Cadenas miofasciales: Línea Posterior Superficial. Parte 1.

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Actualmente, sabemos que existe una completa conexión entre todas las estructuras del cuerpo humano. Por lo que veo interesante hablar de las diferentes cadenas musculares conectadas entre sí a través de tejido conectivo (Tejido conectivo). Thomas W. Myers es uno de los autores más conocidos y actualizados al respecto, y proporciona gran conocimiento de la función de la fascia, así como de sus implicaciones y funciones en nuestro cuerpo.

Esta es la primera parte sobre la explicación de la Línea Superficial Posterior (LPS) según este autor, la cual se dividirá en dos partes para intentar que sea una lectura breve pero consisa y clara, ya que de esta forma será más comodo para el lector. Posteriormente se irán desarrollando las demás cadenas musculares en el orden apropiado.

La LPS conecta y protege la totalidad de la cara posterior del cuerpo, como si de un caparazón se tratase. Esta línea parte del pie hasta la parte superior de la cabeza en dos secciones: desde los pies hasta las rodillas y desde las rodillas hasta la frente.

ESTA LÍNEA TIENE 2 FUNCIONES PRINCIPALMENTE 

1. Función postural

  • Sostener el cuerpo en extensión vertical completa y contrarrestar la tendencia a la flexión es la principal función, por lo que esta línea está expuesta a una gran demanda.
  • Esta línea miofascial debe contar con una musculatura con mayor proporción de fibras musculares de contracción lenta.
  • También debe contar con bandas y láminas extrafuertes en la sección fascial, como el tendón de Aquiles, los músculos isquiosurales, el ligamento sacrotuberoso, la fascia toracolumbar, el erector de la columna y la cresta occipital.

2. Función de movimiento

  • La función general de movimiento es generar la extensión y la hiperextensión, a excepción de la flexión de las rodillas. Todo esto acurre a medida que el niño alcanza la estabilidad en cada una de las etapas de desarrollo que llevan a posición erguida.

CONSIDERACIONES NECESARIAS

  1. Lo más importante a tener en cuenta en esta y cualquier línea anatómica es que el esfuerzo, la tensión, el traumatismo y el movimiento tienden a transmitirse a toda su estructura a lo largo de estas líneas fasciales de comunicación.
  2. Esta línea interviene fundamentalmente en la postura y el movimiento en el plano sagital, ya sea limitando el movimiento hacia delante (flexión) o, en caso de disfunción, exagerando o manteniendo un excesivo movimiento hacia atrás (extensión).
  3. Existen dos líneas, una a la derecha y otra a la izquierda, con lo que los desequilibrios entre ambas líneas deben vigilarse y corregirse en caso necesario junto con los patrones bilaterales de restricción que afecten a esta línea.

PATRONES DE COMPENSACIÓN POSTURAL

Algunos de los patrones de compensación postural relacionados con la LSP son: La limitación de la dorsiflexión del tobillo /  La hiperextensión de la rodilla / La riguidez de los músculos isquiosurales / El desplazamiento anterior de la pelvis / La nutación sacra / La lordosis / El ensanchamiento durante la flexión torácica / La restricción suboccipital que conduce a  hiperextensión de la columna cervical superior / El desplazamiento anterior o la rotación del occipucio sobre el atlas / Descoordinación entre los movimientos oculares y espinales.

PARADAS ÓSEAS DE ESTA LÍNEA POSTERIOR SUPERFICIAL

Cara plantar de las falanges distales de los dedos de los pies / Calcáneo / Cóndilos femorales / Tuberosidad isquiática / Sacro / Cresta occipital / Arco superciliar del hueso frontal (zona de la frente).

VÍAS MIOFASCIALES

Fascia plantar / Gastrocnemio / Tendón de Aquiles / Músculos isquiosurales / Ligamento sacrotuberoso / Fascia toracolumbar / Músculo erector de la columna / Galea aponeurótica / Fascia epicraneal.

COMENCEMOS A DESCRIBIR DESDE LOS PIES HASTA LAS RODILLAS

Figura 1. Vías Anatómicas.
  1. Desde los dedos hasta el talón

  • La primera vía recorre la cara inferior del pie e incluye la fascia plantar y los tendones y músculos de los flexores cortos de los dedos, que tienen su origen en el pie.
  • Estas 5 bandas se unen en una única aponeurosis, que corre hacia la zona anterior del hueso que forma el talón.
  • La fascia plantar recoge una sexta rama adicional e importante de la base del 5º metatarsiano, la banda lateral, que se une a la LPS en el borde externo del calcáneo
  • Estas fascias, y los músculos asociados que traccionan desde el pie, forman una cuerda de arco que ayuda a aproximar los dos extremos y de esta forma mantiene el talón y las cabezas de los 5 metatarsianos en una adecuada relación.
  • El ligamento plantar largo y el ligamento calcáneonavicular plantar también forman cuerdas más cortas y más resistentes en un plano más profundo en el tarso del pie.

2. Fascia plantar

  • Esta suele ser una fuente de problemas que se trasmiten en sentido ascendente a lo largo del resto de la línea. La limitación suele relacionarse con los músculos isquiosurales del muslo, la lordosis lumbar y la hiperextensión persistente de los músculos cervicales superiores, por lo que cualquier método que ayude a su liberación se comunicará a los tejidos superiores.
  • Podríamos utilizar las manos, incluyendo los nudillos y estiramientos bastante fuertes en esta fascia densa, aunque cabe la posibilidad de utilizar una pelota de golf o tenis, de este modo se puede realizar en casa sin ayuda. Cualquier método que ayude a su liberación se comunicará a los tejidos superiores, aunque en ocasiones la ayuda manual puede ser de mayor utilidad.

Comparar las regiones interna y externa del pie de su paciente. Aunque la cara externa del pie (base del quinto ligamento calcaneonavicular plantar dedo hasta el talón) es siempre más corta que la región interna (desde la base del primer dedo hasta el talón), existe una proporción equilibrada normal.

  1. Si la región interna del pie es proporcionalmente corta, el pie suele estar ligeramente elevado en la superficie medial (como en supinación o inversión) y parece curvarse hacia el primer dedo en un patrón de «mano ahuecada», como si una mano ligeramente ahuecada se apoyara en una mesa con la palma hacia abajo. En estos casos, es el borde medial de la fascia plantar lo que es necesario elongar.
  2. Si es la región externa del pie la que está acortada, si el quinto dedo está retraído o la base del quinto metatarsiano está traccionada hacia el talón o bien la región externa del talón parece proyectada hacia delante, en ese caso es necesario elongar el borde externo de la fascia plantar, especialmente la banda lateral. Este patrón acompaña a menudo a un arco interno débil y a la carga del peso sobre la parte interna del pie, aunque también puede presentarse en ausencia de pie plano.
Figura 2. Fuente Vias Anatómicas. La aponeurosis plantar forma un <<trampolín» bajo los arcos — un arco elástico entre cada punto de contacto: el talón, la abeza del primer metatarsiano y la cabeza del quinto metatarsia

Incluso en un pie relativamente equilibrado, la superficie plantar suele beneficiarse de técnicas reactivadoras que aumenten su flexibilidad y comunicación, especialmente en una cultura urbana como la nuestra, en la que los pies se mantienen confinados en prisiones de cuero durante todo el día.

Un abordaje sistemático de los tejidos plantares consiste en la elongación de las zonas situadas entre cada uno de los puntos que sostienen los arcos: el talón, la cabeza del primer metatarsiano y la cabeza del quinto metatarso

 

 

 

3. Desde el talón hasta la rodilla

Figura 3. Fuente web. Músculatura posterior desde el talón a la rodilla.

Las fascias no se insertan simplemente en el calcáneo y se detienen, sino que en realidad se insertan en la cubierta colágena del calcáneo, el periostio, que rodea al hueso a modo de envoltura plástica resistente. De este modo, podemos ver que la fascia plantar se continúa, por tanto, con cualquier otra estructura que se inserte en el periostio. Si seguimos el periostio alrededor del calcáneo, especialmente por debajo de este hasta la superficie posterior del talón, nos encontraremos al inicio del siguiente tramo que comienza con el tendón de Aquiles. Dado que el tendón de Aquiles debe soportar mucha tensión, se inserta no sólo en el periostio, sino también en la red de colágeno del propio hueso calcáneo, de la misma manera que un árbol echa raíces en la tierra. Una vez que deja atrás el calcáneo y su periostio, nuestro tren asciende, ensanchándose y aplanándose a medida que avanza.

Tres estructuras miofasciales  aprovechan el tendón de Aquiles: el sóleo en el plano profundo, el gastrocnemio en el plano superficial y el plantar en el medio.

4. Descarrilamiento o desvio miofascial

  • Siguiendo la vía del gastrocnemio en la LPS, llegamos al primero de los muchos desvíos de las reglas de las vías anatómicas, a las que Meyers denomina «descarrilamientos». Los descarrilamientos son las excepciones a las reglas de las vías anatómicas. Relación de las cabezas del gastrocnemio con los tendones de los músculos isquiotibiales en el hueco poplíteo de la región posterior de la rodilla. En un descarrilamiento, las vías anatómicas funcionan, pero sólo en determinadas circunstancias.
  • Para entender esta primera e importante excepción, es necesario observar con atención la superficie dispuesta entre las dos cabezas del gastrocnemio y los tendones de los tres músculos isquiosurales.
Figura 4. Vias Anátomicas. Cuando se flexiona la rodilla, la miofascia del muslo y la miofascia de la pierna funcionan de forma independiente (A). Cuando la rodilla se estira, estas miofasciasse funden en una unidad funcional conectada (B), como las manos entrelazadas de un par de trapecistas (C). Esta disposición recuerda a un nudo de rizo; capaz de actuar como un nudo apretado, pero que puede aflojarse fácilmente (A y D).
  • Si bien por las reglas más estrictas de las vías anatómicas estos constituyen una continuidad miofascial, sólo funcionan como tal cuando la rodilla está extendida. Las cabezas del gastrocnemio ascienden alrededor de los tendones de los isquiosurales para insertarse en la región superior de los cóndilos femorales. Los músculos isquiosurales descienden y rodean al gastrocnemio para insertarse en la tibia y el peroné.
  • Sin embargo, cuando se produce la extensión de la rodilla, los cóndilos femorales vuelven a poner en contacto estas dos miofascias, tensando el conjunto, enlazando estas estructuras entre sí y haciendo que funcionen juntas casi como si fueran dos pares de manos agarradas por las muñecas.
  • Esto explica el porqué supone un menor esfuerzo recoger las llaves del suelo doblando las rodillas que manteniéndolas extendidas. Una flexión muy leve de las rodillas es suficiente para permitir un notable aumento de la inclinación hacia delante en la columna y las caderas.

5. Liberación miofascial de los músculos isquiosurales distales y gastrocnemios proximales

  • La superficie dispuesta entre las cabezas del gastrocnemio y  los músculos isquiosurales puede enrollarse; generalmente el resultado no es una rodilla flexionada, sino una tibia que parece colocarse detrás del fémur en una vista lateral.
  • Esta técnica exige la adecuada localización del dedo para evitarle dolor al paciente.
  • Figura 5.  Vías Anatómicas. Vista superficial de la musculatura posterior del muslo.

    Indique al paciente que se acueste en decúbito prono, con una rodilla doblada unos 90º. Sujete ese pie con su esternón o su hombro, de forma que los isquiosurales puedan relajarse momentáneamente. Con las palmas mirando hacia un lado, introduzca sus dedos en los músculos isquiosurales de la región posterior de la rodilla, entre estos tendones (dos en la cara interna y uno en la cara externa) hasta llegar a las cabezas del gastrocnemio. Asegúrese de arrastrar a la vez algo de piel y mantener los dedos moviéndose por fuera contra los tendones de los isquiosurales para evitar presionar la delicada zona en el medio del hueco poplíteo.

  • Esta técnica no debería provocar ningún dolor neurógeno ni irradiación. Permita que el paciente retome el control de su pierna y, a continuación, retire el apoyo. Los tendones de los isquiosurales se evidenciarán de repente cuando se tensen, por lo que debe mantener sus dedos en posición.
  • Indique al paciente que baje lentamente la pierna hasta la mesa (la estire) al tiempo que usted realiza un lento movimiento ascendente en el interior de los tendones de los isquiosurales (básicamente usted sólo debe mantener la posición mientras el paciente hace el trabajo).
  • De esta manera, el paciente estará elongando tanto los músculos isquiosurales como el gastrocnemio en contracción excéntrica, liberando sus extremos distales uno de otro. Cuando se realiza adecuadamente, el resultado será un desplazamiento anterior de la tibia bajo el fémur.

En la próxima entrada continuaremos con esta Línea superficial posterior desde la rodilla hasta el cuero cabelludo.

BIBLIOGRAFÍA

  1. Myers, T. W. (2014). Vías anatómicas. Meridianos miofasciales para terapeutas manuales y del movimiento. Elsevier España.

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