How the Liver Impacts Pelvic Floor Function
In this episode of the Unreal Results podcast, I unpack the anatomical and pressure-based relationships between the liver, abdominal cavity, and pelvic floor through both a clinical case study and a deep dive into visceral anatomy. I share how restoring liver mobility changed a client’s stress incontinence, core function, breathing mechanics, and lower body mobility. You’ll also hear why understanding pressure gradients and visceral relationships can completely shift the way you assess and treat the body.
In This Episode, You’ll Hear:
How pelvic floor dysfunction is influenced by ribcage position, breathing mechanics, and abdominal pressure
A detailed breakdown of the liver’s anatomical connections to the diaphragm, abdominal wall, bladder, and pelvic floor
How visceral dysfunction can alter hip rotation, core control, and breathing mechanics
Practical ways to assess objective orthopedic changes when treating visceral or pelvic complaints
If you’ve been treating pelvic floor dysfunction, core instability, or movement limitations without considering the visceral system, this episode may completely change the way you think about human movement and function.
Resources & Links Mentioned In This Episode:
Ep. 58: The Whole Organism Approach w/ Nicole Cozean
Ep. 150: A Clinical Case Study in Sacral Pain & Index of Suspicion
Fit + Fueled Life Podcast: Ep. 334 - What Your Injuries Are Trying to Tell You After 40 (& Why You’re Not Healing)
Pelvic PT Rising Podcast - Beyond The Obvious: An Interview with Anna Hartman
Learn the LTAP® In-Person in one of my upcoming courses
Considering the viscera as a source of musculoskeletal pain and dysfunction is a great way to ensure a more true whole body approach to care, however it can be a bit overwhelming on where to start, which is exactly why I created the Visceral Referral Cheat Sheet. This FREE download will help you to learn the most common visceral referral patterns affecting the musculoskeletal system. Download it at www.unrealresultspod.com
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Anna Hartman: Hey there, and welcome. I'm Anna Hartman and this is Unreal Results, a podcast where I help you get better outcomes and gain the confidence that you can help anyone, even the most complex cases. Join me as I teach about the influence of the visceral organs and the nervous system on movement, pain, and injuries, all while shifting the paradigm of what whole body assessment and treatment really looks like.
I'm glad you're here. Let's dive in.
Hello, hello. Welcome to another episode of the "Unreal Results" podcast. Um, take two. Uh, yesterday I tried to record this episode and, um, it was going pretty good actually, but then a client came over, um, and, uh, I had to pause it, and I was like, "Oh yeah, I'll come back to it after he leaves," but I'm like, "No, I won't."
So instead of, instead of, like, having part one and part two, um, I was like, "You know what? I'll just take that as a sign as it sucked and start again." And so here we are. But, uh, it's been a few weeks since I did a podcast episode. I last left you, uh, the end of April before the, um, Wednesday before the, um, annual MovementRev Mentorship Seminar weekend and, um, it went so great.
Um, we had nine participants, um, and it was just a lot of fun. I really enjoyed the three days with them. Um, did a beach fire and, like, oh, the weather had been so good in San Diego, and then May hit and May Gray came and it was very cold. Um, but still had fun. Still always fun to be at the beach fire.
Though it was a little windy, and nowadays no, like, wood fires are allowed in that area of San Diego beaches, so it's a propane fi- uh, fire and it kept on... The wind kept blowing it out, which is, like, so frustrating. So we have to like, kept on having to relight it, which is, you know, it is what it is. But it's just like, yeah, not ideal.
This makes me miss a beach fire. Besides too, like, like a, a wood fire, like this, uh, uh, it just... I miss the smell. Which is funny because for a while the smell of burning wood, um, would be quite triggering for me because my house burned down in college, and so, like, that smell, that campfire smell, though I loved it growing up, for...
There was a little while there after the house burned down that that campfire sm- smell was just kinda triggering. But we're over that, and now I love it again, and it's sad to go do a beach fire and not be able to do that. So anyways, um, it was a good weekend. We, um, I beta tested the LTAP level three is what I was calling it now, um, then, um, which is basically we explored the contents, right?
So I always talk about this relationship between the container, which is the hard frame, the musculoskeletal system, and the contents, which are the visceral organs. And so we explored the contents, the visceral organs, in a assessment and treatment from more of a movement approach, and, um, it was really great.
Um, we got a little bit more detailed with where the organs were, how they attach to the hard frame, where the s- ligaments are that attach to each other, and the diaphragm, and the, um, spine, ribs, pelvis. And then we explored movement through those joints, so visceral skeletal joints and then visceral, visceral joints.
So, uh, the joints, the movement between the organs, and then the movement between the organs and the r- and the hard frame, and, um, how we could get really specific with our cues or our movements, um, to really isolate different parts of the ligaments or movement of the organ itself. And, uh, man, it was fun.
And I really, I really enjoyed it. Like, at the end of the day, you've heard me say this a lot, I love movement. Um, and I always like to take everything I ba- I learn from a manual therapy standpoint and, like, think about how I can achieve it through movement and movement in my own body, but then also assisting movement or using movement as a intervention tool.
And so it was really fun. And, and the, the... I'd say the most difficult part of the week, of that experience for the participants, but then also me as the teacher, is there is not one way to do things in the world of movement. There is not a perfect exercise to pick for, like, each... You know, like, if we're talking about the liver, like, there's not a perfect exercise to pick for the triangular ligament, or the falciform ligament, or the, um, Glisson's capsule or whatever.
Like, basically, you can pick any movement, and how you cue it or how you even observe someone going through the movement gives you more insight on the relationship between the organ and the hard frame, the relationship between each organ itself. And so therefore, it means that there's just a lot of potential exercises that you could do.
And so I think that was the hardest part for me is- How do you teach this concept of embodied movement in the organs or movement via organ embodiment and make it really precise and specific? But also, how do you teach the critical thinking of it versus the just do this exercise for this thing? And, um, um, I, I think the experience over the three days, like, was great and really came together.
Um, and really, I really captured what I was trying to intend to capture. And a little bit of it too was getting, letting them see the, um, critical thinking process or, like, the creative process that I go through when I'm thinking about organs in this way. So, um, I look forward to teaching it again one day.
Um, but, uh, yeah, for the people that are here, thank you for joining me. It was my pleasure, and I hope you got a lot out of it. Um,
so that was the beginning of the month, and then, and then, like, I was exhausted from that, and then I had totally forgotten I had a trip to New York City for my business mastermind, um, group that I'm, I'm in, um, with Jill Fit. Um, and that was great. That was, uh, right after the, um, weekend seminar. And so, um, I was leaving on Tuesday, so on Wednesday I had to get, like, all my Navy guys in on, um, Monday.
And, um, so I just went from, um, a big weekend of teaching and being on the whole time to then, like, no rest right after, like, just, just powered through. New York was awesome. Um, and then when I got home from New York, I totally crashed, and still kind of riding that tired wave. But, um, feeling better and better and, um, got a lot of good rest in.
Um, and then within those weeks, I also managed to get in two podcast episodes where I was the guest. So, uh, if you're on my email list, you've already saw these, um, or maybe on social media you saw these. But I was a guest on Tina Haupert's podcast called Fit and Fueled. We talked about how, um, visceral- issues come up fr- as musculoskeletal pain, um, especially talking about, um, women and pain they're feeling in, uh, like the perimenopause midlife era.
And then, um, I was also a guest on the, um, Pelvic PT Rising podcast with Nicole Cozean and that was such a great interview. I swear Nicole and I could talk for days, and, um, every time we get together and talk, whether it's in person or just on a podcast, like we just really enjoy talking to each other and really see the body and, um, our role as rehab clinicians, um, similarly.
And so, um, it's fun. It's fun to talk, and I hope you gave that a listen. I'll make sure Joe, um, links those podcasts in the show notes, um, for you. But, um, and also I'll have him link the podcast episode here on the Unreal Results podcast that I did with Nicole a few years back too, um, just so you can have your fill of me, me and Nicole chatting.
And actually, it was a little bit of that chat with Nicole that ins- is kind of my inspiration for this, uh, episode today, along with a case, um, that I had, but it's, it's, it's about, um, some more like pelvic floor, pelvic pain, pelvic dysfunction, um, case. You know, and again, I'll have Joe link it in the show notes, but a few podcasts ago, I shared about, um, technically a pelvic pain, um, case with one of my Navy guys.
Um, so you got to see a little bit of my thought process with that and, you know, that was like a little bit mind-blowing because, um, he, we got him results so fast in a situation where I really thought based on his functional limitations and complaints, and I thought for sure I'd have to send him to a specialist like a pelvic floor physical therapist or something like that, or maybe even urologist and, um, wow, didn't need to at all.
He had great results from us just listening to the body, following the LTAP, directing me where to treat, doing some real specific manual therapy and treatment, um, in the area where he needed it, and that changed so many of his functional complaints. So, um, and that, um, so today's episode, yes, I'm going to share the case with you because it's relevant, um, in- it's relevant.
And then, but really what I wanna talk about is the anatomy and the relationships between, um, the liver and pelvic floor. Um, so without further ado, yeah. So this case, um, I was treating, um, uh, one of my athlete's wives. I've treated her a few times before, um, most- mostly for functional issues, mostly for supporting her, um, fertility journey.
And, um, which actually I end up seeing quite a bit of my athlete's wives for those things. Um, I love, I love, love, love, love helping, um, women in their fertur- fertility journey because this work can be so helpful in that. And, um, much like you've heard me maybe talk about how I occasionally get to work on babies, um, like pediatric patients through working with my, um, athlete's families, I, I just love that work so much.
Um, but it's... Part of me is like, "Oh, I wish I could do this all the time," but then also I'm like, "Mm, I, I really like my niche and, like, working with athletes." And, um, also as an athletic trainer, manual therapy on babies and, um, working with women for fertility is a little bit of, like, a gray area of the scope of my practice.
So, you know, I just am like, no need to push the envelope. Anyways, though, I digress. That, that, that is not important other than, um, kinda setting this up for, like, um, these are people-- This is, um... I have experience in working with functional complaints like this, um, but it is not my everyday thing. And also, it's one of those things of, like, I am not a pelvic floor therapist.
I am not a pelvic floor specialist. Um, I know that though I've gotten some great results, there are still a lot of pieces to those specialties that I don't even, you know, begin t- to know and understand. And, um, which is fine and great, and this is why we have colleagues that we can trust to refer. Sort of like that case with my Navy guy a few weeks ago is like or a few months ago, is like, um, when I took his subjective history, I was like, "Ooh, this might be somebody I'm gonna have to refer somewhere else."
Um, and so it- it's, you know, sometimes the best thing you can do for your people is realize your limitations and, and have a really great network of people that you trust that you can refer out to. So, um, anyways, so this case, like I said, I'm working with my athlete's wife. She's, um, getting ready to do, um, either another IVF experience or, um, at least an IUI.
And, um, she just asked me to work on her because she's just wanting to do all the things, manual therapy, nutrition, um, stress reduction, health-wise, wellness-wise, to support her body in this journey. She's getting older. She's just feeling like, you know, like these might be our last couple tries, and so, like, let's, let's make sure we check all the boxes.
So she's like, "Can you work on me?" She's like, "I ha- I just saw the acupuncturist, and then I'm going to see the pelvic floor physical therapist, um, like in a week or two, and then I'm seeing a womb massage person." And she listed off another person I can't remember who it was, and I'm like, "Oh, that's a lot of people, but yeah, of course I can work on you."
And, um, I was like, you know, obviously I know her goal is fertility, um, but then I was saying, you know, "Yes, I will make sure I check the box on, um, assessing and treating that area of your body." Um, I was like, "But then also, like, how are you feeling? Like musculoskeletal-wise, movement, pain, like what's going on?"
And she's like, "You know, I feel pretty good." She's like, "I do feel bloated from the acupuncture appointment." And she's like, "I don't normally feel bloated, but I feel really bloated since then." And she's like, "I've got," um, she goes, "You know, I get the occasional like low back pain. It's not happening currently, but that's sort of like an on and off again thing."
Um, she's like, "You know, general soreness from like working out again." She's like, "But other than that, like I feel pretty good." Um, and then she said, "Oh, and I also, you know, I guess a, a complaint would be that I do have some leaking, um, since, you know, the last two pregnancies." And she's like, "But you know," she's like, "That's normal, right?"
And I'm like, "Well, I mean, it, it's common. I wouldn't say it's normal, but it's common. Um, w- for sure." And so I was like, "Okay, well let's, um, let's do the assessment and see where your body is taking us." And then like go from there. And so this is one of the things that I really like to emphasize, um, when I'm teaching other clinicians, especially clinicians that are, um, specialized in treating pelvic pain, pelvic floor, um, pelvic functional problems, is you need some orthopedic measures that you think or you know correlate with the functional problems.
So orthopedic measures that might be related to fertility, that might be related to stress incontinence. These are the things that I want to look at when I am assessing and treating patients like this because I'm not going to know within our session if I've changed stress incontinence, if I've changed fertility, and I want evidence for me and for the patient that I have created a change or a shift in their body that could potentially help them with whatever their complaints are, right?
So when it comes to fertility, I'm going to be looking at, um, visceral mobility and motility of the uterus and the ovaries. I'm looking at, like, the position of the uterus, the, um, mobility position of the pelvic bowl, the sacrum, the innominate bones, um, hip mobility because that is very much connected to the function of the pelvic floor.
I'm gonna be looking at hip mobility inflection, extension, adduction, abduction, internal rotation, and external rotation at neutral and at ninety degrees. I'm gonna also be looking at ankle dorsiflexion because that relates quite a bit to pelvic position as well. And, um, these are all actually not only for fertility, but this is the same for incontinence.
I'm going to be looking at all that pelvic thing, those pelvic things, the hip mobility as well as the ankle mobility. Um, I'm gonna look at visceral mobility of the bladder, excuse me, and motility of the bladder, and I'm going to be looking at two general core control, lumbopelvic core control, and I'm also, whenever I'm dealing with pelvic organs, I really want to also assess the thoracic, um, area, thoracic, uh, mobility, thoracic position, rib mobility, and then breathing assessment from a movement standpoint.
Um, I might also add in trunk rotation, side bending, you know, flexion, extension, those kind of things too. So I like to really look at the thorax, the hips, and the ankles. And, um identify if there's any objective dysfunctions here, and those are the ones, those are the things that I'm trying to change then when the primary complaint is that of a functional thing and I can't necessarily reproduce it or, um, reproduce pain as the, um, thing I'm reassessing to see if I've done what I want to do with my treatment intervention.
So, um, going through the assessment on her, she was, um, quite limited in ankle dorsiflexion on both sides. She was limited in hip flexion on the left, um, hip internal rotation bilaterally, and, um, hip extension on the right. Her core control was not great. Um, active straight leg raise, um, she did have some pelvic rotation, no pain or anything.
Um, and then from a breathing standpoint, um, she did not have a ton of posterolateral rib mobility. Um, and then seated trunk rotation, she was limited to the right, I believe, if I'm recalling correctly. Um, so that was it. And then I assessed her, and I found that it was, her body was directing me to her liver.
So then I did a little bit further assessment around the liver, um, how the liver was moving to determine, like, what liver treatment to use. And, um, then we,
um, treated that and reassessed things. And after treating her liver, she, um, improved her hip mobility quite a bit, um, as well as her ankle mobility. Her hip internal rotation was still a little bit limited. Um, and specifically, her hip extension was still a little limited. Um, what was interesting, her too, even in the beginning, I didn't say in prone, when she was laying in prone, her hips were quite rotated.
Um, it was almost like she was, like, laying on something that was forcing her into a rotated, uh, pattern in her pelvis, and that improved a little bit with the liver treatment. And then after treating her liver, um, and I, I treated her liver... Gosh, I don't even remember what I did. I think, um, I did, like, a diaphragm induction technique with the liver and, um, a couple viscoelastic techniques, um, as well with the liver.
Um, and then I did Oh, it was, um, I did a little bit of a specific, like, uh, treatment to like the left triangular ligament, falciform ligament connection, and that was it. So, um, her active straight leg re- raise improved quite a bit too. Like her core control, her core was much better after treating the liver.
So then when I reassessed, started another round of the LTAP or like another round of like asking the body, "Okay, where to next?" Treated the liver, like what else is there to treat? Um, the body basically was sort of like, "We're not protecting something specific, so you can treat wherever you want." And so I decided to just, again, since her focus was the fertility, I decided to treat the, um, uterus because on my assessment, it was the thing that was most dysfunctional, I guess, with my visceral assessment.
She had-- She-- Her uterus was sort of stuck in a right facing torsion in right side bent position, and so I just did some gentle induction techniques with that. It took me down this like, or up this like fascial line on the right side, um, maybe even a little bit of the connection to like the, um, fascia of Tolt and kidney and, uh, liver.
And so w- I, I just followed that and, um, treated until I felt the uterus sort of come back to that midline position, and then it started going into motility. So I did motility at the end there. And then I reassessed everything and that really cleared the rest of the things up. It changed her hip internal rotation quite a bit, um, got even more ankle dorsiflexion out of her, and then in prone, the rotation on her pelvis was no longer there.
And then I asked her to get up off the table and see how she felt and she was like, "Oh." She's like, "You know, it's hard to say since nothing was really bothering me." And I was like, "I get it. Like just take a little walk and see how you feel, and if you don't feel any different, no big deal." But I'm like, "You know, objectively, you've changed these, all these mobility things."
And, um, and then she took a little walk and she came back. She's like, "You know what?" She's like, "I actually feel like not bloated at all right now." She's like, "Which is crazy because I was so bloated when you started, and I feel like I'm not bloated at all anymore." And I was like, "Oh, that's great." And she's like, "And I guess overall, I just feel like a little lighter."
And I was like, "Okay, great." So, um, the next day, I got a text from her and she was like, "Oh my gosh." She's like, "I just wanted to give you an update." She's like, "I still feel so good. No bloating even today." And she's like, "And then this morning, I did a workout, and the workout had a lot of jumping in it." And she's like, "Normally, all that jumping, I would have quite a bit of leaking And she's like, "I barely leaked at all."
And I was like, "Okay. Like, this is awesome." We successfully supported decreasing her stress incontinence. Um, so that was, like, a very great outcome, um, in not necessarily the focus of our treatment, though I had a feeling that she would feel better because I saw such a change in her ankle mobility, which usually correlates with change in her pelvic mobility.
Um, I didn't outright measure or assess her pelvic mobility, if I'm being 100% honest. And then, um, her core control changed quite a bit too. And so, um, I was like, "Yes, I, I'm happy with the changes we made." And so, um, yeah. I, I... And knowing that, uh, we made all those objective changes, and then we also made such tr- changes from the functional stress incontinence piece, I'm like, "Oh, yeah, this is a very good, very good indication for potentially supporting, um, just function of the uterus, um, and ovaries as well."
So, um, now, that case-- To share that case was important because I wanted to say two things. One, again, this emphasis on, like, you still need some objective measures, even when the patient's complaint is not related to the musculoskeletal system or pain. You need some objective measures so you have a way to assess that your treatments did something, right?
Because we don't wanna be walking around here with treatments that aren't changing something. We want treatments to always change something immediately in that session. So, um, so there's that. And then the other reason I wanna talk about it is because I actually see this relationship come up a lot. The liver, the liver comes up so often, especially for women, but just so often.
And the liver too, when we look at the liver, it is just a really great organ to target to have an f- a big effect on a lot of the containers in the a- in the body. Um, it's a very large organ. Its movements are easy to feel. Its motility is easy to feel because it's so big, and it's a hard organ. And so, especially if you're newer to, like, visceral manipulation, if you're newer to just thinking about the viscera, the, the liver is just like an easy lever to p-pull, a easy thing to treat, to focus your treatments on, and it has high payoff because of A lot of its connections, but then also just, um, the role it plays in the intracavity pressures.
So, um, I wanted to talk a little bit about th-the liver in that sense of... So like I actually brought my little model over so I could show you. So here's the liver and the stomach. The liver and the stomach obviously are in the thorax underneath the diaphragm, um, but still within the rib cage. And this is a view of the anterior front for those of you watching on YouTube.
Um, and it's important to recognize that there's two lobes of the liver. Actually, there's four lobes, but you know, there's a right side and a left side to the liver. The left side, um, is, um, a smaller lobe than the right side. Um, but yes, the liver extends all the way to the left midclavicular line, and then it articulates with the stomach.
And if we flip everything around, you then see on the posterior abdominal wall is the right side of the liver, the vena cava, um, and the aorta, which is not necessarily shown on this model. Um, and then the stomach is the left side of the posterior abdominal wall because the left lobe of the liver does not come posterior like that.
Okay? And, um, you also get to appreciate then-- what I love about this model, you get to appreciate that the ligaments between the liver and the stomach, which is the hepatoduodenal and the hepato-- and the hepatogastric ligament. It's also called the lesser omentum. Um, it-- there's a three-D-ness of it to it.
We often forget when we're studying the anatomy that it lives in three dimensions. And so this ligament, the lesser omentum or this hepatoduodenal, hepatogastric ligament, is between the two. I think when we see it in books, we think of it being like between the two like this, like medial to lateral or, you know, right side to left side.
But it's actually has a anterior to posterior and an inferior to superior relationship, as well as the left to right side. And so when, when we're moving, when those organs are moving, you also see that they, they work very similar to like a ball and socket joint in terms of how they move on each other.
And that's exactly what needs to happen in the abdominal cavity. Any of the visceral cavities is the organs move freely, glide on top of each other. There's no space in the abdominal cavity, um- That there's no space. It's a virtual space, but there is fluid between the organs, and this fluid, this serous fluid, um, much like joint fluid in your joints, allows for lubrication, decreased friction, so the organs can move freely on each other.
Okay? Um, ch-ch-ch, the interesting thing... I'm gonna drop the stomach away so we can just see the liver. But the liver suspensory, um, ligaments, there's a, um, ligament that is on the top of the liver called the coronary ligament, like crown. Um, there's a thickening on the left side, the left triangular ligament, and the thickening, a little bit of a thickening on the right side, though the right triangular ligament is, um, not quite as sturdy as the left.
In fact, the left triangular ligament is the main suspensory ligament. The right side of the, um, coronal ligament and the liver and the diaphragm articulation, there's actually a little joint capsule there, which is a fold in the peritoneum called Glisson's capsule, and it kind of adds to the suctioning that holds the liver up and acts, um, supports the suspensory ligament of that right triangular ligament.
But the left triangular ligament is the more dominant actual ligamentous, um, suspensory ligament to the, um, liver. The right and left triangular ligament, um, are continuous with the coronal ligament, so it's all part of the same fascial piece, and it comes... There's an anterior and a posterior, and they come together, and they join up at the, um, falciform ligament that splits the right side and the left side of the liver.
That falciform ligament, um, is the anterior part, and on the posterior part, they come together, and they form a ligament called, like, the li- the venos- ligamentus venosum, which is basically, like, the ligament that surrounds the vena cava and the aor- aorta, the cisterna chyli back here. And it, um, connects with this, like, ligament that goes transverse over it, which provides the rotational axis for the movement of the liver.
Now, that is continuous, like I said, in the anterior part with the falciform ligament, and it is the coronal ligament, specifically the corners, the triangular ligament and the falciform ligament that, um, helps with anterior-posterior roll of the liver, which is basically flexion and extension. What's interesting here and why I am, like, giving you all this information is 'cause the falciform ligament, um, big investment from the left suspensory ligament So left, sorry, left triangular ligament comes in this big investment of the ligamentum, um, of the falciform ligament, which continues on into the ligamentum teres, which is the, um, embryological remnants of the, um, round ligament or the umbilicus ligament.
Um, and that continues all the way into our umbilicus. And so it takes... It, it basically is there's this connection from the liver to the anterior abdominal wall down to our umbilicus on the superior side of it, and invests with the fascia around the umbilicus. On the inferior side of the umbilicus, you have another suspensory ligament to the pelvic organs, the urachus ligament.
The urachus ligament connects to the bladder. Um, and so, um, it invests over the fascia of the bladder into the pelvic floor. And so you have this direct connection between liver and pelvic floor. It is, if we're thinking about the container of the abdomen, the, um, falciform ligament to the umbilicus, and then the ur- umbilicus to the urachus to the, um, bladder and the pelvic floor, it is, um, the backside of the linea alba.
And so this starts to give you some, um, 3D-ness or relationships of how important too the abdominal container and the abdominal fascia is in the role of the abdominal cavity and the liver mobility, the pelvic floor mobility, that kind of thing. And so, um, what's interesting as well is, okay, so there is like a direct mechanical, um, direct mechanical relationship.
What I also want to talk about is this idea of intracavitary pressures. And this goes back to too, like why the thoracic, um, cage, the thoracic mobility is so important when we're talking about pelvic floor or pelvic organ dysfunctions, right? 'Cause it's a often kind of a game of pressures. I think too, and I am guilty of this, I've talked about how like everything's sort of sitting on the pelvic organs, so like no wonder they're so susce- susceptible to pressures.
But when you look at how the body actually sets itself up, the, it's a little bit more complex than that, and also it's a little bit more- Intelligent than that, I guess is a better word to say, is the body's design takes that into consideration. So, um, the negative pressure in our thorax, that's normal, provides this suction phenomenon for all of the organs in the abdomen to be lifted up.
This is what unweights the weight of the liver, um, because the, the pressure, the pressure in the abdomen is higher than the pressure in the thorax. And so those organs are attracted superiorly towards the thorax. But also at the same time, you have gravity pushing down on them. And so what happens is the upper abdominal organs have, or the upper abdominal cavity has less pressure than the lower abdominal cavity and the pelvic cavity.
Because the farther we get away from that negative pressure in the thorax, the more we feel the effects of gravity. Okay. Now, a little bit of that, of that is offset in the pelvis because of the position of the pelvis and the architecture of the pelvic organs. And so I think this is, um, pretty cool, and it sort of also supports this idea of, um, what normal posture is.
And I put normal in air quotes because this is, like, one of those things ge- gets argued in the rehab industry quite a bit, which is, like, where our pelvic position is and where our ribcage position is. If you look at the body, normal pelvic position is thir- about thirteen degrees of anterior tilt. This matches our normal rib position in our thorax, which is the anterior part of the rib is more inferior than the posterior part of the rib.
The reason this happens is because of the thoracic curve. The thoracic spine is curved, so the ribs sit, like, gravity sort of has... It's almost like you put a ring on top of the thoracic curve, and so the, um, posterior side of the rib hi- hits the curve, and then the anterior side continues to fall forward.
So we have this natural anterior inclination in the ribs that are parallel then to the pelvis. And this is where the confusion in the rehab industry gets, because oftentimes we talk about This parallel relationship to the pelvis and the ribs, and people for some reason thought that is flat, horizontal.
It is not. The parallel relationship between the ribs and the pelvis is anterior tilt. And this anterior tilt is actually essential for maintaining good pressures in the pelvis and offsetting the pressure of gravity and the visceral column on top of it. And the other p- cool thing is not only does that anterior tilt offset the pressure, but the shape of pelvic organs do, too.
So the shape of the bladder, the shape of the uterus are domes. And we know domes in architecture, much like the sacrum, are kinda like keystones. A dome, a dome, you know, for, or building a dome with cinder blocks, the apex of the dome is a keystone, triangular shaped piece of, um, block, right? But a sphere is really, like, stable, too, because the, everything that loads on top of it is dispersed along the curve.
Isn't that cool, right? By design, our bladder and our uterus in their dome shapes are intentionally domed to offset the pressure from gravity and the visceral column of the anterior, um, peritoneal organs. And so I'm like, "Wow, that's so cool." The visceral column also is supported, and like this is-- I read this, uh, yesterday and I was like, dang it.
The visceral sup- dang it, but also, yes, makes sense. The visceral column is supported by the abdominal wall and the abdominal activity, a strong abdomen. And then it's like, oh yeah, if you look at the anatomy, no wonder we have a three-layer reinforced system of our abdominal muscles because it is supporting us upright, but it's also supporting all these very heavy, high pressure organs and keeping them stacked up in a column.
And this v- visceral column stacked up helps to provide our stability and shape, but it also helps to maintain good healthy pressures within all the cavities, and then, um, sit on top of those domed pelvic organs in a way that they're not pressing on them. So now- I don't want you to hear this and think, oh, yeah, that's why we give so many people, um, exercises to strengthen their abdominal muscles.
Yes and no, right? Because what you see here, and this is like I'm bringing it back. I'm hoping to bring it back to the visceral piece and bring it back to, like, the change we saw in my client, which I treated her liver, and then her core control improved. I treated her liver, and her breathing mechanics improved.
Because muscles do muscle things, and one of the primary jobs of the muscles is to protect the organs. And so when the organs are not moving well within the c- within the container, the muscles around them stiffen up to protect them. And when the muscles neurologically stiffen up, it creates a hypotonis.
And the hypotonis, uh, or hypertonis, right, the, the, the hypertonis, um, often creates a co-contraction. And so what that can look like is a muscle that has lost its ability to either contract or eccentrically contract, right? It's basically a muscle that becomes a splint. And when a muscle is becoming a splint, it loses the dynamic-ness of stability.
And so that's exactly what we see is people have a hard time engaging their abdominal muscles, engaging their transverse abdominis when they have visceral irritation because the transverse abdominis is neurologically getting a message of like, "Don't change. Don't change length. Just stay splinted." And so by treating the organ, treating the liver, treating the duodenum, tweeting the-- treating the small intestines, whatever it may be, right, wherever the body leads you, treating the uterus e- even it could be.
By treating the organ, what happens is the organ moves better, and then the body goes, "Oh, organ's functioning better, moving better. I can take away the message to the muscles to be a splint." And then now we see in an instant often a improvement of abdominal control. And then what does that mean? We have an improvement of abdominal c- control, diaphragm function, and we have a resolution of improved visceral column stacking and pressure gradient, pressure distribution across the cavities.
And this is what we're looking for, right? This is, this is a really wonderful example of why you can create change so quickly like that. So hopefully this makes sense. But, um- I'm looking at my notes 'cause of course, um, as you know, I... When I think about these podcast episodes, I'm also like, "Well, let me... I think I know what I wanna talk about, but then let me go and learn more."
But, um, I think I pretty much, um, covered it all. Basically, I- my notes, let's just read through them for, for shits and giggles. It says, "Abdominal activity increases turgor of the anterior abdominal visceral column." Check. I explained that to you. This adds to the turgor and intracavity pressure that keeps the kidneys lifted.
This is a wonderful thing because the kidneys don't have suspensory ligaments, and so we want that. Um, that's the posterior side of that anterior visceral column. Normalizes ribcage mobility or pressures increase everywhere. Oh, yeah. So basically, and this is going back to, like, why I care about ribcage mobility, is because the thoracic cavity, that is, like, a little bit of, like, the driver of all pressures in all of our cavities.
And when pressure increases there, pressure increases everywhere. And we're already pretty high pressure in the abdomen. We don't need higher pressure, right? So sometimes we can make things in the abdomen and the pelvis feel more comfortable by just affecting the thoracic cavity to decrease the pressure there.
When we decrease the pressure there, things normalize a little bit better, and this also, like, everything changes. So an increased pressure in the ribcage also increases intracranial pressure, right? It c- be- it causes, like, a backflow of, um, fluid congestion because the pr- when the pressure's high like that, we can't overcome those gradients with our, um, a lot of our venous fluid or our lymphatic fluid.
Um,
oh, I did write down the pressures. It, it's just really interesting. When we're laying down, we have lower pressure in our abdomen than when we're standing up. When we're standing up, um, pressure at the pouch of Douglas is 30 centimeters of water. Um, pressure at the epigastrium is eight centimeters of water.
Um, and then pressure at the diaphragm, like right below the diaphragm, is negative five centimeters of water. So I already spoke to that relationship of gravity in the intracavitary pressures. It's an ombre, right? It's, like, less pressure at the top and then more and more as we get to the pelvis. And when we, um, add pressure in by coughing or bearing down or straining, that pressure at the pouch of Douglas can go upwards of 30 Sorry, not 30.
Of upwards of 100 centimeters of water or more, right? So that's huge. When we're laying down, the pressure's about eight centimeters, right? It's a little bit more continuous throughout because we don't have gravity. We don't have gravity, and this is kind of where the stress incontinence world comes back in, is because like, yeah, in standing, things change.
In standing, things change. So, um,
and also I have in my notes left triangular ligament primary element along with intracavity pressure of maintaining the support of the liver. I talked about that. Oh, um, the other thing I wanted to talk about... Oh, well, I kind of d- I, I didn't specifically, but I explained how the falciform ligament connects into the umbilicus, connects into the urachus ligament, which, um, connects into the bladder and the pubovesical ligaments, the fascia over the, um, bladder, and then into, invests into the pelvic floor, and specifically the obturator internus.
And so why I thought this was interesting is because this long axis internal rotation is something, or, and just short axis too, internal rotation is something that I'm really obsessive about restoring on people. And I think this is a big piece of it, is because when there is a visceral problem or tension via the visceral column or visceral connections, you do see it reflected in this obturator internus tension.
Um, as well as so often our obturator internus and our posterior pelvic floor muscles are very tight when we are lacking that anterior tilted position of the pelvis, when we're tucked under in a more vertical or posterior tilted position, which unfortunately is trained quite a bit. And I'm like, "No, no, no, this is the opposite."
Remember what I said, is the pressures actually are more supported when the pelvic is in a normal position, which is of anterior tilt. So part of this posterior tilt can be trained. Part of it is lack of ankle mobility. This is why I look to the ankle mobility piece, because you have to be able to shift your weight forward on your ankles, on your feet, in order to let your pelvis anteriorly tilt.
Um, part of this is like thought, you know, going back to what the rehab world thinks is neutral, which is a horizontal parallel between the ribs and the, um, pelvis. But then a lot of it is, again, going back to this protective pattern that occurs when the body is protecting the visceral organs. We tuck our butt underneath ourselves.
And so it is, it is a, a very common position that I see in people, that they're lacking internal rotation because when the message to the obturator internus gets, like, go into protective splint mode, ob- obturator internus is a external rotator, and so it does that, right? And so I would measure its mobility into internal rotation.
So this is why I'm, like, so big on restoring internal rotation. Um, oh, the only other thing that I have written in my notes, but I kinda spoke to it, is the motion that happens at the liver, specifically with an inhale breath. So when you inhale, the liver drops down, right, inferior. It also rolls forward, internally rotates, and laterally flexes.
Okay? So it drops down, rolls forward, internally rotates, and, um, side bends to the left. Isn't that fascinating? Okay, so these are the mo- mobility pieces that often are lacking one of these three motions. They either the anterior roll, the superior glide, which is the lateral flexion piece, or the internal rotation piece.
Or as you exhale, it needs to re- re- do the reverse of that, right? It follows the diaphragm back up by externally rotating, posteriorly rolling, and inferior gliding. So, um, these are helpful motions to understand what's going on, but to understand too the mobility we're trying to restore when we're all doing any liver treatments or liver focuses.
And I think it's important too because I always like to go back to sort of like- Things that are really effective for helping the liver in a general way is laying on the quarters ball or laying on sort of like a folded up beach towel on the right side of the liver, and you get twofold of this. One, the liver is really hard, um, and so it responds well to a viscoelastic technique, which is like a sustained compression, and that sustained compression over time kind of creates a creep in the tissues, and then the tissues start to respond and come together.
And then when you let go of that compression, they expand. And so this is really good for the parenchyma or the, um, cells of the liver to have this compression decompression feeling. But then also by laying on something on the right side, you're pressing the liver over towards the left, which is putting that left triangular ligament on slack.
And when-- This is called, in the osteopathic world, this is p- um, putting the thing in the direction of ease. So putting something in the slack allows a little bit of room for the body to start to adjust and open up and find that tension and go from there. So what sometimes is really good is when you're doing this compression from the right side is to open up into rotation to the left or rotation to the right, reaching your arm overhead like some sort of side bending, and this starts to get a little bit of mobility in that really important left triangular ligament, which is going to have an effect on that falciform ligament all the way to the pelvic floor.
Now, are there, there are other ways to get this than lying on something on your right side? Absolutely. That's just an easy way to go about doing it that you don't need visceral manipulation skills for. Can you lay on the left side and treat it that way? Sure, of course. Now you're taking the stomach and the spleen, and you're bringing it closer to the liver, which is slacking not so much the left triangular ligaments, but slacking the hepatoduodenal and hepatogastric ligaments that, right, that is the visceral joint.
And so that is affecting, um, all of the motions as well, but especially the rotational motion around the, um, vena cava, that axis of rotation. So, um, when you start to understand the anatomy, you can start to pick movements, um, or think through your movement interventions a little bit more specifically to be like, how can I treat this really well?
That's a little bit of what the beta test of the LTAP level three was all about. But also, like, you don't need a class to do this. It just comes down to, like, understanding the ligaments and the motions associated with the organ itself, with breath, with ribcage movement, and understanding the relationship between the ribcage movement and the organ, right?
And so we even kind of talked about what happens with the liver when you take a breath. But if we layer on what's happening with the ribcage, you see it's opposite Right? So when you take an inhale breath, what's happening to the ribs? They're opening up. What's happening to the liver? It's pulling away.
The ribs are lifting up. What is happening to the liver? It's dropping forward.
So they're not going together, and I think sometimes that is what people misunderstand is you think musculoskeletal, the, the liver's attached to it, it must be going in the same direction. But this is even understanding what's happening with the diaphragm versus the ribs. The ribs are moving open and away, and the diaphragm is dropping down.
Right? So the more you can understand movements, the more you can understand the anatomy, the better it makes sense of even why your treatments are working for what you're doing, right? It's not magic that I worked on her liver and had such an effect on her core control, her hip mobility, and her ankle mobility, and her thoracic mobility.
It makes perfect sense, right? And then when you start to layer on the understanding of the intracavitary pressures and the relationship to gravity and the relationship to the other container pressures, like, you start to, like, paint a big- bigger picture. And whenever you have a bigger picture of, like, how things are functioning, you should be able to pick interventions more appropriately or at least sort of then troubleshoot your way through, like, w- how else can I help her?
How else can I support this sticking in the long term? Or maybe not sticking in the long term because maybe it does stick in the long term, like my guy from a few months ago, but how can I support this going forward so it be- does not become an issue again? But, um, anyways, I'm gonna wrap it up because this is a long podcast, so hopefully you hung with me.
But it, it's a little bit of, like, two podcasts in one, right? It's a case study, but then also, like, a anatomy deep dive. Um, thank you for joining me. Hope to see you next time.