
14 Ibid
15 Albers C et al Impingement adversely affects 10-year survivorship after periacetabular osteotomy for DDH. Clinical Orthopaedics and Related Research 471(5): 1602-1614 2013
16 Ibid
17 Perry 2013
18 Vandenbussche E et al Hemispheric cups do not reproduce acetabular rim morphology. Acta Orthopaedica 78(3): 327-332 2007
19 Colvin A Harrast J Harner C Trends in hip arthroscopy. The Journal of Bone and Joint Surgery 94: e23(1-5) 2012
20 Jacobsen S Adult hip dysplasia and osteoarthritis. Acta Orthopaedica 77(324) 2006

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A Different Perspective on Hip Pain

Christine Kent, RNIt is a lot to take in and process that the practice of orthopedic surgery has an inaccurate perspective on the anatomy of the hip. And that the surgeries for femoroacetabular impingement (FAI), developmental dysplasia (DDH), and osteoarthritis of the hip are often based on fallacious imaging studies and erroneous diagnoses.

Yet, that is the place we must start if we are to come to the higher understanding that common degenerative disorders of the hip are preventable and best treated by non-surgical means.

In chronic hip disorders, where is the pain and where, exactly, is the disease located? Patients most often experience pain deep in the groin, which radiates around the hip to the lower back. Surgeons insist the disease is usually focused on the anterior-superior aspect of the labrum and bony acetabulum, while 19th century orthopedists verified that it is almost always located in the soft tissues surrounding the joint.

Working with this conundrum gives valuable insights into the true cause of chronic hip disease, and why surgical treatments so often lead to disastrous long-term outcomes.

Figure2.4 copyFirst we must agree that when standing with a wide-radius lumbar curvature, the pelvis does not exist in the ‘anterior pelvic plane’ of the classic orthopedic paradigm. Rather, in this position the pubic bones are underneath the body like straps of a saddle, and the anterior superior iliac spine is located just above the crease where the abdominal wall meets the thigh. A comparison of the chimpanzee and the human skeleton illustrates this point (Figure 1).

Acetabulum2When the pelvis is fully ‘nutated’, or rotated forward, the arched acetabular roof is perfectly symmetrical from front to back (Figure 2). Just behind the human acetabulum sits the ischial tuberosity (sit bone), which along with the acetabulum, forms the most massive area of the bony pelvis.

cow1This orientation of the arched roof of the hip joint occurs in all other mammals (Figure 3 – cow acetabulum). If the pelvis were not in this position, gravity would cause the acetabular roof to form a shape other than a symmetrical half circle. And indeed, this is what happens when the body is held in chronic ‘counternutation’, with the tailbone tucked under and the pelvis rotated slightly backward.

Acetabulum1The forces of gravity cause re-modeling of bone at what is now the anterior-superior aspect of the acetabulum. In a pelvis that is rotated backward, the load-bearing roof of the joint has moved to the front of the acetabulum. Counternutation of the pelvis causes the femoral head to be held slightly up and out of its socket. Over time, the acetabulum becomes oblong in shape (Figure 4) and its fibrocartilage labrum hypertrophies, or expands, which is the body’s attempt to give better coverage to the joint.

This condition is diagnosed as ‘dysplasia’, for which the highly morbid peri-acetabular osteotomy is often indicated. Imaging studies may show the femoral head being held slightly up and out of its socket, yet most surgeons are completely unaware that the heads move down and medially (toward each other) when the patient climbs off the radiology table and stands upright. If the femoral head is still located slightly up and out of the joint, shortened and contracted ligaments are holding it there.

205Similar radiographic illusions are used to diagnose FAI. Countless surgeries have been performed for ‘pincer’ FAI based on AP radiographs such as Figure 5. The bony protrusion (circled) seen in this x-ray has no correlation with the actual architecture of the acetabular roof. The two-dimensional radiograph, taken at an angle that looks up into the pelvis, projects the acetabular wall laterally, when in fact it is rotated down and medially in the standing body. Pincer impingement, as described by Reinhold Ganz, is a figment of the collective imagination of orthopedic hip surgeons.

Humans have a choice whether to sit, stand, and move with the arched acetabular roof forming either a symmetrical half circle, or a lopsided oval. Contemporary hip surgeries attempt to address the symptoms and not the cause of chronic hip pain.

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Christine Kent, RNAbout the Author –
Christine Kent, RN, is the author of Save Your Hips – Heal Hip Pain Naturally and Avoid Dangerous Orthopedic Surgery (Whole Woman Press, 2013). She is also the author of Saving the Whole Woman, Natural Alternatives to Surgery for Pelvic Organ Prolapse and Urinary Incontinence (2nd ed. Bridgeworks, 2007) as well as producer of seven DVDs. She is CEO of Whole Woman Inc., committed to researching and developing non-surgical alternatives to chronic medical conditions common to women. Her books and DVDs are available at www.wholewoman.com/store.



No way!If you are a young, active person with a medical condition and given a choice between

  1. A surgical procedure with known crippling effects, or
  2. Commit to a comprehensive lifestyle change that would restore you to health,

it would be no contest, right?

Yet, young and old alike are choosing to undergo dangerous and experimental hip surgeries because they have no idea how misconceived and out of control the orthopedics industry has become. Their doctors certainly are not going to tell them, because for generations, orthopedic students have been effectively blinded by a highly biased medical education system.

SurgeryThe orthopedist’s perspective on hip pain and hip disease is confined to a small surgical specialty that has been the subject of a century of erroneous theoretical discourse and increasingly dangerous practice.

The public has been led to believe that new diseases have been recently discovered, which can only be treated surgically. These operations employ advanced fiberoptic and robotic technologies, all of which are based on imaging data that does not accurately reflect the true anatomy of the hip.

These are heavy charges to level against the most powerful field of medicine, yet a sense of urgency is called for in revealing the state of orthopedics today.The reason these issues have not been brought to light sooner is because of a surgical paradigm so carefully crafted that the media have been unable to decipher the convoluted rationale of modern hip surgery.

Orthopedics was not always a surgical specialty. Doctors fought long and hard throughout the 19th century to keep orthopedics a therapeutic and biomechanical practice. These physicians were deeply knowledgeable about chronic diseases of the hip, and their treatments were sound, logical, and successful. But a certain faction was determined to steer the practice in the direction of surgery.

Humanity has always required surgeons. Legs occasionally needed to be amputated, and dead fetuses extracted from the womb. In early times it was only reasonable to call in the town butcher to perform the operation, for who else was more familiar with muscles, ligaments, and bones?

These men could not be called ‘Doctor’ because they were not physicians, so they were called ‘Mister’ instead. Treatment of injuries sustained by soldiers in the Civil War helped blur the lines between doctor and surgeon, and the ways in which certain war injuries were ingeniously treated with gold nails or silver wire impressed both the medical community and the public at large.

Surgery has always been associated with courage, skill, and prestige, yet not all doctors were interested in performing surgery. Those who were became a privileged class of professionals who changed the course of Western medicine. Orthopedics was completely transformed between the 19th and 20th centuries, and no place was this change more dramatic than in how common diseases of the hip were conceptualized, diagnosed, and treated.

How degenerative hip disease was described and understood completely changed from a disorder of soft tissues surrounding the joint, to a disease of the articulating surfaces themselves. Even the name changed from ‘cox arthrosis’, a term used to describe hip pain, to ‘osteoarthritis of the hip’, a phrase referring directly to the bones of the joint.

Hip Joint x-rayThe field of radiology potentiated the practice of surgery on the bones of the hip because only bones were brightly visible on newly discovered x-rays. The surgical perspective shaped the practice of radiology, establishing parameters and protocols that reinforced the operative paradigm. Radiographs were acquired in carefully specified positions so the resulting images would reflect a particular skeletal perspective.

Other imaging technologies were developed, each building on the standard radiologic map of the hip. Today, so-called 3D images represent a grossly inaccurate picture of the true anatomy of the hip joint because they are constructed by software driven by an inaccurate set of assumptions. As a result, diseases are being diagnosed and surgically treated from images that do not reflect reality.

Athletes in their teens and twenties, as well as the elderly, are being subjected to unproven and dangerous operations by a surgical practice that changed the rules of traditional orthopedic medicine many years ago. Many will spend the latter part of their lives confined to wheelchairs. This is an urgent message the public needs to hear.

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Any woman with long-standing prolapse knows that Kegels do nothing to improve the symptoms of rectocele, cystocele, or uterine prolapse.

The only logical reason for Kegels improving symptoms of stress urinary incontinence (losing urine when sneezing, coughing, etc) is that they pull the bladder toward the vagina, thereby increasing the symptoms of cystocele.

Women with significant cystocele rarely experience severe urinary incontinence because the bladder bulge kinks off the urethra, much like a garden hose.

The Kegel PerineometerSo if Kegels do nothing to improve prolapse, why are they still touted year after year, decade after decade, since gynecologist Arnold Kegel and his perineometer made such a sensation in the 1950s?

The answer is because Dr. Kegel, and all of gynecology for that matter, have omitted and denied essential aspects of female anatomy that are crucial to understanding the dynamics of pelvic organ support. Why have they done this? Because gynecology has always been a surgical specialty that views the pelvis in a very limited way. Their conceptual framework of female pelvic anatomy does not include much beyond what they can see from the supine, lithotomy position (lying on your back with feet in stirrups).

To the gynecologist, you have a pelvic “floor” above which the pelvic organs are perched. From this perspective, the vagina acts like a tree trunk, holding the organs over a hole in a soft-tissue “floor” at the base of the torso. Because the vagina is holding the organs up, it must be “strong” and “tight” to prevent prolapse. The gynecologic point of view gives the pelvic surgeon license to perform operations based on faulty anatomic understanding.

In reality, your pelvic “floor” is more like a wall at the back of your body. Human pelvic orientation is not different than that of four-legged animals, a fact pointed out in the gynecologic literature in 1954 by J.W. Davies, M.D. Your pelvic organs are positioned over a truly strong pelvic floor, which are your pubic bones that come together underneath you like straps of a saddle.

Dr. Davies pointed out that if the human pelvis was really rotated backward 90º into a “bowl” shape with a “floor”, the pubic bones would dislocate with every step we took. Not only would it be excruciatingly painful to walk with the pelvis in this position, it would be impossible.

Davies’ research was completely ignored in the gynecologic literature until Dr. Linda Brubaker used his original illustrations to make the same point in her 1996 textbook, The Female Pelvic Floor. Unfortunately, the information had little impact and urogynecology has continued on under an antiquated and erroneous conception of female pelvic anatomy. To do otherwise would render all surgeries for prolapse and incontinence faulty and unsound.

Since the time man-midwifery took over the business of women’s health, knowledge about the female body has been placed solely in the hands of the medical profession. Our own bodies have become so mysterious, and the only major sources of information available to us come from practices based in anatomical misunderstanding.

This is why Whole Woman® has sourced knowledge from orthopedics, pediatrics, physics, the biological sciences, and even traditional dance. There is no understanding pelvic organ support outside the context of the whole body. When was the last time a gynecologist talked to you about the importance of natural breathing in preventing pelvic organ prolapse? You will not find this information anywhere else but at Whole Woman®. Yet, women intuitively know the Whole Woman® work is true, because they live it every day.

When a newborn baby girl comes into the world, her spine and funnel-shaped torso are completely straight. Her three pelvic organs and their channels: urethra/bladder, vagina/uterus, anorectum/sigmoid colon form three long lines, or axes, through this little abdominopelvic space. From the beginning she is raising internal pressures whenever she cries, poops, or is held upright. Yet, she is not in danger or her pelvic organs prolapsing because her respiratory diaphragm (the muscle layer underneath her lungs) and her pelvic diaphragm are made up of the same type and the same amount of muscle tissue, so the pressures simply bounce back and forth between the two sets of muscles.

Once she begins to stand and walk and run, her respiratory diaphragm grows very thick and strong and begins to send powerful bursts of pressure through her torso. These pressures don’t go down willy-nilly, but in a very specific pathway. With every in-breath, intra-abdominal pressure strikes against the inside of the lower abdominal wall. You can test this yourself by placing your hand a couple of inches below your navel and taking little coughs. You can feel the exact place intraabominal pressure strikes first before rebounding against the pelvic diaphragm.

Over the course of sixteen or seventeen years, the female pelvis becomes positioned at right angles to the abdominal wall so that the pelvic “floor” has now become a wall at the back of the body. This is only made possible by profound curvature in the lumbar spine, which is genetically more pronounced in females. Astonishingly, the three pelvic organs have also formed strong right angles away from their channels to become positioned right behind the lower belly. In this way, the pelvic organs are supported by the true bony pelvic floor and the lower belly, just as they are in four-legged animals. It is a profound truth that we are horizontal creatures from the hips down and vertical from the waist up.

Now it is easy to understand that contracting the vagina has nothing to do with pelvic organ support. The organs are carried behind the lower belly, and away from the pelvic outlet at the back of the body. Kegels merely draw the bladder and rectum toward the vagina, in other words, toward the direction of prolapse!

Please don’t think that it’s “bad” to contract those muscles. Strong vaginal contractions lead to orgasm and are wonderful to do in that setting, especially if a penis is supporting the vaginal walls to keep the pelvic organs in their proper positions. It’s just that laying on your back doing sets of Kegels can worsen prolapse symptoms.

Now that you understand more about your anatomy, you can see that any exercise aimed at reversing prolapse must be based in the dynamics of pelvic organ support. This means gravity, the breath, the natural shape of the spine, and the weight of the organs themselves.

So in the video below, I offer The New Kegel, which can be done in a chair, on all-fours, or standing. We are simply increasing the natural dynamics of intraabdominal pressure, and by way of the in-breath and lumbar curvature, moving the organs forward. Optimize the process with Whole Woman® posture by keeping your shoulders down (not back), chest lifted, upper back flat and broad, head pulled up through the back of the neck, and slightly tucking your chin.

Traditionally, women spent hours sitting while doing their work, and female anatomy is designed to move the organs forward even while sitting. However, you must keep a strong lumbar curvature and a relaxed lower belly during the process. Go ahead and sit for hours in front of your computer. Every now and then, throw a few New Kegels in to push your organs further forward.

If we lived in a perfect world, regaining pelvic organ support would be the easiest thing on earth. And you know what? It is.

Click here for The New Kegels video.








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A New Model of Core Stability

One of the things that makes human beings unique in nature is the way in which we manage intraabdominal pressure. Intraabdominal pressure is the force that is created through the torso as the lungs fill with air and the respiratory diaphragm moves downward.

When a cat sits, it leans the weight of its torso onto its front paws, and wraps its tail around its body, creating a stable platform. The reason it does not raise its paws off the ground is because it has not learned to stabilize the significant internal pressures moving through its body in the upright position. Doggies can be trained to lift their paws off the ground while seated, but they can only hold this position momentarily.

Humans developed the ability to utilize intraabdominal pressure to stiffen their torso so they could become stable in the upright seated position. In this way, their voice box became open for speech, and their hands were free to work. The human pelvis did not rotate backward on its axis to be able to sit or stand upright, but stayed in the same position as four-legged animals. Range of motion of the hip joints expanded to include external rotation, providing the tail-less human with a broad base from which to sit. Only by way of a wide-radius lumbar curvature did humans become upright.

The deepest muscles of the abdomen, the psoas and quadratus lumborum, share a common attachment site with the tendinous crura of the respiratory diaphragm. In the human, these muscles are “lordotic”, meaning they pull the lumbar spine forward each time the diaphragm contracts downward on the in-breath.

The pressure created as the diaphragm moves down reverberates through the torso in a very specific pathway. It first strikes the lower abdominal wall, before rebounding backward toward the pelvic wall. The distensibility of the central tendon of the pelvis, or perineal body, allows slight expansion and elastic recoil of the pelvic wall. The degrees to which the abdominal wall and perineum are chronically contracted through sub-optimal posture are directly correlated with the degree anatomic movement of intraabdominal pressure is compromised. Fully lengthened front and back body walls are how intraabdominal pressure is optimally managed in the human female body.

The notion that a therapeutic level of “core stability” of the lumbar spine could be achieved by maintaining the transversus abdomini muscles in constant contraction was put forth by a pair of Australian physiotherapists in 1996.1 The idea was that contraction of these muscles increases lateral tension on the thoracolumbar fascia, thus stabilizing the lumbar spine through an increase in intraabdominal pressure.2

The core stability studies of Hodges and Richardson have never been validated. Yet, the “core strength” movement they spawned so invested physiotherapy that to this day the idea of a stabilizing “core”, made up of the respiratory diaphragm, multifidi, transversus abdomini and pelvic “floor”, remains the major operating principle of the profession.

One of the primary problems with this conceptual framework is that it is an inaccurate representation of the way intraabdominal pressure actually moves through the torso. The “core” model views the respiratory diaphragm in opposition to the pelvic “floor”. Thus, there is an assumed direct relationship between downward descent of the diaphragm and descent of the levator ani. The reality is, the concept of “core” is not based in anatomic fact.

Moreover, the actual dynamics of intraabdominal pressure have been misunderstood by an entire culture of “core strength” enthusiasts. Anatomic movement of the diaphragm, abdominal and pelvic organs, and lumbar spine are optimized when the front and back body walls are lengthened, not shortened. Stability of the lumbar spine, and optimal placement of the pelvic organs, also increase when the torso is stiffened. Stiffening of the torso occurs when intraabdominal pressure is increased against its body walls, a dynamic that takes place when the walls are lengthened, not shortened.

The only way the “core strength” model would work is if we retained the straight-spine, funnel-shaped torso we are born with. In the infant, the pelvic outlet is opposite the respiratory diaphragm, as it is in the quadruped. By late puberty however, the human female pelvis has become positioned at right-angles to the abdominal wall. The pelvic organs and their channels, which once formed long, straight axes through the torso, have now become bi-axial, so that the organs are positioned over the pubic bones and against the lower abdominal wall.

The “core” model is simply irrelevant when considering the anatomy of the human female body. In reality, intraabdominal pressure coming down from the diaphragm strikes the lower belly, not the pelvic “floor.” The pelvic wall is positioned around the corner at the back of the body, and protected from the great majority of intraabdominal pressure.

One cannot speak of “proper posture” without considering how intraabdominal pressure moves through the body, how the pelvic organs are moved into their anatomic positions over the course of childhood, and how any level of chronically holding in the abdominal wall disrupts these natural dynamics.


Notes:

1 Hodges P Richardson C Inefficient muscular stabilization of the lumbar spine associated with low back pain. A motor control evaluation of transversus abdominis. Spine 21(22): 2640-2650 1996

2 Lee D The Pelvic Girdle – An approach to the examination and treatment of the lumbo-pelvic-hip region. Churchill Livingston 1999 p. 60

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“Just Do Yer Kegels”


Leave it to a man – Arnold Kegel to be precise – to come up with the nonsensical notion that contracting the pelvic floor has anything to do with improving symptoms of prolapse or incontinence.

In case you’re just joining in the global Whole Woman paradigm shift, we need to let you in on a little secret: there is no pelvic floor. Go ahead and reach around to your back side for a quick reality check. Yep, the pelvic outlet is at the back, covered by a thin, sinewy wall of muscle. In Hippocrates’ time, the pelvic diaphragm was called the “posterior belly”, which is much closer to the anatomical truth than the modern medical misconception of a pelvic floor.

What is underneath you is the true pelvic floor – the strong pubic bones that come together like straps of a saddle. The upper torso actually rides atop the pelvis like it would an English saddle. The concepts of centaurs and satyrs were based upon deep, intuitive understanding of how the body really is: horizontal from the hips down, and vertical from the waist up.

Kegels are based on the misconception that there is an opening in a soft-tissue “floor” at the bottom of the torso, above which the organs are perched. Therefore, making the opening smaller and tighter will supposedly prevent the organs from falling through. It is simply the wrong concept. The organs are at the front of the body and the “hole” is at the back. Therefore, any exercise aimed at prolapse reduction must reinforce this anatomical reality.

If you pull opposite ends of a handkerchief, simulating lengthening from tailbone to pubic bones, the middle comes together like a pair of elevator doors. This type of closure protects the vagina from surrounding organs pressing into its space, while also making the back body wall better able to rebound intraabdominal pressure.

If you make a purse-string closure in the handkerchief, the middle closes like a round sphincter muscle. In the body, this closure (Kegel) pulls the tailbone closer to the pubic bones. It also pulls the bladder toward the front vaginal wall, and the rectum toward the back vaginal wall. In other words it pulls prolapsed organs in the direction of prolapse! This is why women report worsening symptoms after engaging in programs that attempt to “strengthen” the pelvic floor with Kegels. Chronically contracting the pelvic floor greatly misaligns the musculoskeletal system, leading to back, neck and shoulder pain, hip osteoarthritis, and pelvic organ prolapse.

Just Say No to Kegels!

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Re-Thinking Deep Squats During The Last Weeks of Pregnancy

In their landmark book, The Labor Progress Handbook, Penny Simkin and Ruth Ancheta describe six steps in the progression of labor1:

  1. The cervix moves from a posterior to an anterior position
  2. The cervix ripens or softens
  3. The cervix effaces
  4. The cervix dilates
  5. The fetal head rotates, flexes, and molds
  6. The fetus descends and is born.
fetus within pelvis
Figure 1 – Fetus within pelvic inlet

They explain that when the cervix has not undergone the first three steps of anterior movement, ripening, and effacement, significant dilation rarely occurs. “If this progress is ignored, an incorrect diagnosis of dysfunctional labor may be made before the woman is even in labor!”

Cesarean section for the indication of “obstructed labor” has steadily increased over the past 40 years. Simkin and Ancheta illustrate that failure to progress is often a result of fetal malposition, such as persistent asynclitism or occiput posterior.

“If early contractions are painful and irregular with little or no progress in dilation, it makes sense to consider persistent asynclitism or another unfavorable fetal position, such as occiput posterior. Labor normally begins with the fetal head in asynclitism, (the head is angled so that one of the parietal bones, rather than the vertex, presents at the pelvic inlet). This facilitates passage of the fetal head through the pelvic inlet, and then the head usually shifts into synclitism so that the vertex presents as the head descends further. Sometimes the asynclitism persists and, if so, it can keep the fetus from rotating and descending. Without descent, the head may not be well applied to the cervix and contractions often become irregular and ineffective.”

Maternal positions alter the forces of gravity, and midwives have long known that “having the woman lean forward moves the fetus’s center of gravity forward, which encourages its head to pivot into a more favorable position, leading to more regular, more effective contractions.”

While the major cause of failure to progress is well described, it remains unknown how non-progression ocurrs. How does the fetus get stuck? The anatomic reason for persistent asynclitism has not been fully described by either midwifery or obstetrics. However, biomechanical data from orthopedics and observations by gynecologic surgeons fill gaps in understanding of this very common phenomenon.

In their classic text, Vaginal Surgery2, Nichols and Randall describe how gradual the early stages of labor progression really are:

“Normally, and certainly in the labor of the primipara, at full dilation of the cervix the presenting part does not at that time emerge from the cervix and, for the first time, begin to descend into and through the vagina. Rather, the fully engaged presenting part, almost completely covered by thinned, beginning to dilate cervix, has in all probability occupied the upper third to half of the vagina for 2 weeks or more. As a result, distention of the upper vagina, with accommodation of the engaging vertex or breech, has occurred very gradually, so gradually in fact that the patient may not be aware of the descent taking place until she notices a new awareness of heaviness, low backache, and at times rectal pressure, while at the same time breathing becomes somewhat easier, for ‘lightening’ has occurred.”

Figure 2 – The pelvic “floor”

For the fetal head to enter the pelvic inlet, the top of the sacrum must move up and out of the pelvic interior, into a position known as “counter-nutation”. When the pelvis is in this position, the lumbar spine is flattened. As described above, the fetus moves very slowly through this early progression. This means the maternal pelvis stays in a counternutated position from the time the fetus enters the pelvis, until it is born. While it is often assumed that maternal lumbar curvature increases throughout pregnancy, it was proven in 1976 that the spine actually flattens during the final weeks before birth3. Even if a fully gravid woman is trying to maintain a full lumbar curvature, her spine remains in counternutation.

Figure 2 shows the correct orientation of the pelvis in the standing body, the entrance into the pelvis, and the pelvic diaphragm with anal opening at the back. Toward the end of pregnancy, the cervix, which has been pointing toward the back all these months, must now rotate anteriorly toward the vaginal opening before labor can progress.

Figure 3 – Improper sitting position
in late pregnancy

The most likely reason anterior rotation of the cervix becomes stalled is because the fetal head has moved too deeply into the back of the pelvis. In order for the cervix to rotate forward, the fetal head must move forward and into a more favorable position. This is supported by Simkin and Ancheta, who show that forward-leaning maternal positions help labor to progress after persistent asynclitism.

With this understanding, it becomes obvious that the very worst position a woman in the last weeks of pregnancy can spend time in is a full squat with her knees higher than her hips. The pelvic inlet is fully open at this stage and the fetal head has entered the pelvis. Therefore, gravity simply moves the asynclitic head further into the back of the pelvis where it prevents anterior rotation of the cervix and stalls the progression of labor.

Deep squatting is being advised as preparation of the pelvic “floor” for birth. However, no scientific data exists that the pelvic floor needs special preparation outside of normal physical activity. If the pelvic diaphragm were anything but fully supportive, the sharp angle that it makes as it wraps around the anus would widen, and fecal incontinence would ensue.

The pelvis and pelvic diaphragm have a range of motion that is utilized in many functions, including vaginal childbirth. While pelvic nutation and full lumbar curvature represent the position of pelvic, pelvic organ, and spinal stability, during the last weeks of pregnancy the pelvis takes advantage of its full range of motion by remaining in counternutation as the cervix is prepared for birth. Support the subtle and lengthy early stages of labor progression by keeping sitting positions where the knees are lower than the hips.


Notes:
1 Simkin P Ancheta R The Labor Progress Handbook Wiley-Blackwell 2000

2Nichols D Randall C Vaginal Surgery Williams and Wilkins 1989

3Snijders C et al Change in form of the spine as a consequence of pregnancy. Digest of the 11th International Conference on Medical and Biological Engineering August 1976

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Hysterectomy and the Whole Woman® Posture

When we come into the world as newborn baby girls, our spine is completely straight. Our three pelvic organs and their channels: urethra-bladder, vagina-uterus, rectum-sigmoid colon, form long, straight lines through a funnel-shaped torso.

Only when we begin to stand, walk and run under the forces of gravity do pronounced arches appear in our lower back and bottoms of our feet. By early childhood, the lumbar curve is a fully developed, large-radius arc.

As the lumbar spine is pulled forward with every breath we take, so the pelvic organs are pulled down and forward against the lower abdominal wall. The pelvic outlet is at the back of the body and the pubic bones are positioned front to back underneath like straps of a saddle.

It is the muscular uterus, and the equally muscular and contractile “round ligaments” of the uterus, that work to keep the uterus pulled forward. Because the bladder is connected to the uterus at the level of the cervix, when the uterus pulls forward, it takes the bladder with it. It is important to understand that prolapsed organs have not fallen down, they have fallen back from the lower belly to the outlet at the back of the body. When the uterus is positioned fully forward, or anteverted, the vaginal walls are pulled up taut, providing support to the bladder and rectum.

It is important that every woman understand that the uterus is the hub of a pelvic ring, and connected 360º around the body. Natural dynamics of breathing under the forces gravity either pin the organs into position at the front of the body, or push them backward toward the pelvic outlet, depending upon body alignment, or posture.

The uterus not only helps to hold itself and surrounding organs in place, but it also holds the bony pelvis together from the inside. The pelvis is made up of three bones and six moveable joints. Although unstudied by gynecology or orthopedics, there is much anecdotal evidence that great musculoskeletal change occurs after hysterectomy, especially if the surgery was performed during the reproductive years. The pelvis widens and the rib cage settles very close to the hips. The lumbar curve flattens, while a hump develops at the base of the neck. By age 60, one-third of American women no longer have the “hub of the wheel” and these musculoskeletal changes are very easy to identify in our population.

With these changes comes significant back pain as the lower spine is no longer connected to the muscular, forward pulling uterus. Prolapsed bladder and rectum are inevitable, and the possibility exists for the small intestines to eviscerate through either a closed and everted vagina (vault prolapse), or a vagina that has re-opened at the top due to dehiscence of sutures.

The surgical response to post-hysterectomy cystocele and rectocele is “A&P” repair, with or without mesh. In traditional anterior and posterior repair, front and back vaginal walls are dissected at the midline, and a strip of vagina is removed with the goal of “narrowing” the vaginal opening. The conventional framework is that a narrow “hole” at the bottom of a soft-tissue “floor” is less likely to allow organs to fall through. In reality, the opening is at the back and the organs are positioned at the front of the body.

When the uterus is removed and the vaginal walls “narrowed”, the long, normally flattened vagina becomes like a shallow cave. No longer can it protect itself by flattening down against intraabdominal pressure. Sitting atop the cave are the entire intestines, soft tissue against soft tissue. Just standing and breathing creates a tremendous amount of intraabdominal pressure and it is those pressures that result in epidemic proportions of post-hysterectomy vaginal vault prolapse.

Since its formation in the early part of the 20th century, gynecology has envisioned the orientation and dynamics of the female pelvis incorrectly. In truth, we have a strong, bony pelvic floor that, along with the multi-layered abdominal wall, supports all our pelvic and abdominal organs. This concept is very important for the post-hysterectomy woman to understand. You may not have your uterus, but the top of your back vaginal wall is still connected to your intestines through fascial layers. You can use the weight of your intestines to pull your vaginal walls forward enough so they can flatten against intraabdominal pressure. In this position, they are protected from the pelvic outlet, which is at the back of the body. This is a head-to-toe posture that pulls the abdominal wall up, never in.

Post-hysterectomy women need to understand the true dynamics of pelvic organ support as much as wombed women. The key is whether enough vaginal length has been left to flatten against internal pressures. All vaginal surgery for prolapse further ruins the dynamics of pelvic organ support.

Support the natural shape of your pelvis, as well as the health of your hip joints, with external belts worn lower in front and higher in back. Understand that the lower spine has lost its major internal support structure and begin the Whole Woman postural work slowly and carefully.

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Whole Woman Posture and the Horizontal Spine

~ Still Shouting After All These Years ~

From the beginning of Whole Woman, over a decade ago, I realized that challenging the status quo was going to require a tremendous amount of effort. From the start I called for an end to urogynecology – a practice formed in the late 1970s to take advantage of the huge numbers of women being surgically managed for prolapse and incontinence. I called for a new women’s yoga – one that honored the dynamics of the female pelvis. I pleaded for PT to wake up to the fact that although Kegels are not inherently bad, they are simply the wrong concept in terms of stabilizing and reversing prolapse.

As I brought forth a new description of female pelvic anatomy and function, I knew there would be push-back from gynecologists and physical therapists, whose livelihoods were invested in the conventional paradigm. I knew some percentage of women would not be able to hear my call to self-care and self-responsibility. I discovered that many post-hysterectomy women did not want me to speak candidly about an operation that obliterates the very core of the female body. I received angry letters from Christians, who did not want me to use the word “evolution”, and on and on.

Although the Whole Woman paradigm has been supported and moved forward by scores of thinking women, I was not prepared for how slowly it would be accepted by the female population at large – midwives, postpartum mothers, naturopathic physicians and women in leadership roles. I believe this is due in large part to self-promoting “experts” maligning the Whole Woman posture in favor of old, linear models based on anatomical misconception.

Like the little girl in the fairy tale, I can only continue to shout at the top of my lungs, THE EMPEROR HAS NO CLOTHES!! The truth of the matter is, you have a completely horizontal sacrum, which allows you to stand fully upright by way of a very pronounced lumbar curvature. Your pelvis is positioned just like that of four-legged animals, and the bottom of your spine is horizontal.

This has tremendous bearing on how you think about and relate to your own body. If you imagine that your spine is vertical, then of course it makes sense to draw an imaginary plumb line head-to-toe and try to become as straight as possible within that linearity. However, the reason plumb lines are deeply entrenched in orthopedic reasoning is because orthopedics – and gynecology – and anthropology – have misconstrued the true orientation of the human pelvis for well over a century. This colossal error has meant we all have come of age believing we have a pelvic “floor”, a vertical sacrum, and an abdominal wall that must be pulled in to support the spine.


In truth, the pelvis merely widened and became much more massive on top (arrow), as the hipbones and sit bones shortened. While many qualities make us human, the ability to double extend through the hip and knee allows us fully upright posture.Non-human primates must bend at their hips and knees to avoid banging their femurs into long sit bones that hang down their backside.

Humans developed the ability to straighten at the hip and knee by fully flexing their toes as they walked and ran. When the toes stop flexing completely, as they do in most modern women, the knee has a tendency to slightly bend. Because the knee is coupled with the lower spine, when it bends the lumbar curve flattens. When the lumbar curve flattens, normal range of motion at the shoulders is limited. When the shoulders are limited, the head hangs in front of the body and a hump develops at the base of the neck.

Natural human posture is self-evident. Try this…pull into Whole Woman posture with your back leg extended, like our model at left. It is impossible to hyperextend your upper spine when your shoulders are down, your upper back flat and broad, and your head and neck pulled up throughout the back by slightly tucking your chin. Place one hand on your sacrum. Now bend your back knee slightly and feel what happens – your sacrum drops and your lumbar spine flattens. This is an anatomical coupling that cannot be avoided. When your lumbar spine flattens – even a little bit – your rib cage collapses in and down.

Remember that the fundamental ability to double extend through the hip and knee is a distinctly human quality. Any postural feature that interferes with double extension will eventually cause postural decay. This certainly includes the popular instruction to “anchor your ribs” by pulling them in and down.

Magnetic resonance imaging gives us wonderful insights into the essentially horizontal nature of the human spine, which is located very deep in the center of the body. Long spinous processes jut out behind the actual vertebrae, another reason people are fooled into thinking they have a straight spine.

The myth that the human pelvis rotated backward from the quadrupedal to the biped position is simply a mistake that was made long ago. The deep mystery is why people continue to perpetuate such an unreality.

Having an essentially horizontal spine means we have a wide, stable platform from which to stand and move. Like the model at left, who is standing in Whole Woman posture, the abdominal wall is pulled up, never in. When we try to straighten spinal curvatures based on old, inaccurate theories of biomechanics, we set ourselves up for chronic conditions of the musculoskeletal and pelvic organ support systems. To stay healthy, enjoy your natural curves!


Notes:
Inguinal ligament photo from McMinn and Hutchings. Color Atlas of Human Anatomy. 1977

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