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From the Townsend Letter
February / March 2009

Hiatal Hernia Syndrome
by Steven Sandberg-Lewis, ND
National College of Natural Medicine
Portland, Oregon

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Hiatal hernia syndrome is one of the most common functional GI disorders. Patients manifesting this condition may present with gastroesophageal reflux symptoms, and it may also trigger asthmatic bronchoconstrictive episodes.

The patient may already have had an upper GI barium study or endoscopy (esophagogastroduodenoscopy), which may not reveal organic disease/hiatal hernia. This does not preclude the possibility that you will detect this syndrome. I get many referrals for this condition, and the relief the patients get from the approach described below is often immediate and dramatic. I teach this technique along with others in a weekend seminar titled "Functional Gastroenterology Level I." You can also use this technique to treat a true hiatal hernia.

The recognition and management of this syndrome was greatly advanced by the work of Dr. Ralph Failor, a naturopathic and chiropractic physician who practiced in Hillsboro, Oregon, during the last half of the twentieth century. This syndrome is a functional relative to the true hiatal hernia, a gastric pathology in which the proximal stomach is herniated into the mediastinum. Hiatal hernia syndrome is distinguished by the fact that the proximal stomach may only cause upward pressure against the diaphragmatic hiatus and not actually protrude into the chest (Figure 1).

A hernia smaller than 2 cm may not be visible on barium films or endoscopy.

Figure 1: Normal Stomach and Hiatal Hernia


Clinical picture
The possible symptoms are the same for both the true hernia and the syndrome. These may include fatigue, mental dullness, easy satiety, shallow thoracic breathing, relatively rapid respiratory rates, globus sensation, dysphagia, chest oppression, reflux, stitching chest pains, regurgitation, aversion to constriction at the waist, flatulence, a "spare tire" bulge just below the inferior margin of the ribs, and a tickling, nonproductive cough.

This syndrome may be due to an inherited wide diaphragmatic hiatus, or may be acquired from trauma or increased intra-abdominal pressure. Examples of trauma include abdominal surgery, the impact of jumping from a height, horseback riding, strenuous abdominal exercise, a blow to the abdomen or a "belly flop" dive, falling from a height, or merely exertion with breath holding.

An increase in intra-abdominal pressure may also be due to pregnancy or abdominal obesity or any space-occupying lesion of the abdomen.

Dr. Failor used the following tender points for detection of the syndrome:

Reflex points

· Left of xiphoid (hiatal hernia syndrome (HHS) point –
see Figures 2 and 3)
· 4th ICS (intercostal space) midclavicular
· 4th ICS midaxillary
· T10-11 left paravertebral area

I ask the patient to rate these on a 0-4 scale and reassess after treatment.

Figure 2: Hiatal Hernia Point

Hiatal Hernia Point

Figure 3: Hiatal Hernia Reflex Point Testing

Hiatal Hernia Reflex Point Testing

Another method that I have found very useful is an applied kinesiology test:
Step 1. Find any muscle that tests strong (I often use the rectus femoris).

Step 2. Retest the strong muscle while having the patient using both hands to press the upper abdomen inward and cephalad, which increases the pressure of the proximal stomach against the diaphragm (Figure 4).

If the muscle weakens, this is a positive indicator.

Check the spine with a focus at the occiput, C3,4,5 and T10,11.

Figure 4: Position of Patient's Hands for Muscle Testing of Hiatal Hernia Syndrome

Muscle Testing for Hernia

Table 1: Hiatal Hernia Syndrome - A Synopsis

Onset abdominal surgery
impact of jumping
horseback riding
abdominal exercise

blow to the abdomen
"belly flop" dive
falling from a height
exertion with breath holding
mental dullness
easy satiety
shallow thoracic breathing
chest oppression
stitching chest pains
relatively rapid respiration

globus sensation
aversion to constriction at the waist
"spare tire" bulge just below the rib margin
tickling, nonproductive cough
Assessment Reflex points:
Left of xyphoid (HHS point)
4th ICS mid clavicular
4th ICS mid axillary
T 10-11 left paravertebral

Retest a previously strong lower extremity muscle while having the patient use both hands to press the upper abdomen inward and cephalad.
If the muscle weakens, this is a positive indicator for the syndrome.
Treatment Standing to the left of the supine patient, use a left hand "claw" contact. Support the contact hand with your right hand. (Figure 5).

Use continuous traction toward the left ASIS, and wait for the soft tissue to begin a counterclockwise rotation.

Follow the rotation as it shifts to clockwise – maintaining traction.
When the rotation is finished (usually 2–3 minutes at the longest), perform three clockwise thrusts (ballooning the stomach).

Treatment of the syndrome (or an actual sliding hiatal hernia) involves the following:
Visceral manipulation: Dr. Failor taught us his technique in 1977, and many doctors still use it.1 It is effective, but can be a bit forceful. I trained in structural integration in 1996, and over the last five years I have developed a gentler method. I contact the epigastric area just inferior to the costosternal angle. I use a "claw" hand contact and support the contact hand with my other hand (Figure 5). I traction toward the left anterior superior iliac spine (ASIS) and wait for the soft tissue to begin a counterclockwise rotation. I just allow my fingers to follow the movement while continuing to apply the traction. In most cases, the rotation will shift to clockwise as I continue the traction. When the rotation is finished (usually 2 to 4 minutes at the longest), I add three additional clockwise thrusts of my hands. Dr. Failor called this "ballooning the stomach" and thought that it was important in order for the manipulation to hold.

Figure 5: Visceral Manipulation of the Hiatal Hernia Syndrome

Visceral Manipulation

Any additional techniques that you already use to free the thoracic vertebrae, ribs, and diaphragm muscle in general are helpful, should you find these necessary. Dr. Failor found that the T10 and T11 were especially important, so I tend to check there. In addition, the occiput is often essential to check and correct. The basic "cranial base release" is effective; or use myofascial or other cranial techniques, or osseous manipulation if you prefer. In addition, check C3, 4, and 5, which "keep the diaphragm alive" (innervate the diaphragm).

After treatment, recheck the tender point or use kinesiology testing. The change should be immediate.

Post manipulation exercises:
Heel drops. The patient drinks (not sipping) 12 to 16 ounces of warm water on waking, stands and rises onto the toes, and then drops onto the heels eleven times in succession. The downward momentum of the water-filled pendulous stomach supports the benefits of the visceral work.

Leg raise. Lying supine on a flat surface with legs adducted, the patient inhales, and then while exhaling raises both legs 12 to18 inches, slowly abducts and adducts the legs, and then lowers them to the resting position. Gradually increase the number of repetitions over time.

Knee raise. Sitting in a chair, the patient supports the upper body by holding the arms or seat of the chair. Keeping the knees adducted, the patient inhales, then exhales as he flexes the legs, bringing the knees toward the chest (as far as possible). Taking the next breath as he extend the legs and rest the feet on the floor, he exhales as he repeats the procedure. Gradually increase repetitions over time.

Dietary basics:
In general, I find that having patients avoid foods to which they have sensitivities is important. Simplifying meals (simple combinations) is also important. Just as important as what they eat is how they eat:
· Avoid overeating and large meals.
· Take time to sit and chew food until it becomes liquid before swallowing (known as Fletcherizing).
· Avoid stressful discussions or watching television while eating.
· If family-of-origin issues are still affecting eating habits, consider counseling or energetic psychology interventions.

Treating hypochlorhydria or achlorhydria if present is also essential for these patients.
Functional breathing and lifting: This is crucial. Teach these patients functional lifting and exertion. Have them take a slow abdominal breath before exerting and then exhale as they exert. This prevents a build-up of intra-abdominal pressure, thus preventing reinjury.

Developing your skills and protocols for treatment of hiatal hernia technique will gain you many referrals and the ability to get rapid, lasting results with many cases of functional esophageal, gastric, and diaphragmatic syndromes.

Steven Sandberg-Lewis, ND, DHANP, is a full professor at NCNM. He has taught GI physiology, psychophysiology, GI pathology, and gastroenterology since 1996 and has been in continuous practice since graduating from NCNM in 1978. He supervises student clinicians at the NCNM Natural Health Center with a focus on digestive and musculoskeletal health. The practice emphasis is on diet; myofascial, visceral, and spinal manipulation; functional analysis; and mind-body clearing techniques. Dr. Sandberg-Lewis teaches a two-part seminar series on functional gastroenterology. Level One will be held on February 28 and March 1, 2009. To attend: go to and click on "Register for CE Classes Here." His new book, Functional Gastroenterology, will be available from the NCNM bookstore on May 1, 2009. Go to or e-mail

1. Failor RM. The New Era Chiropractor, R. Palm Desert, CA: R.M. Failor; 1979.


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