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Danger and Excitement in The Femoral Triangle

Anatomist's Corner By Thomas Myers Illustrations by Andrew Mannie Originally published in Massage & Bodywork magazine, December/January 2003. Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved. When we call an area of the body an endangerment site, we quite properly call attention (based on the healer's principle of "do no harm") to the possibility of causing tissue damage there with heavy-handed work. But the possibility of doing harm is not the same as a certainty. With proper knowledge of exactly what we are doing and where, we can reduce the areas we designate as off limits and open new possibilities of effective treatment. One of these areas is the femoral triangle, known colloquially as the groin. The groin is not an easy area to work, and it must be approached carefully and precisely, But avoiding it makes it difficult to address chronically flexed hips and anteriorly-tilted pelvises, and thus some lower back and sacral problems. In this column, we will define the femoral triangle and lay out the anatomy and the position of the structures within it. We will call attention to the possible endangerment sites, but we want to give equal billing to the intriguing possibilities of working within the "leg pit." For the femoral triangle is exactly that -- the armpit of the leg. The armpit is a vulnerable area where neural and vascular bundles connect the arm to the interior of the thorax. The challenge is to be precise and skillful when we work within this pyramidal space between the ribs and the humerus -- but if we do not work here, how else can we get to subscapularis, serratus and pectoralis minor? The femoral triangle is the equivalent spot on the leg, and it likewise has a neurovascular bundle within it, connecting the leg fascially and viscerally to the abdominal cavity. Besides being viscerally vulnerable, the femoral triangle can also be a very charged area, as it is so close to the pubic bone, and thus to our sexual selves. Clients can often store a lot of emotional resistance and social taboo here, so an extra-careful, sensitive, slow and compassionate approach is definitely called for.

Most four-legged animals keep the hip and knee flexed, at about a right angle, for mechanical advantage and also for protecting the groin where the viscera of the leg joins the viscera of the trunk. An infant often starts out with a milder version of the same cursorial (running) pattern in the leg. A seated adult recapitulates the angles of the quadruped. But only a fully-mature, upright human hangs out for any length of time with the leg fully extended and the groin exposed.

The Fully-Extended Femur

The groin is an essential area for structural work because it often does not fully "open," leading to a host of problems elsewhere. Human development calls for a complete opening of the hip joint to full extension. Like most mammals, we develop in the womb with very flexed hips. In the fetal position, our knees are near our chests. In the course of our first year, we learn to sit and crawl, developing the muscles and joints around the pelvis and lumbar spine. When we finally stand and walk sometime around the end of the first year of life, the hip joint opens fully to where the femur is nearly in line with the spine. Most mammal femurs, in contrast, stay pretty flexed at the hip even into adulthood, protecting the vulnerable groin. Try taking the hind leg of a cat, dog or horse into full hip extension, where their femur lines up with the spine, and they will let you know in no uncertain terms they are not accustomed to this position. The trouble is, the same is true for some humans. As children, a majority of individuals arrive at standing, with the femur still resting in a somewhat flexed position relative to the pelvis. (Our love affair with sitting also contributes to this slightly flexed-hip syndrome.) This "mammalian position" involves a short groin, and the inability of the myofasciae to lengthen can lead to a variety of compensations, including hyperextended knees, tight low back, pelvic floor problems, and even breathing and neck difficulties. Part of being fully human involves having the hip joint fully open. To test whether this is your client's problem, perform the same test you just did with the cat, dog or horse. Have your client lie on his side, knees flexed. Bring the femur passively back toward full extension, in line with the spine. Note when the pelvis begins to go into an anterior tilt, or lumbar hyperextension begins to happen. Although normal human variability prevents me from saying there should be a certain degree for someone to be "normal," do this with 25 clients, and you will soon see some folks cannot get their femur close to the line of the spine without going into swayback.

With your client on his side, passively bring his leg back from the knee.At what point does the pelvis start to tilt anteriorly? Now, have the client actively hold his pelvis in a posterior tilt while you do the same passive movement. If the restriction is primarily muscular, this may improve the incursion considerably through reciprocal inhibition. If the restriction is more fascial, or deeply-held tension, the pelvic movement will occur at about the same place.

Short groin tissues will cause the femur to get linked into the pelvis sooner. Well-stretched tissues will allow the femur to come into line with the trunk or even beyond before the pelvis is affected. Since modern development (because of chairs and strollers, and because we are ignorant of the signs of this incipient problem in our children) often leads to this flexed joint, it becomes part of our job to help clients complete their development by bringing their awareness to the short tissues in front of the hip joint. The femoral triangle is a wonderful access point to these crucial tissues.

Exploring the Femoral Triangle

The femoral triangle is defined by its three edges: the inguinal ligament, the adductor longus muscles and the sartorius. Two of the corners are easy to find: the anterior superior iliac spine (ASIS) and the pubic tubercle are on the side of the pubic bone. The third corner is down the inside of the thigh a few inches from where the femoral triangle blends into the septum, separating the quadriceps and the adductors.

The top two corners of the leg pit are marked by bony landmarks - the pubic tubercle and the anterior superior iliac spine. The lower corner just fades off into the medial intermuscular septum between the quads and the adductors. The sides of the femoral triangle are the sartorius on the outside, the adductor longus on the inside and the inguinal ligament along the top. It is best to be familiar with these structures on yourself before finding them in others. First, sit crosslegged in your underwear. The big muscle with the round tendon that is usually evident and easily palpable in everyone is the adductor longus. (Some of you have been taught this is the gracilis, but it isn't.) Follow this tendon up to the pelvis, and you will be on the pubic bone, quite near the knobby bit of the pubic tubercle. Palpate just in front of the ASIS and lift your knee a bit to your chest. The thin sartorius will pop into your fingers. These two muscles define the femoral triangle, and if you now try exploring between them, you will be able to feel both why this is a charged area and also what kind of important gunk might be hiding here. The palpations we are about to describe are not easily done on yourself, so once you are familiar with your femoral triangle, seek out someone you know well -- a lover, a good friend or a massage buddy -- to get to know someone else's. Have her lie on her back with her knees up. Sit on or stand by the edge of the table, so that her knee is against your side. Reach around and put your palm against the inside of her thigh causing her knee to almost be in your armpit. Her leg is now securely held under your arm, thus she can relax it. Keeping your palm fully against the inside of the thigh (it feels better than just poky fingers), find the adductor longus tendon -- the prominent one from the pubic bone -- and the sartorius tendon from the ASIS. Putting your ring finger just in front of the adductor longus tendon, and using it as a guide, let your fingers drop slowly, sensitively, softly, but definitely into the pocket between the tendons. Your fingers need to be by the edge of the underwear, or even under the edge -- if you are three inches south of her underwear, you aren't going to find what you're looking for, and you thus aren't going to get the results you want. Now the cautions: Don't press on anything that pulses back. The femoral artery is here. My Thai massage practitioner sometimes puts her heel into my groin to stretch my leg, temporarily occluding the artery. Though the flush of blood when she lets go feels good, I personally would not want to do this maneuver with a sedentary, obese, meat-eating Westerner who may have a tendency toward abdominal aneurism. The second caution is to be careful of the lymph nodes and tissue that inhabit this area. The lymph tissue hangs out here in the femoral triangle, draining off fluid from the genitals and preventing any poisons in the leg from getting into the trunk. The kind of work we are describing is contraindicated for anyone with lymphedema, and general caution and seeking direct feedback from your client is always called for. I like maintaining eye contact with the client for this work. A third caution is that with a male, you are awfully close to the family jewels. I remember Ida Rolf, when going for this area in one young man, asked him to "move his moveables." You can use your own judgment here, but most men I know would rather move themselves out of the way than have a bit of scrotum between your fingers and his muscle. From this point, use your ring finger against the prominent adductor tendon as a guide, and drop into the femoral triangle. Gently straighten your fingers, and you will find the pubic tubercle, a hard bit of bone just inside and above the tendon. Ask your client to lift her knee toward the opposite shoulder. As soon as this movement is initiated, the pectineus will pop against your fingers.

The lesser trochanter lies on the medial and posterior part of the crook of the femur. Letting your fingers sink down and back and out toward the outer hip is a good way to gently contact the lesser trochanter. The pectineus is a short hip flexor and adductor that runs from the lesser trochanter and just below to the pubic bone. That is why the movement is a combination of hip flexion and adduction. Pectineus is often one of the culprits in an anterior-tilt pelvis. Having positively identified it, you can do a gentle pin-and-stretch by having your client extend the leg out from under your arm along the table. Have her push the heel out while she keeps her lower back on the table -- those last few inches when the heel lengthens away from the hip are when the stretch really occurs. Now curl your fingers along the pectineus toward the inside of the femur. On some (clear-tissued) clients you will be able to feel the lesser trochanter on the inside of the femur. Don't force the issue -- some clients have tight tissue there, and you will not be able to access it. But if you can reach it, you can use your fingertips to clear the accumulated, glommy stuff around this attachment, using the client's movement and their verbal and non-verbal feedback. Give her a moment to rest, then come back into the pocket. Avoiding the artery (and moving immediately if you get any tingly nerve sensations), move laterally and a little headward in the space. By having your client flex, you will be able to identify the psoas tendon (it feels like a greasy clothesline jumping into your fingers) and even more laterally, right up next to the sartorius, the softer muscle of the iliacus. The iliacus will respond to a similar pin-and-stretch technique when your client runs her heel down the table and slowly draws it back up.1

Increasing Body Awareness

Some of our work is the definite and skilled lengthening of myofascial tissues and the relief of trigger points. But because so many people have reduced awareness in this area, a lot of our work is simply to recreate somatic remembering, breaking the sensori-motor amnesia and filling in body image.

The usual placement within the femoral triangle is the pectineus on the medial side and the artery (part of the neurovascular bundle) just outside pectineus. Outside the artery, but still medial to the sartorius, is the strong tendon of the psoas and the softer meat of the iliacus. Even exploring this area -- again, gently -- can have a salutary effect by bringing the area back into the sensori-motor loop. After such an exploration, whether you think you did anything significant or not, have your client stand up to see if the pelvis is more mobile, especially in the hip extension dimension. Or, have her lie on her side and perform the passive extension test we described earlier to see if there is more free and easy excursion. The femoral triangle is an essential piece of human structural anatomy, and as long as we respect both psychological and physiological limits with our clients, we can help them reoccupy this area so the regions above can lift, lengthen and breathe more freely. Thomas Myers, Certified Advanced Rolfer, LMT, NCTMB, studied directly with Drs. Ida Rolf and Moshe Feldenkrais, and has practiced integrative bodywork for more than 25 years in a variety of cultural and clinical settings. Myers directs Kinesis, Inc., which develops and runs training courses internationally for manual and movement therapists. He served as a founding member of the NCBTMB, and as chair of the Rolf Institute's anatomy faculty. His articles have appeared in a number of magazines, and his book on myofascial continuities, Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists, was published in 2001 by Harcourt Brace. Myers retains a strong interest in perinatal and developmental issues around movement. His practice in Boston combines structural integration, physiological rhythmic sensitivity and movement. He lives, writes and sails on the coast of Maine. References 1. There is not much you can do with the psoas at this level. We have described the abdominal approach to the psoas in a four-part series in this column in Massage & Bodywork magazine (Feb./Mar. 2001-Aug./Sept. 2001).