Diaphragmatic pain- treatment and prevention

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As the diaphramatic pain blog got a fair amount of interest in terms of people looking at it, I re-read it and obviously there is a lot of information about what is happening and why things are hurting, but not so much about how to stop it happening or how to treat the pain.

As alluded to by one of the comments I have been in touch with a couple of people and suggested some stretches, which seems to have stopped the symptoms. I basically sat down and worked out some things which would stretch out the tissues mentioned.

The general key when stretching out psoas/iliacus/abdominals is that you don't just sit there and stretch out one portion of the fibres. Move around within the stretch and get into the different fibres of the muscles. They don't just work in one plane, and have a multitude of minor variation of angles which it is beneficial to stretch into.

Here are a couple of pics of the stretch cycle that I tend to do before a run/race to warm up the torso ready for the miles that lie ahead. These are a series that stretch one hip flexor, you then have to do it all in a mirror image to get to the other.

Make sure the back knee doesn't touch the ground, and look UP to the hand. Move back and forth, into and around the stretch. Apologies for the non-level shot, but Lynne didnt think she'd get me in the frame.

Now look at the other hand, again, the back knee doesn't touch the ground. Move around in the stretch, feel the different fibres of muscles and breathe into them. Don't count the seconds. Do it so that it feels right.

Last one, stretch out over the top, this is stretching the same area as the last 2 stretches, but puts the enphasis on other parts of the tissue and fascia. Again, breathe into it. To stretch the other Hip flexor do it all again but starting with the other leg forward to begin with.

You can follow these if you like, or make up your own, I find they work. If they don't work for you, find something that does.

Another point that is worth making is that if the psoas or iliacus has become chronically shortened through overuse/abuse/misuse, it may be that just stretching might not be enough to loosen the structures out enough to be able to run painfree (hopefully it will be, but maybe not). In that case, all is not lost. It is a treatable condition, and there are a number of things that we might be able to help out with - involving assisted stretching, muscle facilitation and Soft Tissue Release, (much like the well vaunted and much publicised Active Release Therapy- its the same thing, just under a different - and I believe patented- name).

Obviously every situation is different, and each client is individual, but if you do have an issue with this and want to get it looked at to see if we can help you out, please do drop us a line, Lynne or I would be glad to help. (I've had it and self-treated it, and Lynne has treated me and knows what its all about - psoas, iliacus and diaphragmatic release are underused by a lot of soft tissue therapists, but having come to realise just how important they are, we try to implement it in our treatments as much as possible).

Diaphragmatic pain while running

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I have mentioned pain in my diaphragm when running in a couple of blogs recently. I used to get it a bit when I was starting out, it put me off running for a while, and then I went back and hoped it wouldn't hurt. Sometimes it would, sometimes it wouldn't. I never really knew what it was, and didn't think about it until recently when I started to get the same pain in races, stretching out on down hills, or just running on the flat.
Funnily enough, it never really happened when I was running uphill.

So I went about trying to workout what it was that was hurting.
The area that was most in pain was just under the xiphoid process (the bottom of the central part of the rib cage), to the right of centre. Somewhat contrary to common sense I tend to start poking around things that hurt to see if I can make it hurt more, generate a response and see if I can find trigger points - even when I'm running.

After this happened a couple of times in races, and running around with my hand jammed into my solar plexus, racing while trying to work out what hurts is a little detrimental to your final placing - but is a good way of working out what it is that actually is causing the pain.
I worked out that it was the diaphragm that was hurting... it has an attachment to the inner surface of the lower 6 ribs and to the xiphoid process. As I poked around, I could feel that the pain continued around the inside of the ribs, left and right, but it was mostly painful right under the xiphoid process.

I also noticed that as I was running, I felt more free when my body turned in one direction (twisting at the waist), than in the other. Hmmm. Rotation around the spine was easy in one direction, but restricted in another.
Interestingly, the diaphragm attaches posteriorly (at the back) on the upper 2 or 3 Lumbar vertabrae.

Following along a logical trail, there must be something else that is causing this pain - to hammer home a point, I was pretty sure that this pain in the diaphragm was the smoke, the symptom of something not being quite right, and the fire - the cause was somewhere else.

Working Anterior to Posterior, what muscles could possibly be causing this pain?
Directly attaching to the cartiledge of the lower 6 ribs is the Transverse Abdominus, favourite of Pilates instructors, and a muscle that compresses the abdominal contents,
Internal Obliques also attach to the bottom 3 ribs AND the abdominal aponeurosis (fascia)
Rectus Abdominus attaches to the xiphoid process and 5-7 ribs
External Obliques attach to the lower 8 ribs.

A very rough idea of whats going on. Black is External obliques, Green is internal obliques, Blue is Rectus Abdominus, and red is obviously the pain. (this is not an exact representation of origins and insertions, more to give an idea of where the tissues are and which direction the fibres go in).

Wow. All the flexing and rotating muscles of the front of your body, all attaching to pretty much the same place. Fascially they are all very much connected. If any one of them is slightly off, or is crossbridged to another by collagen, or is damaged, then its going to upset the whole lot. Once that happens, because they fascially connect together and are fascially connected to the diaphragm, guess what happens.
Yes, they will affect the breathing.

slightly difficult to draw on a person

After a bit of abdominal self massage I worked out that although they were a little tender, they were not spasming, and they didn't seem to be eliciting the pain that I was feeling in the diaphragm. So the obvious has been ruled out. What other structures are associated with the same attachment points as the diaphragm?
Well, posteriorly, psoas attaches to the bodies and transverse processes of L1-L5, lower down it shares an attachment with iliacus. Both are major hip flexors, and have a lot to do with running. Both are often neglected when it comes to massage, and psoas is a muscle that is fascially connected to the diaphragm.
Hmmm. Thats a possibility.
The way to test this is to stretch out before a race and see what happens.

Interestingly, if you go ahead and really stretch out the psoas and the iliacus, there is no way you can stretch them out with out also stretching the main abdominal group which I have also been talking about. By working through one muscle group, the other is automatically worked as well.

I have been working specifically on hip flexor flexibility for the past couple of weeks now, including stretching before races, and I haven't had any of the pain which bugged me in past races. I'm not going to come out and say that it was specifically psoas, or it was specifically iliacus, restraining psoas and making the diaphragm spasm, or it was specifically the abdominals and I'm going to refrain from making a statement like that for good reason.

All these muscles are fascially connected, the only reason they have different names is because someone went around arbitrarily dissecting and naming things, actively disgarding the fascia as they did so. I suspect it is something to do with an imbalance in the muscles and fascia somewhere, perhaps some collagen binding between psoas and iliacus, and aggravated by weak abdominal muscles. However, the answer seems to have been to stretch out the muscles and fascia associated with the motion of flexing of the hip - and so far, that answer has been vindicated.

As a minor note to this, from my visit to an Osteopath recently, it seems that my sacrum was wonky - which may well have contributed to the feeling of freedom on one side of my body, and stiffness on the other. Muscle, bone, and fascia are all linked and connected and the more I learn, the less physical distinctions I seem to be making.

Yes, I know they are only drawn on, but still.... grrrr.