LWW Massage Therapy & Bodywork Educational Series
Jocelyn Granger, NCTMB
Neuromuscular Therapv Manual is the long-awaited text that distills the essential content ofTraveil
&
Simons' Myofascial Pain and Dysfunction needed
by massage therapy students and practitioners into a concise, easy-to-under stand textbook. Part I of this text gives an in-depth overview of the basics of neuromuscular therapy, including its history and physiological basis, client assessment, body mechanics, and more. Part II is organized by body region, with each chapter providing detailed information on each muscle in that region, such as origin, insertion, and action. Students will also learn the trigger points and referral zones, trigger point activation, stressors and perpetuating factors, precautions, and massage considerations for each muscle. Key Features • Classic trigger point and referral zone charts fromTravell and Simons are included for each muscle. • Anatomical illustrations of each muscle are featured. • Case studies apply knowledge of neuromuscular therapy to client scenarios. • Sample routines sections include step-by-step massage procedures for each body region and are illustrated with a wealth of photographs. • Review questions test knowledge of the content covered in each chapter. • Online video clips demonstrate neuromuscular therapy routines for each region of the body.
LWW.com
ISBN-13: 978-1-58255-800-4 ISBN-10: 1-58255-800-0 90000
. Wolters Kluwer Lippincott Health Williams & Wilkins
9 781582 558004
NEUROMUSCULAR TH ERAPY MANUAL Jocelyn Granger, NCTMB Founder and Director Ann Arbor Institute of Massage Therapy Ann Arbor, Michigan
I
. Wolters Kluwer Lippincott Williams Health
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Library of Congress Cataloging-in-Publication Data Granger,Jocelyn. Neuromuscular therapy manual/Jocelyn Granger. p.; cm. Includes bibliographical references and index. Summary: "Neuromuscular T herapy Manual is a concise "essentials" manual of neuromuscular massage therapy and trigger point therapy. The book is designed specifically for the needs of massage therapy students. Content is presented in a highly easy-to-use format"-Provided by publisher. ISBN 978-1-58255-800-4 (pbk. : alk. paper)
I. Massage therapy. [DNLM:
2. Myofascial pain syndromes.
I. Massage-methods.
3. Soft Tissue Injuries-therapy.
I. Title.
2. Myofascial Pain Syndromes-therapy.
WB 537]
RM72I.G765 2011 615.8'2--dc22 2010026299 DISCLAIMER Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. T his is particularly important when the recommended agent is a new or infrequently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the F D A status of each drug or device planned for use in their clinical practice. To purchase additional copies of this book, call our customer service department at orders to
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o ... en o CJ) o o
To Bob King and]im Hackett, the founders of the Chicago School of Massage T herapy; they mentored me and generously shared their school curriculum information and manuals while helping me start the Ann Arbor Institute of Massage Therapy. Because of their generosity with a certain neuromuscular therapy manual, the idea for this book came about. But if it weren(t for Kathie King who constantly reminded me that I can write and encouraged me to do so, this would never have happened. 1 am sad, though, that she did not have the chance to see the finished product.
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PREFACE This book was created to help massage therapists grow into
illustrations of anatomy showing attachment sites, and illus
effectiv� neuromuscular therapists and be able to specialize
trations of trigger points and their referral areas.
in working with individuals in chronic pain. Although it is
Throughout the book, many pedagogical features are
meant to be a textbook for massage therapists, it may be use
included to facilitate learning. These are described
ful for osteopaths, athletic trainers, physical therapists, and
below:
other health care providers. This text is devoted
to
•
providing a concise manual of
neuromuscular therapy that contains the most relevant con tent from Travel! and Simons' Myofascial Pain and Dysfunction:
and appear in a glossary at the end of the book. •
T he Trigger Point Manual, volumes 1 and 2, in a highly struc tured, regionally organized, accessible, and user-friendly text
Key terms: are listed and defined at the beginning of each chapter, boldfaced on first mention in the text, Chapter introductions provide a brief overview of
each chapter's contents. •
Case studies discuss clients with particular pathologi
for massage students. As so much of the information in
cal conditions and how neuromuscular therapy rou
these volumes is regarding medical treatment and is thus
tines, as presented in the text, can address them. A few
highly detailed and technical, it is often intimidating to
critical thinking questions regarding the scenario pre
massage therapists to read. Thus, this textbook bridges that gap and highlights the information that is most helpful
to
a
massage therapist.
sented are included at the end of each case study. •
procedures for each body region. •
OVERVIEW OF CONTENTS Part I of the book gives an in-depth overview of the basics of neuromuscular therapy, including information about its his tory, the phy iological basis on which neuromuscular ther apy is founded, client assessment, body mechanics, and more. Part II is divided into sections by body region. Each
Sample routines sections include step-by-step massage Chapter summaries briefly review the content covered
in each of the first four chapters. •
Chapter review questions, appearing at the end
of each chapter, allow readers to test their knowledge of the content covered in each chapter and consist of multiple choice questions, short answer questions, true/false, and matching.
chapter gives specific information regarding the muscles in that region, such as origin and insertion. Also included here is further information regarding trigger points and referral zones, perpetuating factors, and massage considerations for each muscle, along with color pictures of the anatomy and trigger points. There is also a step-by-step guide to perform ing the treatment of each muscle, which is coordinated with online videos of the same making it easy to practice this work at home.
PEDAGOGICAL FEATURES
USE OF THIS BOOK It will be imperative for you to read and study the chapters in Part I and gain a comprehensive understanding of the theory of neuromuscular therapy before attempting
to
mas
ter the techniques in Part II. This is very advanced work and it will be important that you also have an excellent grasp on anatomy to be able to master this work. A neu romuscular therapist must work from the heart, wh ich means working with integrity. Integrity means to be mas terful and knowledgeable, in this case. Last of all, it is
This text is easy to read and includes features such as
important that you enjoy challenge. It will be challenging
bulleted lists for easy reference, photos of the technique,
to become masterful with this technique; it will also be
v
vi
PREFACE
challenging when working with clients in chronic pain and
improvement or questions about this book or workshops
dysfunction. Challenging clients are what will keep the
may be addressed to:
work fresh for the neuromuscular therapist: it will never become boring. So, enjoy the work and the sense of fulfill
Jocelyn Granger
ment it will provide and always remember that it is an
Ann Arbor Institute of Massage Therapy
honor to work on an individual who needs your help.
180 Jackson Plaza, # 1 00 Ann Arbor, MI 48 1 03
• FEEDBACK This author appreciates any feedback from students, profes sional therapists, school instructors, etc. Any ideas for
E-mail:
[email protected]
ACKNOWLEDGMENTS I first wish to acknowledge Georgine L ynett. As soon as I
information I received from my reviewers was valuable and
was given the "go-ahead" for this project, she informed me
a great help. I truly appreciate all of their patience in read
that she would do as much as she could for me at home, so I
ing the information and taking the time to give me their
would have the time to work on this book. It was only then
critiques and correction suggestions.
that I realized I would actually be able to take on the project.
Thanks to the photographer, Mark Lozier, and the video
Having this support at home kept me on track and bolstered
grapher, Michael Licisyn, those long days went smoothly
me emotionally. My appreciation of this is huge!
and we have some great photo and video shots that add
It is with gratitude that I offer this simple acknowledge
more dimension to the book. Also, a huge thank you to the
ment and thanks to the many people out there who contrib
Cortiva Institute, Pennsylvania School of Muscle Therapy,
uted and supported me through this project. The opportu
and Jeff Mann, its President, for providing us with a nice
nity to work with L ippincott W illiams & W ilkins on this
room to do our photo shoot. They also found the therapists
book was a dream come true for me.
that served as models. All models we used, both the models
In particular I would like to thank David Payne for being
on the table and the professionals serving as models, were
so nice while trying to keep me on track and off the ceiling.
excellent: thank you for your hard work and being part of
David is a great editor and works well with others. His calm
this book.
ness at the photo shoot really helped me to be present and keep my energy at a high level during those very long days.
Finally, I extend my appreciation to Melanie Gibbs, Administrator, and Sara Martens, Academic Coordinator,
Of course, my gratitude also goes out to Jennifer Ajello,
at the Ann Arbor Institute of Massage Therapy. They took
an editor at LWW, and John Goucher, a previous executive
on more of a workload for the last 2 years to give me the
editor at LWW. These two saw the value in this project and
time to work on the book while I was in the office. They also
offered me a chance to write. There were many, many more
helped make my life much easier with their emotional sup
folks involved from LWW that should also be thanked. The
port, and I am greatly appreciative.
vii
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REVIEWERS Rebecca Birch-Blessing, MS, DC
Suzie Goggin, BA, BSRN, LMT
Health Science Department
Massage Therapist
University of Phoenix
Rising Spirit Institute of Natural Health
Sandy Springs, Georgia
Dunwoody, Georgia
Rebecca Buell, BS
Leigh Ann McNair, LMT
Instructor
Mas age Therapist
Massage Therapy Department
Oviedo, Florida
McIntosh College Dover, New Hampshire
Jason Schiller, LMT
Massage Instructor Nancy Cavender, MM, CMT, CNMT
Massage Program
Teaching Faculty
Sun State Academy
RSI
Clearwater, Florida
Atlanta, Georgia Heather Cooperstein, BS, BA
Senior Massage Therapist Out-Patient Therapy Kessler Institute Piscataway, New Jersey
ix
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CONTENTS Preface/v Acknowledgments/vii Reviewers/ix List of Muscles Covered in T his Text/xiii
PART I: Neuromuscular Therapy Basics / 1 1
Introduction to NeuromuscularTherapy /3
2
Neuromuscular Physiology /11
3
Client Assessment /23
4
Basic NeuromuscularTherapyTechniques and Body Mechanics /45
PART II: Muscles and Neuromuscular Therapy Routines by Body Region / 59 5
Head and Neck /61
6
UpperTorso /103
7
Arm, Wrist, and Hand / 163
8
LowerTorso and Abdomen /215
9
Hip,Thigh, and Anterior Knee /245
10
Leg with Posterior Knee, Ankle, and Foot /285
11 Trigger Point and Referral Guide /323 Appendix A: Answers to Chapter Review Questions/331 Glossary/337 Index/341
xi
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LIST OF MUSCLES
COVERED IN THIS TEXT
HEAD AND NECK / 61
Splenius Capitis and Splenius Cervicis: Ache Inside the Skull / 707
Posterior Cervical Muscles / 62
Supraspinatus: Subdeltoid Bursitis / 709
Posterior Suboccipital Muscles / 62
Infraspinatus: Shoulder Joint Pain / 777
Rectus Capitis Posterior Major and Minor, Obliquus
Teres Minor: The Silver Dollar Pain / 773
Capitis Superior and Inferior: The Rock and
Latissimus Dorsi: Pernicious Midthoracic
Tilt Muscles / 62
Backache / 775
Levator Scapula: The Stiff Neck Muscle / 64
Teres Major: Twin to Latissimus Dorsi / 777
Anterior Cervical Muscles / 66 Sternocleidomastoid: Amazingly Complex / 66 Scalenes: Anterior, Medius, and Posterior: The Entrappers/ 68
Anterior Suboccipitals / 70 Rectus Capitis Anterior and Rectus Capitis Lateralis / 70 Longus Capitis and Longus Colli: Military Neck / 77
Suprahyoid Muscles / 72 Mylohyoid / 72 Geniohyoid / 73 Digastric: Pseudo-sternocleidomastoid Pain / 74
Head and Face Muscles / 75 Occipitalis: The Scalp Tensor / 75 Frontalis: The Scalp Tensor / 77 Corrugator Supercilii / 78 Temporalis: Temporal Headache and Maxillary Toothache / 79 Masseter: The Trismus Muscle / 80
The Pterygoid Muscles / 82 Medial Pterygoid: Ache Inside The Mouth / 82 Lateral Pterygoid: TMJ Dysfunction / 83
Serratus Anterior: Stitch in the Side Muscle / 778 Rhomboids, Major and Minor: Superficial Backache and Round Shoulder Muscles / 779 Deltoid: A Dull Actor / 727 Serratus Posterior Superior: Cryptic, Deep, Upper Back Pain / 723
Thoracolumbar Paraspinals: Lumbago / 124 Spinalis / 724 Longissimus / 726 Iliocostalis / 728 Semispinalis / 730 Multifidus / 737 Rotatores / 733
Anterior Shoulder/Chest Area / 135 Sternalis: Anomalous Substernal Ache / 735 Pectoralis Major: The Poor Posture and Heart Attack Muscle / 737 Pectoralis Minor: Neurovascular Entrapper / 740 Subclavius: Poor Posture and Heart Attack / 742 Subscapularis: The Frozen Shoulder Muscle / 744
ARM,WRIST,AND HAND / 163 Upper Arm (Brachium) / 164
UPPER TORSO / 103 Posterior Shoulder/Upper Back Area / 104 Trapezius: The Coat Hanger / 704
Biceps Brachii: A Three-Jointed Motor / 1 64 Coracobrachialis: Hide and Go Seek / 1 66 Brachialis: Workhorse Elbow Flexor / 1 67 Triceps Brachii: Three-Headed Monster / 1 69 xiii
x iv
LIST OF MUSCLES
Forearm / 171 Brachioradialis: Painful Weak Grip / 1 71 Supinator: Tennis Elbow / 1 73
Extensor Group: Painful Weak Grip / 175 Extensor Carpi Radialis Longus / 1 75 Extensor Carpi Radialis Brevis / 1 77 Extensor Digitorum / 1 78 Extensor Carpi Ulnaris / 1 80 Anconeus: The Little Helper / 1 81
HIP, THIGH,AND ANTERIOR KNEE / 245 Posterior Hip / 246 Gluteus Maxim us: The Swimmers Nemesis / 246 Gluteus Medius: Lumbago Muscle / 248 Gluteus Minimus: Pseudo Sciatica / 250 Piriformis: The Double Devil / 252 The Other Five Short Lateral Hip Rotators / 253
Posterior Thigh: Chair-Seat Victims / 255
Flexor Group: Lightening Pain and
Hamstrings: Biceps Femoris, Semimembranosus,
Trigger Finger / 183
and Semitendinosus / 255
Flexor Carpi Radialis / 1 83 Flexor Carpi Ulnaris / 1 85 Flexors Digitorum Superficialis and Profundus / 1 87 Palmaris Longus / 1 89 Pronator Teres / 1 91
Wrist and Hand / 192 Adductor and Opponens Pol/icis: Weeders Thumb / 1 92
Anterior Thigh / 257 Tensor Fascia Latae: Pseudotrochanteric Bursitis / 257 Sartorius: Surreptitious Accomplice / 258 Quadriceps: The Four-Faced Troublemaker / 259
Lateral Thigh / 263 Iliotibial Band / 263
Flexor Pollicis Longus: Lightening Pain / 1 94
Medial Thigh / 264
Extensor Indicis: Stiff Fingers / 1 95
Adductors: Obvious Problem-Makers / 264
Interossei and Lumbricals: Associates of
Gracilis / 264
Heberden's Nodes / 1 96
Pectineus: The Fourth Adductor / 266
Abductor Digiti Minimi / 1 98
Adductor Brevis and Longus / 267 Adductor Magnus / 268
• LOWER TORSO AND ABDOMEN / 215 Quadratus Lumborum: Trochanteric Bursitis / 216
• LEG WITH POSTERIOR KNEE,ANKLE, AND FOOT / 285
Serratus Posterior Inferior: Nuisance Residual Backache / 218
Anterior Leg Area / 286
External and Internal Obliques: Pseudovisceral
Tibialis Anterior: Foot-Drop Muscle / 286
Pain / 21 9
Extensor Longus Group: Muscles of Classic
Transverse Abdominis: Pseudovisceral Pain / 221
Hammer Toes / 288
Rectus Abdominis and Pyramidalis: Pseudovisceral Pain / 223 Iliopsoas: The Hidden Prankster / 226 Intercostals / 228 Diaphragm / 230
Dorsal Foot Area / 290 Extensor Digitorum Brevis, Extensor Hal/ucis Brevis, and the Dorsal Interossei: Sore Foot Muscles / 290
LIST OF MUSCLES
Plantar Foot Area / 292
Posterior leg And Ankle Area / 301
Abductor Hallucis, Abductor Digiti Minimi,
Gastrocnemius: Calf Cramp Muscle / 307
and Flexor Digitorum Brevis: Sore
Soleus: Jogger's Heel / 303
Foot Muscles / 292 Quadratus Plantae, Lumbricals, and Interossei: Vipers' Nest / 294 Adductor Hallucis, Flexor Hallucis Brevis, and Flexor Digiti Minimi Brevis: Vipers' Nest / 296
lateral leg Area / 298 Peroneal Group: Peroneus Longus, Peroneus Brevis, and Peroneus Tertius-Weak Ankle Muscles / 298
xv
Flexor Longus Group / 305 Flexor Digitorum Longus and Flexor Hallucis Longus: Claw Toe Muscles / 305 Tibialis Posterior: Runner's Nemesis / 308
Posterior Knee Area / 310 Popliteus: Bent-Knee Troublemaker / 370 Plantaris: Jogger's Heel / 372
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PART I Neuromuscular Therapy Basics
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INTRODUCTION TO NEUROMUSCULAR THERAPY Acute� of recent onset
Noxious: harmful or painful
Chromc: of long standing
Postural and biomechanical dysfunction: abnormal function of
Concentric strain: a condition in which a muscle is chronically
the body because of poor posture and poor biomechanics
shortened because of overuse or postural dysfunction; its
Range of motion the amount of movement of a joint
opposing muscle will most likely be eccentrically strained,or
Trigger point: an area of hypersensitivity that when
overstretched
compressed creates referral sensation at a distance from that
Etiology: the cause of disease
area
Hypertonicity: excess muscular tonus
Trigger point referral: the sensation felt at a distance from a
Ischemia: local and temporary deficiency of blood supply
trigger point
Neuromuscular therapy is a comprehensive and advanced system
come injuries and postural dysfunction. If we can balance each
of soft tissue manipulation that specializes in working with chronic
area of the body, we can help people change their posture and
myofascial pain and pain syndromes. On the basis of neurologi
gait. This work may also be used to enhance the function of
cal laws, this therapy works toward bringing the body's central
joints, muscles, and general biomechanics of the body while
nervous system into homeostatic balance with the musculoskeletal
speeding healing by the facilitation of release of endorphins, the
system using various Swedish massage strokes, such as effleur
body's natural painkillers.
age, petrissage, and deep transverse friction, along with trigger point release. Neuromuscular therapy techniques, along with a thorough structural evaluation, are needed to understand and treat the causa
Neuromuscular therapy has many broad applications in today's health care setting. It is used to treat people who suffer from acute or chronic pain stemming from various injuries, such as those related to the following:
tive factors involved in acute, or of rapid onset, and chronic, or
•
Sports injuries, such as strains and sprains
long-lasting, myofascial pain and dysfunction. Specifically, neu
•
Automobile injuries, such as whiplash
romuscular therapy is used to deactivate trigger points in muscle,
•
tendon, and ligaments. It is also used to lengthen chronically short ened muscles and balance muscle groups, especially when working
•
with people suffering from postural dysfunction or distortion, such as internal rotation of a shoulder girdle or scoliosis. Thus, being trained in this therapy will allow a massage thera
Repetitive strain injuries, such as epicondylitis, carpal tun nel syndrome, etc. Accumulative trauma injuries, such as temporomandibular joint dysfunction
•
Skeletal problems, such as spinal disc herniation
pist to specialize in working with chronic myofascial pain and
There are, of course, many more uses for this technique. There
pain syndromes and take an active role in helping people over-
are only a few contraindications, however. The most common
3
4
NEUROMUSCULAR THERAPY BASICS
PART I
include large bruises, phlebitis, varicose veins, o/Jen wounds, and
amount of movement in any given joint, that has been com
skin infections.
promised by pain and discomfort.
In addition to massage therapists, many other health care
By lengthening chronically shortened muscles, this ther
/Jrofessionals use neuromuscular therapy today. T hese include
apy helps clients recover their range of motion. By deacti
chiro/Jractors, /Jhysiatrists, nurses, physical therapists, occupa
vating trigger points, it relieves clients of the pain and other
tional thera/Jists, osteopaths, and dentists.
sensation brought about by the trigger points.
The /Jur/Jose of this chapter is to introduce you to neuromus
Not only does neuromuscular therapy treat pain and sensa
cular therapy and provide you with foundational information you
tion that is local to trigger points, but it also treats pain that is
will need to become an effective /Jracritioner of this modality.
"referred" to parts of the body distant from the actual site of
S/Jecifically, we will consider how neuromuscular therapy works,
the trigger point. This type of pain is known as referred pain.
what the key com/Jonents of a session are, a brief history of the
Skeletal muscle makes up approximately 50% of the
modality, goals and therapeutic intent, knowledge and tools
body's weight and can develop trigger points that produce
required, and how to effectively relate to clients.
sensations such as varying degrees of pain, itching, tickling, and thermal sensation (hot or cold). It is daily activity that
HOW ITWORKS In neuromuscular therapy, therapists first assess the body's
causes the most wear and tear on the muscle tissue in our bodies. If the client is experiencing pain as the sensation of referral from trigger points, it could be extreme pain.
soft tissues to locate chronically shortened muscles and trig ger points, using effleurage, petrissage, and friction. Once
COMPONENTS OF THE TECHNIQUE
the areas in question are identified, more specific techniques
The technique approach in this text is an integration of sev
are used. Lengthening techniques such as myofascial release, deep
eral different approaches that produce optimum therapeutic
effleurage, muscle stripping, and passive stretching are per
impact when working with chronic myofascial pain. The fol
formed to help break the concentric strain, or chronically,
lowing is the list of the components of this approach: Health history intake, evaluation, and assessment skills
pathologicall y shortened muscles. A concentric contraction
•
occurs in a muscle when both ends of the muscle are brought
•
Soft tissue assessment and treatment
closer together, shortening the muscle during the active
•
Trigger point therapy (Fig. 1-2)
phase of muscle contraction. Trigger point pressure or a pin
•
cer technique is used to deactivate the trigger points formed
Myofascial release and other lengthening techniques
•
in the soft tissues (Fig. 1-1). Once a client is able, practi tioners add active stretching to the treatment schedule. This helps the client to increase range of motion, or the
Passive stretches, muscle energy technique, and active stretching
•
Postural stress analysis
•
Identifying and reducing perpetuating factors
•
Client management and follow-up
These components will be discussed in greater detail throughout the book.
HISTORY There have been many people involved with the origins of neuromuscular therapy. Most agree that the first to discover and develop this technique was a European named Stanley Lief, who was trained in osteopathy and naturopathy. Lief established a famous natural healing resort, Champneys, in Hertfordshire, England, in 1925. Along with Boris Chaitow, his cousin, Lief studied with teachers such as Dewanchand Vanna and Bernard MacFadden to become competent with the concepts of assessment and treatment of soft tissue dys •
FIGURE '-1
Horse receiving neuromuscular therapy. Even horses
function. Lief and Chaitow, also trained in osteopathy and
have trigger points that can be effectively deactivated using
naturopathy, began using these methods of assessment and
neuromuscular therapy.
soft tissue manipulation on the patients coming to the
C HAPTER
1
I NTRODUCTION TO NEUROMUSCULAR T HERAPY
5
trigger points on examination of the muscle is the presence of exquisite tenderness at a nodule in a palpable taut band." Over the course of several decades, neuromuscular therapy as a distinct system began to develop, supported by the writ ings of Janet Travell and David Simons. In the late 1970s, a student of Nimmo, Paul St. John, began teaching his system of this technique. He has traveled the United States training massage therapists and challeng ing the massage industry to become competent in the study of anatomy and kinesiology. Judith (Walker) Delany began teaching with St. John in the mid-1980s and has gone on to develop her own version of this modality, teaching it across the United States. St. John has recently upgraded his teaching program and renamed it as "Neurosomatics." Specifically, his program applies Travell and Simons' information about radiography to determine core body asymmetry and shoe reconstruction to help correctly realign posture. European and American versions of neuromuscular therapy are very similar in theory but different in the hands-on tech niques. Both versions agree on the need to incorporate a home-care program encouraging clients' commitment and participation in their healing process. A primary focus for both •
FIGURE 1-2
Pressure to a trigger paint.
versions is to understand the formation, the cause of disease, or etiology, and treatment of trigger points, locating the source of
healing resort. They spent the years between the late 1930s
referral, any perpetuating factors, and reducing and or elimi
and early 1940s testing and developing these theories and
nating them. One of the goals of this method of soft tissue
techniques. The techniques they used then very closely
manipulation is to promote the person to independence.
resemble the techniques we use today. Lief's idea of neu
Janet Travell and David Simons published a two-volume
romuscular therapy (called "neuromuscular techniques" in
set of textbooks for the medical professions, called Myofascial
Europe) incorporated a holistic approach to healing by using
Pain and Dysfunction: The Trigger Point Manual, that has
nutrition, psychology, hydrotherapy, and soft tissue manipu
impacted the medical, dental, and massage communities.
lation.1 Lief's methods eventually became incorporated into
This is the first definitive exposition on myofascial trigger
the training system at the British College of Naturopathy
points, making these coauthors true pioneers in the under
and Osteopathy.
standing of trigger points and myofascial pain.
Since then, several other osteopaths and naturopaths,
Before treating pain, Dr. Travell taught clinical phar
such as Peter Lief, Brian Youngs, Terry Moule, and leon
macology at Cornell University and was a heart specialist
Chaitow, have further developed this work. Osteopaths and
in New York in the mid-1950s. Interestingly, her father,
chiropractors have included the use of some of the tech
Dr. Willard Travell of New York City, had specialized in
niques used with neuromuscular therapy to manipulate soft
the study of pain, and particularly the pain of muscle
tissue. It has been this use of techniques that has helped to
spasms. later, she served as President John F. Kennedy's
develop this work. Neuromuscular therapy is consequently
personal physician, treating his chronic back problems.
now being taught in osteopathic and sports massage institu
She became a specialist in treating muscle pain and, in
tions in Great Britain.
general, pain management.
Within a few years of neuromuscular therapy emerging in
Janet Travell published more than 40 papers on myofas
Europe, Americans Raymond Nimmo and James Vannerson
cial trigger points between the years 1942 and 1990. David
published a newsletter called the Receptor Tonus Techniques.
Simons has long experience as a research scientist and
In this publication, they described their experiences with
worked as an aerospace physician. After hearing a lecture by
noxious nodules. These noxious nodules are what we now
Janet Travell, he was intrigued by her work. When he retired
call trigger points. According to Travell and Simons, "It
from the Air Force, he began an apprenticeship with her.
now appears that the most reliable diagnostic criterion of
They worked together for 20 years before producing The
6
PART I
NEUROMUSCULAR THERAPY BASICS
Trigger Point Manual. The first volume of The Trigger Point
neuromuscular therapy techniques. When using neuromus
Manual was published in 1983.
cular therapy techniques, the therapist works directly on muscle bellies, origins, and insertions. It is important to
GOALS AND THERAPEUTIC INTENT As with any type or style of bodywork, the therapist's intent is important. With the proper intent, the therapist's energy may actually help make the work more dynamic. This, along with choosing the correct approach for the area of the body being worked, should be given serious consideration. Historically, neuromuscular therapy involves a thorough and systematic examination of the muscles and other soft
know this information along with fiber direction of each muscle in both theory and practice. That is, the therapist should not only be able to cite attachments but should also find them on the body and palpate them. The therapist must also have an understanding of nerve reflexes and nerve physiology to be effective when using neuromuscu lar therapy, as the nervous system plays a central role in producing and perpetuating chronic pain.
tissues to isolate and identify "noxious" (harmful or painful)
"If you really want to utilize your intuition, know your
points and then treat these tissues with various methods. An
-Paul St.John
essential theoretical component to the approach is that the practitioner is working directly and therapeutically with the neuromuscular system, function of which is adversely affected in the establishment of chronic myofascial pain. The goals and therapeutic intent of neuromuscular ther apy are as follows: •
Identify and isolate tissue irregularities related to chronic myofascial pain, perhaps mapping these on a body chart for future reference
•
Restore local tissue circulation and reduce ischemia local and temporary deficiency of blood supply-so that the tissues there will begin to heal
•
Reduce hype r tonicity-excess muscular tonus-and spasm to regain integrity
•
Reduce soft tissue pain
•
Reduce and eliminate noxious or excessive nerve stim ulation and normalize reflex activity of the neuromus cular system
•
Reduce and eliminate trigger points
•
Restore normal range of motion to affected muscles
•
Release related adhesions or fascial binding and lengthen chronically shortened muscles, fascia, and other soft tissue
•
Identify and reduce or eliminate the perpetuating fac tors that continue to aggravate the trigger points and chronic pain patterns
KNOWLEDGE AND TO O LSREQUIRED
anatomy!"
Along with anatomic precision comes a much more com prehensive style of bodywork that invites one's intuition to come into play. To be able to use intuition, there must be a core body of knowledge to draw on. A neuromuscular thera pist armed with precise anatomical and kinesiological knowledge, along with an understanding of the theory and practice of neuromuscular therapy, will be able to use any intuitional responses he comes across when reading over a client's health history form and assessment information and/ or when actually working with the client's soft tissues. Without the core body of knowledge, the intuition has no way of producing information. This is a faSCinating subject that takes interest or passion, study, practical use, and time to master. You are encouraged to continue to study anatomy through all available means. Being able to palpate and work at an exact attachment site of any muscle is crucial to the success of this work.
Analysis and Kinesiology The therapist also needs to develop an overall orientation to stress and trigger points with respect to the interrelatedness of the body's structure and position. An understanding of struc tural kinesiology is a must here. Body reading, postural stress analysis, and an examination of the client's everyday use of his or her body must become a part of a therapist's repertoire to reduce and eliminate structurally based soft tissue problems.
Tools
Neuromuscular therapy is an advanced form of soft tissue
Besides being armed with knowledge, you also must have the
therapy that requires skills and integration of several tech
proper tools with which to practice neuromuscular therapy.
niques. The following principles are essential to your success of this work.
Anatomy
As with many forms of massage, an effective lubricant is needed. Small amounts of lubrication-using gel, oil, lotion, or cream-are required at certain times during each session' to mildly reduce friction to the skin. It is important, however, to
A precise and thorough knowledge of musculoskeletal
use only as much lubrication as necessary to be able to prop
anatomy is necessary to confidently and effectively use
erly engage the tissues, such as when performing effleurage, as
C HAPTER
1
I NTRODUCTION TO NEUROMUSCULAR T HERAPY
7
Dependency, Participation, and Support As a massage therapist, you should feel privileged to serve each client and be a part of his or her support system in life. However, you should be careful to not become part of
a
dependency system. A dependant client is not a healthy client, as he is look ing for a therapist, nurse, doctor, physical therapist, and so forth, to "fix" his problem. This is a client who feels "less than" the person he is dependant on. This places the thera pist, in this situation, in a "greater than" position in the client's mind. The client then has expectations that the therapist will fix his problem, and his own responsibility ends there. We want the client to feel responsible for his •
FIGURE 1-3
T-Bar pressure bar. Pressure bars are wooden tools
with rubber or plastic tips that can be used to apply pressure into the tissues.
recovery rather than expecting us to do it all for him. For a client to recover and stay healthy, he must take on some responsibility and understand that the therapist is only one of the tools he is choosing to use to recover. Now the
a small amount of drag against the skin is required for this.
responsibility of recovery is his.
Most nerve endings are at the level of skin. If you do not use
To avoid this dependency system, encourage your clients
a small amount of friction against the skin when treating an
from the very first session to participate in the therapy and
area, you will miss the opportunity to treat tissue and bone
assist you in understanding their conditions.
directly below that area. Certain techniques, however, are performed on dry skin to increase effectiveness. For example, when using any myofascial release techniques during a ses sion, begin with them so they can be done before lubricating . for best effectiveness. In addition, pressure bars can be an invaluable asset in performing this modality. Pressure bars are wooden tools with rubber or plastic tips that can be used to apply pressure into the tissues. One such tool, a TBar with a beveled rub ber tip, is used in routines presented in this book (Fig. 1-3). Pressure bars are particularly useful to reduce strain on the thumbs in doing extensive amounts of therapy, such as six to eight sessions per day. When using a pressure bar, be sure to hold it in a stable manner. With enough practice, the pres sure bar will become a natural extension of the hand. Another tool, called "Thumby," may be used to apply effleurage, friction, and trigger point pressure. It is also an excellent tool for a client to use at home for trigger point work. This is a device made of silicone and, like a pressure bar, can help reduce the strain on hands and thumbs, in particular.
RElATING TO THE CLIENT
Client-Therapist Communication To succeed in this vital work and to encourage participation from the client, you must establish effective, two-way com munication with the client. Specifically, during the first ses sion, communicate with the client to determine the extent of ischemia in tissues, find the location and referred zones of trig ger points, and determine the ability of the tissues to release spasms and respond to the therapy. This communication can be accomplished by asking the client the following three ques tions and listening carefully to his or her responses.
1. Where is it tender or sensitive to my touch? Tlssues that are in a hypercontracted state are more tender than that of healthy, flexible tissues. In questioning the client about this, be careful not to use words that may have a negative connotation, such as "painful" or "hurt ing." Use more positive terms when referring to tissues, such as "tender" or "sensitive," so that the client does not associate your work with causing pain. Furthermore, many therapists ask their clients to rate their discom fort on a scale from 1 to 10, with 10 being the greatest discomfort. Having this information will not only let you know what your client is experiencing at the
Another critical consideration when performing neuromus
moment but also how effective the treatment is later,
cular therapy is how you relate to the client. Discussed below
when you again ask them to rate their discomfort.
are how to avoid fostering dependency in your client and
2. Do you feel any referred sensations to other parts of
how to promote his or her participation and provide sup
your body? Explain to the client what "referred"
port. Also discussed is how to effectively communicate with
means and that these sensations might include tin
the client during therapy.
gling, burning, numbness, pain, or thermal sensations.
8
PART I
NEUROMUSCULAR T HERAPY BASICS
It is important for the client to know that a referral sensation may be something other than pain. Without that knowledge, a client might not relate to the thera pist certain sensations that may be coming from trig ger points and the work you are doing with them. Often when discussing trigger points, therapists, teachers, and authors call the referral sensation a referral pain only. When this is the case, some may not understand that pain is only one of several sensa tions that can occur because of trigger points.
3. Do you feel a release or decrease in discomfort as
I
press on this area? Ask this question as you are pressing and holding a trigger point for 10 or more seconds. If you are using the numbered scale, as described above, have the client rate the level of discomfort from moment to moment to indicate any changes. Some therapists, how ever, find this method distracting to clients-possibly causing them to focus more on the discomfort itself than on the release-and simply ask clients to let them know when the discomfort changes or lessens. Try both systems to see which works best for you.
PRECAUTIONS Precautions must always be taken when working with a cli ent. This helps us keep our work safe for the client to receive. Some precautions are very general and are used with any massage work, whereas others are quite specific to an area. These precautions include, but are not limited to, things such as being sure the client does not have an unstable heart condition, untreated high blood pressure, brittle diabetes (especially when working on legs), varicosities, bruises, phle bitis, broken bones, inflammation, and sunburn. Fears of being injured during bodywork need to be considered, along with restricted range of motion, very recent surgery, an upcoming sports event within the next 5 days, or degenera tive arthritis, pregnancy, and disc herniation. Precautions regarding the performance of this work include being sure that the referral patterns, pain, and trigger points you are treating actually lend themselves to neuromus cular therapy. A client demonstrating signs of swelling, discoloration, or neurological symptoms should be referred to the appropriate health care provider.
C H APT E R S UMM ARY In this chapter, we have looked a t some of the basics of neu
how to relate effectively with clients. However, it is important
romuscular therapy, including a brief explanation of how it
to note that you need more than this information to adminis
works, its components, and its history. We have also consid
ter a neuromuscular therapy session; you need to use critical
ered the goals of this modality and the importance of thera
thinking in applying this information. You may then ensure a
peutic intent when performing it. Finally, we have learned the
treatment session that will produce the most effective results
essential knowledge and tools required for this therapy and
possible in the shortest amount of time necessary.
CHAPTER
1
I NTRODUCTION TO NEUROMUSCULAR THERAPY
9
REVIEW QUESTIONS
Short Answer Questions 1. Describe neuromuscular therapy.
2. List at least three of the goals and therapeutic intents of neuromuscular therapy. 3. Regarding the approach for neuromuscular therapy, list
C. Good jokes, problems with coworkers, and family issues D. All of the above
10. Which types of injuries may be treated using neuromus cular therapy? A. Acute trauma and infections
at least three of the components of performing this
B. Repetitive strain and automobile accident injuries
modality.
C. Organ failure and accumulative trauma
4. Name three techniques that are used to help locate chronically shortened muscles and trigger points.
5. Neuromuscular therapy is a specialized technique. Which systems of the body does it tend to balance? Multiple Choice Questions 6. What is necessary to apply neuromuscular therapy
effectively and with confidence? A. Palpatory artistry and good luck B. Preci e and thorough knowledge of anatomy C. A medical degree D. Really strong hands
7. Who are known as the pioneers of trigger point therapy and myofascial pain? A. Raymond Nimmo and James Vannerson B. Stanley Lief and Boris Chaitow C. Peter Lief and Leon Chaitow D. Janet Travell and David Simons
8. In communicating with clients, many therapists like to use which of the following to evaluate the client's dis comfort level and the effectiveness of trigger point release? A. A verbal discomfort scale from 1 to 10 B. A stethoscope C. A medical reflex hammer D. Needles
9. When establishing communication with the client, what three areas are important to discuss with the client? A. Codependency, delinquency, and stress levels B. The extent of ischemia, location of trigger points and referrals, and whether the tissues are releasing/ responding to the work
D. Inflammation and open wounds True/False 11. The techniques we use to assess and locate chronically
shortened muscles and trigger points arc effleurage, petrissage, and friction.
12. Paul St. John was the first person to discover and develop neuromuscular therapy in Europe.
13. The term acute usually refers to an injury of recent onset.
14. We u e very small amounts of lubrication when treat ing with neuromuscular therapy so that we can use friction to more effectively stimulate the nerve endings in skin.
15. It is not necessary to have an understanding of struc tural kinesiology when using neuromuscular therapy. Matching a. Pressure bars
d. Range of motion
b. Postural dysfunction
e. Referral sensation
c. Concentric contraction
f. Eccentric contraction
16. What one feels at a distance from an active trigger
point?
17. Internal rotation of a shoulder girdle and scoliosis are examples of what?
18. Name a wooden tool with various rubber or plastic tips. 19. A type of contraction in which the muscle shortens in response to tension.
20. Name the term used for the available movement at a given joint?
10
PART
I
/
NEUROMUSCULAR THERAPY BASICS
R EF E R E N C E 1. Chaitow L. Modem Neuromuscular Techniques. Philadelphia: Elsevier, 1996.
NEUROMUSCULAR PHYSIOLOGY Active trigger point: a trigger point that causes clinical pain
that body part; it includes a large group of conditions that
complaints; it is always tender, prevents the musCle from
result from using the body in a repetitious way causing
fully lengthening, causes muscular weakness, refers
injury;it is also known as repetitive strain injury
sensation that is obvious to the client, and causes
Radiculopathy. any diseased condition of roots of spinal
sensation to the reference zone
nerves;the sensation caused by such disease
Biomechanics' the study of the forces exerted by soft tissue
Reciprocal inhibition: inhibition to muscles antagonistic to
(muscle) and gravity on the skeletal system
those being facilitated; this is essential for coordinated
Hypertrophy: increase in a muscle's size without an increase
movement
in the number of cells
Reference or referral zone: sensory and motor phenomena such
Key trigger point: a trigger point responsible for activating
as pain, itching, and thermal sensation caused by a trigger
one or more satellite trigger points
point while occurring at a distance from the trigger point
latent trigger pOint: an inactive trigger point;it will be tender
Sarcomere: the portion of striated muscle fibrils between two
and refer sensation only upon palpation
Z-disks
Medulla oblongata: an enlarged portion of the spinal cord
Sarcoplasmic reticulum: a network of fine tubules filled with
above the foramen magnum;the lower portion of the
fluid present in muscle tissue
brainstem
Satellite trigger point: a central trigger point induced by the
Motor endplate' a plate ending where a branch of the axon
activity of a key trigger point
or a motor neuron makes synaptic contact with a striated
Stress factor. any stress-inducing condition that aggravates
muscle fiber
a trigger point and its referral pattern, leading to pain/
Neuropathy: disease of the nerves
sensation
Overuse syndrome: a condition in which a part of the body is
Z-disk: a thin, dark disk that transversely crosses through and
injured by repeated overuse or exerting too much strain on
bisects the clear zone of a striated muscle fiber
To be able to effectively use neuromuscular therapy, you must first have an understanding of the underlying physiology of the neuromuscular system. That is, you need to know on a physio logical level what causes pain and trigger points and how they may be effectively treated. Specifically, this chapter introduces stress factors, along with the physiology involved with trigger points and referrals. It then presents rehabilitation and, finally, a discussion of the laws of physiology.
TRIGGER POINTS Daily activity, along with its corresponding stress to muscle tissue, is our primary source of postural dysfunction and, hence, trigger points. Trigger poihts can develop in any of our 200 pairs of skeletal muscles, which are responsible for almost 50% of body weight. In this section, we will briefly consider the history of trigger point research, trigger point 11
12
P A RTI
N E U R O M U S C U L A R THE R A P Y B A SIC S
anatomy and biochemistry, muscle structure and pain, the interaction of trigger points with the nervous system, and trigger point activation.
A
Trigger Point Complex Nodule
Brief History of Trigger Point Research
Our understanding of trigger points has evolved over time. Many people have "discovered" them and given them differ ent names. In 1900, Adler first came upon trigger points, referring to them as "muscular rheumatism, " whereas a text book from 1904 by Gowers described them as "fibrositis. " In G ermany, a paper was written by Schade, in 1919, about trigger points calling them "myogelosis. " Our understanding began to grow from there, and we now have the definitive exposition written by Janet Travell and David Simons, Myofascial Pain and Dysfunction: The Trigger Point Manual.1 The first edition of Volume I (Upper Half of Body) was pub lished in 1983, and Volume II (The Lower Extremities) was published in 1992. Before writing the Trigger Point Manual, Travell wrote more than 40 papers on the subject. One writ ten in 1942 described trigger points as "idiopathic myalgia. " She then published a paper in 195 2 referring to trigger points as "myofascial trigger points, " a term that has with stood the test of time. Anatomy of a Trigger Point
A trigger point is a relatively small hard lump typically found within a taut band of muscle fiber that is quite sensi tive or tender to the touch. It may take some practice on the part of the therapist to be able to locate the epicenter of the muscular nodule, or the trigger point. When there is a trig ger point present, there is intense contractile activity in the absence of nerve excitation. This is similar to a muscle cramp but will be a small, circumscribed area within the muscle rather than the entire muscle. There is usually not any inflammation present, yet Travell and Simons cite stud ies that seem to indicate there may be ischemia present. See Figure 2-1 for further information. In Figure 2-1, we see a trigger point complex. This is show ing contraction knots that most likely make trigger points feel nodular and cause a taut band within a muscle. This figure presents an explanation of the palpable nodules and the taut bands associated with trigger points. P art B illustrates three single contraction knots within normal muscle fibers, show ing that beyond the thickened segment of contractured mus cle fiber at the knot, the muscle fiber becomes quite thinned, consisting of stretched sarcomeres in compensation for the contractured ones in the knot. The upper right portion of part B shows contraction knots separated by empty sarcolemma. According to Travell and Simons, this may represent one of the first irreversible complications that result from the con tinued presence of the contraction knot.
B
• FIGURE 2-1 A trigger point. ( Reprinted with permission from Simons D G, Travell J G, Simons L S. Upper Half of Body. 2nd ed. Baltimore: Lippincott Williams & Wilkins, 1999. Trovel! & Simons' Myofascial Pain ond Dysfunction: The Trigger Point Manual; vol 1. p. 70, Fig. 2.25).
These muscle fibers containing contraction knots are clearly under increased tension at the knot itself and beyond. Part A of Figure 2-1 indicates that this sustained tension could produce local mechanical overload of the connective tissue attachment structures in the vicinity where the taut band fibers attach. This type of distress to soft tissue would most likely induce the release of sensitizing agents to local nociceptors, producing local tenderness and the characteris tics of a trigger point. Characteristics of Trigger Points
A trigger point in a muscle prevents the muscle from being able to stretch to its full range because of a sensation, usually pain. It also restricts the muscle's strength and endurance. This restriction of stretch range along with a palpable increase in the muscle's tension is usually more severe in more active trigger points. An active trigger point, accord ing to Travell and Simons, is identified when a client can recognize the pain or other sensation that is induced by . applying pressure to the trigger point. The therapist can gently apply transverse friction across a superficial muscle to feel the nodule at the trigger point as well as the tautness in the attachments of the muscle. If the
C H APT E R 2
N E U RO M U S C U L A R PH Y S IO LO G Y
13
work done by the therapist is appropriate and effective, the palpable signs will become less and, at times, disappear. This nodule within the muscle will be extremely sensi tive when palpated. A therapist using the correct pressure to this nodule can markedly reduce this pain response. Most likely there will be limited range of motion when an active trigger point is present. If a therapist attempts a passive stretch beyond this limit, there will be severe pain present due to muscle fibers that are under substantial increase of tension at its resting length. This limitation will not be so great during active movement due to reciprocal inhibition. Range of motion will return to normal upon inactivation of the trigger point and normalization of the taut band. According to Travell and Simons, some muscles demonstrate a more marked limitation due to trigger points than do others. For example, subscapularis is likely to be far more limited by trigger points than would latissimus dorsi. Travell and Simons state that when a client takes an affected muscle into a strong isometric contraction, he will feel pain, and the pain felt will be more marked when the contraction is done when the muscle is in a shortened position. Regarding weakness in an affected muscle, Travell and Simons discuss electromyographic (EMG) studies that indi cate that muscles with active trigger points start out being fatigued. These muscles will fatigue more rapidly and become exhausted sooner than unaffected muscles.
The myosin filament heads are actually a form of the enzyme adenosine triphosphatase (ATP) that contacts and interacts with actin to be able to produce a contractile force. H observed under a microscope, these appear as cross bridges between the actin and myosin filaments. It takes ionized calcium to trigger the interaction between the filaments, and the ATP provides the energy. With each cycle, the ATP releases a myosin head from the actin and then immediately gets ready for another cycle. The presence of calcium is what triggers another cycle. It takes many of these cycles to produce what Travel! and Simons call a "rowing motion, " which is required of many myosin heads o f many filaments to accomplish one smooth twitch contraction. In the presence of both free calcium and ATP, the actin and myosin continue to interact, using energy and force to shorten the sarcomere. This interaction cannot happen if the sarcomeres are lengthened until no overlapping remains between the actin and myosin heads, in other words, when the muscle is being stretched. This is what is beginning to happen in the lower portion of Figure 2-2. Each sarcomere of a given muscle can generate maximum force only in the midrange of its length, but it can expend energy in a fully shortened position trying to shorten further. It is the absence of free calcium that stops the contracti Ie activity of the sarcomeres. 1n the absence of ATP, the myosin heads remain firmly attached and the muscle becomes stiff.
Muscle Structure and Contractile Mechanism
According to Travell and Simons, motor units are the final common pathway through which the central nervous sys tem controls voluntary muscular activity. Figure 2-3 illus trates a motor unit consisting of a cell body of a motor neuron in the anterior horn of the spinal cord, its axon that is passing through the motor nerve to enter the mus cle at its branching into fibers, and the motor end plates where each nerve branch terminates on one muscle fiber or cell. The motor unit contains all of those muscle fibers innervated by one motor neuron. So, we could say that a motor unit includes one motor neuron and all of the mus cle fibers that it supplies. One muscle fiber normally receives its nerve supply from only one motor endplate and therefore only one motor neuron. The motor neuron deter mines the fiber type of all of the muscle fibers that it sup plies. In postural as well as in extremity muscles, one motor unit supplies between 3 00 and 1 500 muscle fibers. The smaller the number of fibers that are controlled by an incli vidual motor neuron, the finer the muscle control in that muscle will be. When the cell body of a motor neuron initiates an action potential, the potential propagates along the nerve fiber or axon to the specialized nerve terminal that helps to form the
To understand trigger points, it is important to understand various points of basic muscle structure and function. Often this information is not emphasized in detail during an initial massage therapy training program. Striated, or skeletal, muscle is a grouping of fascicles with each being a bundle of many muscle fibers. The upper por tion of Figure 2-2 shows the muscle bundle broken down. Each fiber, or muscle cell, is a grouping of thousands of myofibrils in most skeletal muscles. A myofibril is made up of a chain of sarcomeres connected continuously, end to end. The basic contractile portion of skeletal muscle is the sarcomere. The sarcomeres are connected to each other by Z lines, which are like links of a chain. Each sarcomere has many filaments, which consist of actin and myosin mole cules interacting ro produce a contractile force. The middle portion of Figure 2-2 shows a sarcomere in rest length with complete overlap of actin and myosin filaments during max imum contractile force. When in maximum contraction, the myosin molecules push against the Z line to block fur ther contraction. The lowest portion of Figure 2-2 shows an almost fully stretched sarcomere with incomplete overlap of actin and myosin molecules.
Motor Units
14
P A R TI
N E U R O M U S C U L A R TH E R A P Y B A SI C S
Muscle
Muscle shortened
Cross bridges Muscle stretched I
Ca+
Sarcomere
+-,
I
Zline_ ----,
"
/ / / ""-
"
��� / /
I
_I band-----l
�;; "
/
A band
"
"-
�
I
1.--1 band--
• FIGURE 2-2 Structure and contractile mechanism of normal skeletal muscle. ( Reprinted with permission from Simons DG, Travell JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore: Lippincott Williams
& Wilkins, 1999. Travel! & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual;
vol 1. p.46, Fig. 2.5).
neuromuscular junction, motor endplate, on each muscle fiber. On arrival at the nerve terminus, the electrical action potential is relayed chemically across the synaptic cleft of the neuromuscular junction to the postjunctional membrane of the muscle fiber. This message is now an action potential again that propagates in both directions to the ends of the muscle fiber, causing the fiber to contract. It is the firing of all the muscle fibers innervated by one neuron at the same time that produces a motor unit action potential. Interestingly, the diameter of one motor unit in the biceps brachii muscle can vary from 2 to 15 mm. This gives space for the intermingling of the fibers of approximately 15 to 30 motor units. According to Travell and Simons, both EMG and glycogen depletion studies show that the density of muscle fibers supplied by one neuron is greater in the center of the motor unit than toward its periphery.
The Motor Endplate
In terms of what actually causes trigger points on a physio logical level, it seems that the motor endplate is central. Research done by Travell and Simons indicates that spikes in electrical activity, along with spontaneous electrical activity, found in trigger points arise from motor endplates, which are plates ending where a branch of the axon or a motor neuron makes synaptic contact with a striated muscle fiber. To summarize, to contract a muscle fiber must be stimu lated by nerve impulses. These nerve impulses are carried from the brain or the spinal cord to a muscle fiber by axons. Axons are part of a motor neuron. Motor neurons are action causing neurons; that is, their impulses produce action in target cells. Each muscle fiber is innervated and controlled by a motor neuron. This is considered to be neuromuscular interaction.
C H A P TER 2
---f---:i--
Anterior horn
Cell body of motor neuron
Muscle nerve
N E UR O M U S C UL AR P H Y S I OL O G Y
15
pioneers in the study of motor endplates, indicates that regardless of fiber arrangement of a muscle, the principle of the trigger points presenting within a muscle belly applies most of the time. Furthermore, owing to the research by Gunn,} it has been found that trigger points may be caused by neuropathy of the nerve serving the affected muscle. He was able to dem onstrate by way of EMG studies that neuropathic changes are significantly related to trigger points in the paraspinal musculature. This evidence shows that compression of motor nerves can activate and perpetuate a primary trigger point dysfunction at the motor endplate. It has also been found that if endplate dysfunction per sists for extended periods of time, it may eventually lead to chronic fibrotic changes. This research, according to Travell and Simons, has not gone far enough to determine how quickly or under what circumstances this might occur. Neuromuscular Junction
• FIGURE 2-3 Schematic of a motor unit. (Reprinted with permission from Simons DG, Travell J G, Simons LS. Upper Half of Body. 2nd ed. Baltimore: Lippincott Williams & Wilkins, 1999. Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1. p. 48,
Fig. 2.7).
A motor neuron along with the muscle fibers to which it is attached form a motor unit. A muscle fiber is attached to only one motor neuron; a single motor neu ron can innervate from 3 to 2,000 muscle fibers. A motor endplate is where each axon attaches to and innervates muscle fiber. The part of a motor neuron that leads to a muscle fiber is an axon. The connection between terminal branches of an axon and the sarcolemma of muscle fiber is called a "neu romuscular junction." There are many secretory vesicles in the axon tip containing neurotransmitters. These neuro transmitters attach to the receptors, triggering a series of reactions to cause the muscle fiber to contract. Understanding the location of motor endplates is very important when it comes to management of trigger points, according to Travell and Simons. They claim that it appears that the pathophysiology of trigger points is closely associ ated with endplates, and, therefore, we can expect to find trigger points only where there are motor endplates. Endplates in almost all skeletal muscles are located near the middle of each fiber, midway between its attachments, or within muscle bellies. A study done by Coers and Woole
The neuromuscular junction is a synapse that depends on acetylcholine (ACh) as a neurotransmitter (Fig. 2-4). The nerve terminal produces ACh. By doing so, the nerve termi nal consumes energy that is supplied mainly by mitochon dria found in the nerve terminal. The nerve terminal responds by opening calcium chan nels, which allow ionized calcium to move from the synaptic cleft into the nerve terminal. The channels are located on both sides of the specialized portion of the nerve membrane. When many packages of ACh are released, this quickly overwhelms the chemical barrier in the synaptic cleft. Quite a bit of the ACh then crosses the synaptic cleft, reaching the postjunctional membrane of the muscle fiber, where the ACh receptors are located. The chemical barrier decomposes any remaining ACh, limiting its time of action. The synapse can now respond quickly to another action potential.
.���"""""!'!"I-P'!"!"'!Il�-.-J. / Synaptic cleft •
(cholinesterase) Acetylcholine receptors
•
FIGURE 2-4 Cross section of a neuromuscular junction. (Reprinted with permission from Simons D G, Travell J G, Simons LS. Upper Half of Body. 2nd ed. Baltimore: Lippincott Williams
& Wilkins, 1999. Travell &
Simons'Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1.
p. 55, Fig. 2.13).
16
PAR T I
NE UR O M U S C UL AR THER A P Y B A S I C S
Muscle Pain
Interaction with the Nervous System
The subject of muscle pain is vast and, according to Travell and Simons, requires a separate book to adequately cover it. What follows, then, is a brief summary. There are several substances that can sensitize muscle noci ceptors. These would be bradykinin, E-type prostaglandin , and 5-hydroxytryptamine. The combination of these has the potential to sensitize. The release of prostaglandins by noradrenalin may influence the trigger point mechanism at the endplate. Peripheral sensitization of nociceptors would be responsible for local tenderness to pressure, and most likely for referred pain. It is unknown which of these is responsible for this sensitizing of nociceptors at this time. Travel! and Simons state that this offers a fertile field of research investigation that may involve drugs. According to Travell and Simons, much of the suffering from chronic pain is preventable if the acute pain is con trolled promptly and effectively. They go on to claim that clinical examples of the importance of this principle are increasing rapidly. Specifically with regard to trigger points, they refer to Hong and Simons' study4 showing that the length of treatment required for patients who had devel oped a trigger point in a pectoralis muscle because of whip lash injury was directly related to the length of time between the accident and the beginning of trigger point therapy. With longer initial delay, more treatments were required and the likelihood of complete symptom relief decreased. Travell and Simons discuss that there are more recent stud ies that show that different areas of the brain become activated in response to an experimentally induced acute pain as com pared with chronic neuropathic pain. Neuropathic pain shows by positron emission tomography a striking preferential acti vation of the right anterior cingulated cortex regardless of the side of the painful mononeuropathy. Activation of this region of the brain is associated with emotional distress and suffering. Acute pain activates both motor and sensory portions of the cortex, producing a cognitive and motor behavioral experi ence rather than an emotional experience. Travel! and Simons state that these findings emphasize the importance of the affective-motivational dimension in chronic ongoing neuropathic pain that is not involved in acute pain. Chronic pain causes suffering that is processed differently in the brain than is the experience of acute pain. These neurophysiological facts emphasize the importance to the patient and to the health care delivery system of pre venting chronic pain and properly interpreting patients' descriptions and behavior. Newly activated trigger points that are poorly identified and poorly managed can become a major unnecessary cause of expensive, misery-producing chronic pain.
Sensation from an active trigger point can cause a person to be aware of the dysfunction it causes. On the other hand, sensation and/or dysfunction from latent trigger points may be overlooked by a person experiencing them. This person will connect this sensation to a trigger point only if the trig ger point is pressed upon. We must also look at key and satellite trigger points. A key trigger point is responsible for the activity of satellite trigger points. One key trigger point may actually control more than one satellite trigger point. When inactivating a key trigger point, one or more satellite trigger points may also become inactive without any direct treatment. Table 2-1 shows key and satellite trigger points mostly based on a report by HongS about keys in the upper trapezius and sternocleidomastoid muscles and their satellite trigger
•
TABLE 2-1
Muscles That Exhibit Corresponding Key Trigger Points and Satellite Trigger Points
MUjch s.wltb�e'yJrigg�poil1t�
�i!tellite Tngg.PfJlojnt�
Sternocleidomastoid
Temporalis Masseter Lateral pterygoid Digastric Orbicularis oculi Frontalis Masseter
Upper trapezius
Splenius capitis and cervicis Semispinalis capitis Levator scapulae Rhomboid minor Occipitalis
Lower trapezius
Upper trapezius
Scalenes
Serratus posterior superior Pectoralis major and minor Deltoid Extensor digitorum communis Extensor carpi radialis and ulnaris Triceps brachii: long head
Infraspinatus
Anterior deltoid Biceps brachii
Latissimus dorsi
Triceps brachii: long head Flexor carpi ulnaris
Reprinted with permission from Hong Cl. Considerations and recommendations regarding myofascial trigger paint injection. J Musculoskel Pain 7994;2(1):29-59.
C H A P TE R 2
Direct stimuli
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NEU RO M U S C UL A R P HY SIO LO GY
17
-----
-Acute overload -Overwork fatigue -Radiculopathy -Gross trauma
visceral disease -Joint dysfunction -Emotional Spinal
reference zone
•
distress
cord
FIGURE 2-5 Schematic of the central nervous system interactions with a trigger point. ( Reprinted with permission from Simons D G, Travell J G, Simons LS. Upper Half of Body. 2nd ed. Baltimore: Lippincott Williams & Wilkins, 1999. Travel! & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual; vol
1. p. 20, Fig. 2. 1).
points that show up in the digastric, masseter, and tempo ralis muscles. Key trigger points and satellite trigger points are always related, and there is usually a hierarchy. This hierarchy may not be clear when it comes to which came first. What is clear is that certain trigger points in certain muscles are related to those in certain other muscles and that inactivating one of these related trigger points may inactivate others. It may be easy to overlook a key trigger point when the client is com plaining of the sensation caused by a satellite trigger point. Travell and Simons cited a case study done by J. Whiteside (personal communication, 1995). This is an interesting exam ple of a three-step satellite trigger point system that had set into a fourth-year college student. The student complained of a toothache in her right upper jaw, along with an ache in her right upper trapezius, when she studied for long periods of time. She had undergone extensive dental work, includ ing a root canal, without getting any relief. When pressure was applied to a trigger point in her right lower trapezius, she felt the dull ache in the upper trapezius, just as when she studied. Then, in response to pressure on the trigger point in the upper trapezius, she experienced a pain she had not pre viously felt in the right temporal region. Then, in response to pressure on the right temporalis, she felt the pain in the tooth that had been bothering her when studying. The inten ity and extent of the referred sensation depends on the degree of irritability of the trigger point, not on the size of the muscle. Trigger Point Activation
Trigger points are activated directly by acute overload, over work, fatigue, direct impact trauma, and radiculopathy, according to Travell and Simons. Trigger points can be acti vated indirectly, as well, by other existing trigger points, visceral disease, arthritic joints, joint dysfunctions, and emotional distress (Fig. 2-5).
Satellite trigger points are prone to develop in muscles that are within the reference zone of key trigger points, or within the referral zone from a diseased visceral organ. Examples of this would be the area of referred pain from a heart attack, peptic ulcer, or renal colic. Perpetuating fac tors will increase overload stress that converts latent trigger points to active trigger points. With enough rest, along with the absence of perpetuat ing factors, an active trigger point may become latent on its own. Pain and other sensations disappear but can reactivate with new stress. This, according to Travell and Simons, may explain recurrent episodes of the same symptoms over a period of time.
SOURCES OFTRIGGER POINTS AND REFERRALS Although trigger points usually set up within somatic tis sue, they are actually capable of setting up within any of the body's soft tissues and visceral organs. Also, most trig ger points refer from the trigger point in somatic tissue into a referral area also within somatic tissue in a specific pat tern. However, it is possible that a trigger point may refer into any area of soft tissue or visceral organ in the body. There are four distinct patterns of trigger points to referral areas: 1. From somatic tissue into somatic tissue 2. From somatic tissue into a visceral organ
3 . From a visceral organ into somatic tissue 4. From a visceral organ into a visceral organ
LAWS OF PHYSIOLOGY As a massage therapist, and especially as a neuromuscular therapist, it will be important to develop a deep understanding
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of what you are doing when working with others who are in pain. The laws of physiology will be an important tool to help explain what it is we do. It is necessary to learn these laws to be able to properly grasp the physiological principles on which neuromuscular therapy is based. Taber's Cyclopedic Medical Dictionary defines a law of physiology as a scientific principle that is uniformly true for a whole class of natural physiological occurrences. A law is defined as a uniform or constant fact or principle. The fol lowing is a list of laws of physiology that correspond to what we work with as a neuromuscular therapist. Law of Facilitation
When an impulse has passed through a certain set of neu rons to the exclusion of others, it will tend to take the same course on future occasions, and each time it traverses this path, the resistance will be less. The nervous system tends to train itself to find the path of least resistance. When a neural pathway is activated, this is a habitual pattern produced by the body. This law explains why pain often occurs in the same place. It does not take much to aggravate an old injury again. The patterns of pain will usually become a set pattern in the body. With an area that was previously injured or compromised in some way, it is likely that it will take far less stimulation to reinjure. Also, it will take less time to heal that area again. This seems to also explain why the more massage one receives, the easier it is to relax. Davis'Law
If muscle ends are brought closer together, the pull of tonus is increased, thereby shortening the muscle, which may cause hypertrophy. If muscle ends are separated beyond normal, then tonus is lessened or lost, thereby weakening the muscle. If soft tissue is placed under unremitting tension, the tissue will elongate by adding more material. This law seems to indicate that if we do not use it, we will lose it. Imagine a muscle imbalance in which the set of hypertonic muscles has chronically shortened and become hypertrophied while the antagonist set of muscles has become chronically over stretched and weakened. An example of this might be hyper tonic pectoralis major and minor muscles versus weakened, overstretched rhomboid major and minor muscles. Hilton'sLaw
A nerve trunk that supplies a joint also supplies both the muscles of the joint and the skin over the attachments of these muscles. When there is an injury, it is hard to decide whether the pain is coming from the skin, muscle, or joint. Stimulation of any of these areas will have an effect on all of the areas. This seems to explain two things. The first is why working superficially may
create a release of spasm in deeper tissues of the body. The second is why applying the skin rolling technique works to help decrease tenderness in the deeper tissues. Arndt-SchultzLaw
Weak stimuli activate physiological processes; very strong stimuli inhibit physiological responses. This law indicates that one should use a gentle approach, slower and less stim ulating, if one's intent is to activate physiological responses. Using force to an area will be less effective than a gentle, slow approach to deeper work. If we gently stimulate the tissue, it will heal faster than if it is ignored. A weak stimu lus activates tissue healing and growth processes. Trigger points usually give strong impulses that tend to tum off certain processes. An example of this is that a whip lash injury may actually affect the thyroid gland in a nega tive way. So, to tum off a physiological response, one may use a strong stimulus. Thus, we could use deep transverse friction for several minutes to actually stop pain. Pfluger's Laws
Pfluger's laws are a series of laws that explain how a body can transition from acute pain to chronic pain. These describe the progress from acute injury left untreated to chronic pain. Law of Unilaterality If mild irritation is applied to one or more sensory nerves,
the movement will take place usually on one side only, on the side that has been irritated. This law explains that at the site of an injury, the body will respond to the tral.ma with the sensation of pain. Any light stimulation will remain localized. If this person were to experience mild irritation, it may affect the localized site and stay on the side of the body that has been injured. Law of Symmetry If the stimulation is sufficiently increased, motor reaction
is manifested not only by the irritated side but also in similar muscles on the opposite side of the body. This law indicates that if the trauma to the body was great enough, the opposite side of the body may also begin to feel pain. If the therapist uses increasing levels of pressure on one side only during treatment sessions, there will be a bilat eral effect. If the unaffected side were also massaged, the therapist would actually be addressing the injured side indirectly. Law of Intensity Reflex movements are more intense on the side of irritation
and less intense on the opposite side. This law is similar to the law of symmetry, but now the levels of pain have increased.
C H A P TER 2
Law of Radiation
If me excitation continues to increase, it is propagated upward and reactions take place through centrifugal nerves coming from the cord segments higher up. This law indicates that irritation will move up the spinal cord and create reactions in corresponding areas of the body that are innervated by those nerve segments impacted. Spasms and pain above the actual site of injury are possible, which is called "muscle guarding. " In this case, the body is trying to protect the site of injury. Law of Generalization When the irritation becomes very intense, it is propagated in the medulla oblongata, which becomes a focus from which stimuli radiate to all parts of the cord, causing a gen eral contraction of all muscles of the body. When a client is in this state, the therapist must not use rough or intense massage techniques, as they can cause the person's body to go into muscular contractions or complete muscle guarding. This condition is sometimes called "general adaptation syn drome." When a client receives work that is too rough or too deep too quickly, the body's experience is identical to that of receiving trauma. In other words, the therapist can
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19
traumatize this individual's body if gentleness and sensitiv ity are not used. This person's body will react with a general ized contraction of the entire body. Wolff'sLaw
Every change in the form and the foundation of a bone, or in its function alone, is followed by certain definite changes in its internal architecture and secondary alterations in its external conformation. This law is also known as the law of bone transformation. It states that form follows function. Righting Reflexes
Righting reflexes are reflexes through various receptors in the labyrinth, eyes, muscles, or skin that tend to bring the body back to its normal position in space and which resist any force acting to put it into an abnormal position. This law speaks to why we can, for example, have a high shoulder on one side of our body with a tilted occiput high on the other side of the body and still see levelly on a horizontal plane and not feel dizzy. The bones of the face and head will become asymmetrical to realign the eyes and ears to the horizon, allowing us to see straight and not experience vertigo.
C H A PT E R S UMMA R Y In this chapter, we have considered various factors and principles involved with the physiology of neuromuscu lar therapy. You should now have a basic understanding of trigger points and referrals, including their anatomy, biochemistry, sources, interaction with the nervous
system, and activation. The laws of physiology have been presented to give you the information necessary to help a client understand his or her condition and why it will be important for him or her to follow a specific plan to rehabilitate.
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� REVI EW QU ESTIO N S
Short Answer Questions
1 . Describe a motor end plate. 2. What is a statin? 3. What does it take to aggravate a trigger point and its
referral pattern? 4. What is a law of physiology? 5. Name one law of physiology. Multiple Choice Questions
6. The following are characteristics of trigger points:
A. Referred pain, local tenderness upon palpation, adhesion formation B. Jump sign, local twitch response, nerve entrapment, ischemia C. Paresthesia, local twitch response, referred sensa tion, tight bands D. Ischemia, referred sensation, hyperirritable upon palpation 7. The difference between a latent and active trigger point
is that A. a latent trigger point does not exhibit referred sen sation patterns. B. an active trigger point is usually in spasm. C. an active trigger point is clinically painful, whereas a latent one is painful only upon palpation. D. a latent trigger point has not come out of the closet. 8. Which is a suggested reason for why the calcium
switch will not tum off in the presence of a trigger point?
9. Trigger points are activated by
A. playing sports while not eating in a nutritious way. B. uncaring massage therapists applying incorrect pressure during a massage. C. acute overload, overwork fatigue, direct impact trauma, and radiculopathy. D. only indirect methods. 10. Which are patterns of trigger points to referral areas ?
A. From somatic tissue into a visceral organ B. From somatic tissue into somatic tissue C. From a visceral organ into somatic tissue D. All of the above E. None of the above True/False
1 1 . There should be no concern regarding where one begins
when it comes to rehabilitation after a soft tissue injury, because everything helps. 1 2. As a neuromuscular therapist, it is not important to
have an understanding of the laws of physiology to be able to properly grasp the physiological principles of neuromuscular therapy. 1 3. Trigger points usually set up within somatic tissue;
however, they are capable of setting up within any of the body's soft tissues as well as in visceral organs. 1 4 . Radiculopathy is the sensation referring from a trigger
point. 1 5 . Neuropathy is a disease of the bones. Matching
A. Mechanical stress to the sarcoplasmic reticulum
a. Law of Facilitation
g. Law of Intensity
B. The ATP production has been interrupted
b. Davis' Law
h. Law of Radiation
C. The sarcoplasmic reticulum has reabsorbed too much calcium
c. Hilton's Law
i. Law of Generalization
d. Arndt-Schultz Law
j. Wolff's Law
e. Law of U nilaterality
k. Righting Reflexes
D. The person is not taking the right kind of drugs
f. Law of Symmetry
C H A PT E R 2
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21
1 6. When an impulse has passed through a certain set of
1 9. Reflexes that through various receptors i n the laby
neurons to the exclusion of others, it will tend to take the same course on future occasions, and each time it traverses this path, the resistance will be less.
rinth, eyes, muscles, or skin tend to bring the body i nto its normal position in space and that resist any force acting to put it into an abnormal position.
1 7 . Reflex movements are more intense on the side of irri
20. If mild irritation is applied to one or more sensory nerves, the movement will take place usually on one
tation and less intense on the opposite side. 1 8. Every change in the form and the foundation of a bone,
side only, on the side that has been irritated.
or in its function alone, is followed by certain definite changes in its internal architecture and secondary alterations in its external conformation.
REFEREN CES 1 . Simor.s DG, Travell JG, Simons LS. Upper Half of Body . 2nd ed.
4. Hong CZ, Simons DG. Response to treatment for pectoral is
Baltimore: Lippincott Williams & Wilkins, 1 999. Travell &
minor myofasc ial pain syndrome after whiplash.
Simons ' Myofascial Pain and Dysfunction: The Trigger Point
Pain. 1 993 ; 1 ( 1 ):9- 1 3 1 .
Manual; vol 1 . 2 . Coers C, Woolf AL. The Innervation of M uscle , A Biopsy Study. Oxford: Blackwell Scientific Publications, 1 9 59; Fig. 9- 1 5 . 3 . Gunn Cc. Prespondylosis and some pain syndromes following denervation supersensitivity. Spine . 1 980; 5 ( 2 ) : 1 85 .
]
Musculoskel
5 . Hong CZ. Considerations and recommenclations regard i ng myofascial trigger point injection. 2( 1 ) : 29-59.
]
Musculoskel Pain. 1 994;
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CLIENT ASSESSMENT Bruxism: clenching the jaw and grinding the teeth, especially
Paradoxical breathing patterns: an imbalance in osseous
during sleep
structures above the core (determined by the integrity of
Informed consent: competent and voluntary permission for a
the fascial planes of the body) that causes the osseous and
procedure, test, or medication; consent given on the basis
myofascial structures to begin to pull down unevenly on
of understanding the nature, risks, and alternatives of the
the respiratory diaphragm, affecting the thoracic inlet and
procedure or test
causing serious implications for the proper functioning of
Inert tissue: tissue remaining in a sluggish state until acted upon by an outside force
IsometrIC contraction' a contraction in which a muscle increases its tension without shortening
our breathing apparatus
Perpetuating factor ' Something that prolongs the existence of a condition, such as neck pain due to improper work station setup causing neck strain daily; also, a chronic condition or disease that a person must learn to manage and work with,
Malocclusion' malposition and imperfect contact of the
such as an athlete with diabetes or a person with post-polio
mandibular and maxillary teeth
syndrome
Orthopedic assessment: the assessment of disorders involving the locomotor structures of the body, especially the skeleton, joints, muscles, fascia, and other supporting structures such as ligaments and cartilage
Orthopedic testing various tests developed to help in the assessment of disorders and injuries of the locomotor
Rotoscoliosis: rather than or along with a lateral curve of the spine, the vertebrae are rotated to one side or the other
Thoracic kyphosis: derived from Greek, meaning humpback or hunchback; an exaggeration or angulation of the normal posterior curve of the spine
structures of the body
As a neuromuscular therapist, you must thoroughly assess your
neuromuscular therapist must have many ways of assessing a
client, as findings of the initial assessment will determine your
client. It is this assessment along with the client's report of
treatment plan, To work effectively and efficiently with any cli
symptoms that give the therapist the clues necessary to form a
ent, it is important that the assessment be correct and encompass as much of the client's lifestyle as possible. Some therapists like to
well-rounded and comprehensive treatment plan. This chapter equips you to effectively assess your client and
have a first session with a client include extra time for the assess
covers such topics as obtaining the client's health history, inter
ment, whereas others like to have the first appointment be only
viewing the client, performing range of motion and postural
about assessment and education of the client, while making a
assessment on the client, palpation, and consideration of predis
second appointment to begin treatment.
posing and perpetuating factors.
A client visiting a neuromuscular therapist will most likely be in pain due to a postural dysfunction or an injury. Thus, a 23
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• HEALTH INFORMATION FORM As a therapist, it is your responsibility to gain comprehen sive health information from the client as the initial por tion of your assessment of each client you treat. It is this information that governs your analysis as well as your for mulation of a therapeutic regimen, or plan, for each client. This health information gives you clues as to contraindica tions, for instance. It is always important to be safe in regard to treatment of a client. This information from the client will also help decide where to begin your work, how long it might take to complete the work, which techniques to employ, and possibly where you might expect to find trigger points. This information must be recorded in a health infor mation form and include a date and the client's signature (Fig. 3-1 ) . Moreover, it is wise to include a disclaimer of diagnosis and any policies regarding treatment and pay ment in a statement in the form prior to the signature. This way, there can be no miscommunication of either your expectations of the client or your intent and treatment policy. The health information form is a legal document and must be filled out, dated, and signed by the client in ink. Should you ever be involved in a lawsuit either as the defendant or as a witness, it will be important to have writ ten on the form further information gained by questioning the client. This should also be in ink with a date and your signature. This information should be preceded by a state ment such as "As stated by the client." This proves that you have done your job well while placing the responsibility for this information on the client. It also demonstrates that the therapist has gained informed consent from the client before beginning treatment. You will most likely want several sections to this form. The first section will contain personal information, such as name, phone number, address, birth date, occupation, and so on. Within this first section be sure to include space for the client's physician and phone number. The second sec tion could include any present symptoms the client is pres ently experiencing; for this you might want to consider check boxes so the client does not have to write much. A third section could have illustrations of bodies, both ante rior and posterior, with instructions to color in any area that has difficulties. A fourth section might include information about previous massage the client has had, any medications being taken and what the medications are taken for, and any previous injuries with the dates they happened. For the final section, you might wish to include a disclaimer that massage therapists do no diagnosis or prescribing, nor do they perform spinal manipulation, and so on. Also consider including a positive statement about the benefits of massage therapy.
Another statement you may wish to place in this final sec tion is a statement of your policy regarding change or can cellation of an appointment. The final thing for this form would be a line for the client's signature and the date. There are many more things that could appear on such a form, however. It might be wise to check out others' health information forms to see what you would like to include. The part of the health information form that is especially important in helping you locate trigger points and pain refer ral patterns in your client consists of simple sketches of the human body, both anterior and posterior views, on which clients may indicate the areas in which they feel discomfort by drawing. On questioning a client who has completed such a drawing, you may darken in the areas that are worse while leaving the other areas of discomfort lighter. This will give you an "at-a-glance" summary of the information regarding the person's pain. When compared with a good trigger point chart, this is very valuable information, as it may show the referral areas from the trigger points this person is experienc ing, helping you pinpoint the actual trigger points. Also, be sure to record any additional information regard ing the quality of the client's discomfort gained from inter viewing the client, as discussed below, on the chart next to the drawings. As the quality of discomfort changes, be sure to chart this information as well. You may go back over this history form again and again looking for more clues as to how to proceed with treatment. The more information that is provided on this form, the more clues there are to consider-it is that simple.
INTERVIEWING THE CLIENT Another critical component of the assessment process is to thoroughly interview the client regarding his or her health. Clients will often not record key information about their health on a health information form, and in other cases infor mation that they do provide will require further explanation. In interviewing the client, remember to be sensitive to the client's feelings regarding his or her pain and previous treatment. Be sure to actively listen to the client's responses to questions while maintaining eye contact. Gaining this person's trust and confidence will be extremely important to the outcome of the course of treatment you decide upon. If the client has no confidence in you or does not think you are competent, he or she will not return for more sessions and/or will not be compliant regarding home care. Another tip regarding interviewing is to have a few refer ence books on anatomy and good, comprehensive trigger point charts on hand. Using these references, you may be able to show clients where the work must be done on them, along with confirming their pain. Again, this goes toward
C L I ENT ASSESSMENT
C H A PT E R 3
HEALTH INFORMATION
Manual Therapist Patient Name
25
_______
Date
________ _
ID#/DOB
Date of Injury A. Patient Information
Address City
____________ __ __ _
State
_______
__
Zip
_ _ __
List Daily Activities Limited by Condition
Work
_________________ __
Phone: Horne Work
______
Employer
_ __ _ ___ _ _
________________
Work Address Occupation
_______________ _
Phone: Horne
______________
_
Cell
________ _
Primary Health Care Provider
Name
_ ________________ _
Sleep/Self-care
_ __ _ _ _ _ __ _ _ _ _
Social/Recreational
___________ __
List Self-Care Routines
How do you reduce stress? Pain?
__ __ _ _ _ _
_________________ _
________________ _
City/State/Zip Phone:
_ _ __ _ _ _ _ __ _ __ _
__ ________ _ _
______
Address
Horne/Family
_____________ _
Emergency Contact
Work
Cell
___ __________
_______
Fax
__ _ __ __ _
List current medications (include pain relievers and herbal remedies)
__________ __
I give my massage therapist permission to consult with my health care providers regarding my health and treatment. Comments Initials
_ _______________
______
_ _ _ _ __ _ _
Have you ever received massage therapy before?
___
Frequency?
_______ _
B. Current Health Information
What are your goals for receiving massage
List Health Concerns Check all that apply
therapy?
Primary
D D D D
symptoms i w/activity
D J, w/activity getting worse D getting better D no change
Secondary
D D D D
_ __________ _
C. Health History
List and Explain. Include dates and treatment received. Surgeries
________________ _
_ ______________ _
D moderate D disabling D intermittant symptoms i w/activity D J, w/activity getting worse D getting better D no change mild
constant
treatment received Additional
D D D D
_ ____ _ __ ___ ___ _ _
___ _______________
mild D moderate D disabling constant D intermittant
treatment received
________________ _
_ __ _______ _ _
D moderate D disabling D intermittant symptoms i w/activity D J, w/activity getting worse D getting better D no change mild
constant
FIGURE 3-1
Injuries
_ _ __ __ _ _ _ _ _ _ __ _
treatment received •
Date
Major Illnesses
_ _ _________ _
Health information form, includ i ng anterior and posterior views of the h uman body. (Reprinted with perm ission from Thompson DL.
Hands Heal: Communication, Documentation, and Insurance Billing for Manual Therapists. 3rd ed. Philadelphia: Lippi ncott W i l li a m s & Wilkins, 1 996; pp. 2 50, 2 51 , 2 63.)
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HEALTH INFORMATION page Check All Current and Previous Conditions General
current D D
past D headaches D pain
comments _ _ _ __
D sleep disturbances
D
D fatigue
D
D infections
D
D fever
D
D sinus
D
D other
_____ _
____ _ __
past D rashes
comments
D
D other
Muscles and Joints
D D D D D D D D
comments pas t D head injuries, concussions
current D
D
D dizziness, ringing in ears
D
D loss of memory, confusion
D
D numbness, tingling
__
D
D detergents D other
D
__ _ _ _
___ ___ _
Digestive /Elimination System
current D
comments past D bowel problems
_ __ _
D
D gas, bloating
_ _ _ __
D
D sCiatica, shooting pain
D
D bladder/kidney/prostrate
D
D chronic pain
D
D abdominal pain
D
D depression
D
D
D
D other
Respiratory, Cardiovascular
current D comments
past D rheumatoid arthritis D osteoarthritis D osteoporosis D scoliosis D broken bones D spinal problems
past D heart disease
comments
current D
D
D blood clots
D
D stroke
D
D lymphadema
D
D high, low blood pressure
D
D irregular heart beat
D lupus D TMJ,jaw pain D spasms, cramps
D
D swollen ankles
D
D varicose veins
D
D chest pain, shortness of
D tendonitis, bursitis
comments
_ _____
D diabetes
___ __ _
past D pregnancy
comments
_____ _
D
D painful, emotional menses
D
D fibrotic cysts
current D D
D poor circulation
D
past D thyroid
____ _
Cancer /Tumors
D
D sprains, strains
current D D
D
Habits
Contract for Care I promise to participate
D stiff or painful joints D weak or sore muscles
__
current D D D D
D asthma
___ _
______ _
Reproductive System
D disk problems
D
other
Endocrine System
__
breath
D D
past comments D scents, oils, lotions
_ ______
D athlete's foot, warts
D
Allergies
current D
______ _
D
current D
Nervous System
_____ _
Skin Conditions
current D
Please Explain
______ _
D
2
past D benign
comments
_ ______
D malignant past D tobacco D alcohol D drugs
_____ _
comments __ _ _ __
_ _ __ _ _
__ _ _ _ _ _
D coffee, soda
_____ _
fully as a member of my health care team.
I will
make
sound choices regarding my treatment plan based on the information provided by my manual therapist and other members of my health care team, and my ex perience of those suggestions.
I
agree to participate
in
the self care program we
select. I promise to inform my practitioner any time I feel my well-being is threat ened or compromised. I expect my manual therapist to provide safe and effective
D
D neck, shoulder, arm pain
treatment.
Consent for Care It is my choice to receive manual therapy, and
•
I
give my consent to receive
D
D low back, hip, leg pain
treatment. I have reported all health conditions that
D
D other
Signature
FIGURE 3-1
(Continued)
I
am aware of and
will
inform my practitioner of any changes in my health.
_______________ __ __
Date
_ __ _
C H A PT E R 3
____ ____ ____ ______ ____ __ _
Date of Injury
CLIENT ASSESSMENT
HEALTH REPORT
Manual Therapist Patient Name
I
Date
_ _ __ _ _ _
ID#/DOB
A. Draw today's symptoms on the figures.
1. Identify CURRENT symptomatic areas in your body by marking letters on the figures below.
Use the letters provided in the key to identify the symptoms you are feeling today. 2. Circle the area around each letter, representing the size and shape of each symptom location. Key P
=
S
=
N
=
pain or tenderness joint or muscle stiffness numbness or tingling
"' /
)
r
\
J
B. Identity the intensity of your symptoms. 1. Pain Scale: Mark a line on the scale to show the amount of pain you are experiencing today.
No Pain "'1-----------------------tl Unbearable Pain 2. Activities Scale: Mark a line on the scale to show the limitations you are experiencing today
in your daily activities. Can Do Anything I Want ..1-----------------------11 Cannot
Do Anything
C. Comments
Signature •
FIGURE 3-1
_ ___ ______________ _______ _
(Continued)
Date
_ _ ____ _
27
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trust and informed consent. This too will be charted on the history form by you. Two specific areas to cover when interviewing a client are the cause of the client's pain and previous treatment that the client has undergone for the condition. Cause of Pain
Of specific interest in this interview process is to learn more about the origination of the client's pain. For instance, a person may or may not write down how his or her pain originated, even though there is a portion of the health information form that asks about the reason for making the appointment or about previous injuries. Whether the client has it written down, it is imperative to ask many questions about injuries. It is impor tant to know about the injury or event that led this person to the therapist as well as about all previous injuries. The therapist must determine whether the pain is stemming from an acute trauma, chronic overload, or some other source. Any or all previous injuries may have set up trigger points that have remained latent until the event that brought the client to seek treatment caused them to become active. Again, it is imperative that you ask as many questions as you can think of. Here are some sample questions: • How exactly did this injury occur? •
In what position did you land?
•
How did it feel as you landed?
•
How did it feel to get up?
•
Were you sore immediately after the accident, or only after a day or two?
•
When did you first notice that you were experiencing the pain/discomfort?
•
What activities do you do on a daily basis?
•
What makes it feel better? Can you demonstrate that?
•
What makes it feel worse? Can you demonstrate that?
•
How does it feel right now?
The goal of this questioning is to understand your client's pain and discomfort as clearly as possible. To this end, try to imagine how this individual feels, possibly by putting your body into the client's dysfunctional posture so you may experience a similar discomfort. This exercise may give you even more questions and insights. Again, be sure to write the answers to all questions down in ink with your initials and the date right on the health information form. Previous Treatment
Often, clients will have undergone medical diagnosis and treatment before seeking massage therapy. These experi ences could have been either positive or negative. If there
has been a negative experience, try to refocus this person on his current treatment so that he is feeling positive. There will be quite a bit of information you can use due to his previous treatment, however. By finding out what worked and what did not work, you can more easily setup your treatment plan while avoiding those things that pre viously did not work. This information also gives you fur ther information regarding any contraindications that may be present. Another factor to consider here is the opportunity to contact the client's other health care professionals to gain even further information about his condition. You will most likely want to have a permission for medical information form for the client to sign. Often this client has had various testing such as MRI, CAT scan, X-rays, and so on, amI you will be able to receive a copy of the reports from these tests. These reports will often give you very valuable information regarding the client's condition. Should the client still be working with these other health care professionals, you will have the opportunity to work with them as a team, which may lead to future referrals. A series of questions about previous treatment will be helpful to gain the information you will need. Here are some sample questions: • Have you sought medical attention for this problem before coming here? •
If so, what was the diagnosis and course of treatment?
•
What was the outcome of the treatment?
•
Do you feel this diagnosis and/or treatment was com prehensive and/or correct?
•
How do you feel about your outcome from the previous treatment?
• ORTHOPEDIC TESTING Once you have an understanding of the client's health his tory, current pain or discomfort, and previous treatment, it may be helpful to put the client through a series of ortho pedic testing procedures. Orthopedic testing may also be referred to as manual muscle testing or evaluative muscle testing. There is an art to these tests. A therapist must be very carefu l when handling an injured body part, for instance, being very gentle when positioning the person for the test to avoid any pain or discomfort, being very careful and working slowly with a muscle that is either very weak or fatigued, and also having the ability to give the right amount of counter pressure to allow the client to give the optimal responding pressure. There is also a science to these tests. The therapist must be attentive to each detail that has the capacity to change the test's accuracy and alter results. The tests will only be
CHAPTER 3 /
useful if they are accurate. Accurate muscle testing must include knowledge, skill, and experience by the therapist. Orthopedic testing is a very important part of client intake, as it will give usable information regarding specific muscles and/ or joints to help us plan the course of treatment. This testing can also be used at various times during the course of treatment to help keep the treatment plan on track. There are many neuromuscular conditions that include muscle weakness, muscle fatigue, and muscle imbalance; orthopedic testing will give insight regarding these condi tions. A therapist with extensive knowledge of muscle action and joint range of motion will usually be able to perform well in regard to this testing. Keep in mind that our ultimate goal with treatment is to restore and maintain good range of motion, good postural alignment, and muscle balance. Be sure to document all findings of each test, as this information will help you determine where to begin and what the exact course of treatment must be. Once you note that the client's condition is changing, these tests may be used again and again to measure improvement. In fact, demonstrating improvements in range of motion and level of discomfort the client is experiencing through repeated tests can be a significant psychological boost to the client. Having objective proof of improvement can moti vate the client to continue and help him or her heal com pletely and as quickly as possible. As this text was not meant to teach orthopedic testing, it will be important that you take a course to learn these tests if this information was not included in your initial massage therapy program. Range of Motion Assessment
One type of orthopedic testing is range of motion assess ment. Along with inflammation that stems from an injury comes loss of function or range of motion. This loss of func tion may begin simply in response to pain, but then may continue to develop because of scar tissue that is not prop erly formed. The longer a person experiences loss of range of motion, the greater the loss of range of motion becomes. In time, a person will have no use of the area and will be in danger of developing a compensatory injury. First, however, you must have an understanding of the normal range of motion of each joint in question, so you will know whether the test is positive. Table 3-1 lists the degree of motion each joint should be capable of. Range of motion refers to the number of degrees of motion that are present in a joint. These tests can be done actively, passively, or actively against resistance, with the last one being more involved with muscles that are painful and most likely involved in the injury or dysfunction. It may be necessary to use all three
CLIENT ASSESSMENT
29
tests, although discrepancy between the types of tests should be noted. Passive Testing
Passive testing provides information about passive struc tures, such as joints, bursas, or ligaments, also known as inert tissues. The client stays relaxed while the therapist moves the joint in question in each direction. The effect of conscious control and muscular effort is eliminated; thus, this test separates the muscles from the passive structures. The client should report whether pain is provoked. Keep in mind that even relatively small differences in range of motion, in conjunction with varying levels of pain, can be significant. For instance, 5 degrees of limita tion of movement without pain could indicate a signifi cantly different condition from full range of motion with pain, in a given joint. Thus, it is important to be precise in your assessment. Moreover, you may need to persuade a client to move through a painful arc to find out whether the pain ceases at full range. The beginning of pain may not correspond with the extreme range; for example, a straight-leg raise may start to hurt at 45 degrees, but con tinue to 90 degrees without increased discomfort. Thus, the examiner must determine whether the appearance of pain and the extreme of the range of motion are reached together or separately. Each primary movement of the joint must be tested pas sively to allow the emergence of a pattern, the relation between the degree of movement obtainable in all directions. This will distinguish capsular from noncapsular limitation of movement. If there is pain upon this passive movement, most likely the problem will be within a passive structure. Be sure to refer back to your information on this type of testing from your general therapeutic massage course. Again, as this book is about performing neuromuscular therapy, it is suggested that you take a class or perhaps purchase a hook for further study of these tests. The author's favorite refer ence book for orthopedic testing is Muscles, Testing and Function with Posture and Pain, Fifth Edition, by Kendall, McCreary, Provance, Rodgers, and Romani published by Lippincott Williams & Wilkins. Active Testing
Active testing will give you a sense of the involvement of the injury-the seriousness of the injury. In this type of test ing, the client provides all of the effort to move a joint through its range of motion. For example, an active test might involve having a client begin to lift his arm out to the side and then above his head to show lateral shoulder move ment. If he must also move his shoulder along with the arm during the test, it will be obvious to the observer. Thus, in this case, an active test is called for instead of a passive test,
30
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•
TABLE 3-1 Range of Motion for Fundamental Movements
N�ck
ROM
�houlder
���
Flexion
90°
Flexion
90°
Extension
0°
Extension
0°
Hyperextension
45°
Hyperexten sion
45°
Lateral flexion
45°
Abduction
90°
Rotation
1 80 °
Adduction
0°
Me�a��1
Outward rotation
90°
Inward rotation
90°
Hori zontal flexion
90°
Hori zontal a bd uction
90°
Wrist
Flexion
90°
Flexion
80 -90°
Extension
0°
Extension
90° 80 -90 °
Hyperextension
0-20°
Hyperextension
A bd uction
30°
Ulnar flexion
35-45°
Adduction
0°
Radial flexion
20-25°
Proximal lnterjthalangealJoint Flexion
DistallMerphalal!!ll1al�oint 1 00-1 1 0 °
Extension
Knee
Flexion
200
Extension
0°
�tata[sal Phalang�alJoint
Flexion
1 30-1 35°
Flexion
20°
Extension
0°
Extension
0°
Hyperextension
90°
Ankle Plantar flexion
50 -60°
Dorsi flexion
1 0 -20°
Abduction
1 5-20°
Adduction
0°
rroximallnterphalanl J eal JQinJ{fooO Foot Plantar flexion
50 -60 °
Dorsi flexion
1 0 -20°
Inversion
40-45°
Eversion
2 0 -2 5°
Flexion
50 °
Extension
0°
Distal lnterpl)Miffilel al Joint (FooO Abduction
Flexion
Add uction
Extension , ,
which would not have revealed the restriction resulting from injury. Active Against-Resistance Testing
The goal of resistive testing is to gain clear information on the state of each muscle group in question. The client con tracts his muscles forcibly against resistance using enough strength to prevent all articular movement, or joint move ment, while the joint is held somewhere near mid-range. Mid-range of motion is halfway through the arc of move-
ment for that particular joint. No movement takes place at the joint; the only tension that alters is within the muscle itself. The person is using the muscle and tendon but not moving through space. Both the therapist and the client will push into each other using equal and opposite force, an isometric contraction. An example of pushing into E;ach other would be having the client lie supine with a leg lifted to a 90-degree angle. The therapist provides support at the distal end of the anterior femur, just above the patella to be sure the client does not bend his knee during the test. With
CHAPTER 3 /
the other hand, the therapist applies pressure to the poste rior. calcaneus. Both the therapist and the client push into each other using the exact same force. The leg will not move through space. If the client tells the therapist that he feels pain in a hamstring muscle, the test is positive. When muscles contract, they squeeze together the opposed cartilaginous material of the joint they span. Cartilage contains no nerves, so this compression is pain less. This increased approximation of the bone ends relaxes ligaments and joint capsules. Thus, if the joint is arthritic, the resisted movements are found painless. So, this type of test tells us about the muscles, not the joint. This remains so, surprisingly enough, when a tendon blends with a joint capsule, such as in the case of the supraspinatus. A resisted movement may provoke pain or demonstrate weakness, occasionally both. If this test elicits a pain response, it will help you localize and identify an injury and/ or weakness in a muscle or muscle group. You must pay close attention to where you stand and how you apply your hands. When strong muscles are tested, minor weakness may not be detected unless your hands are well placed for resistance and counter pressure and body mechanics are proper. It is due to neglect of these simple practices that muscle weakness is so often overlooked. If in doubt, you may have to encourage the client to push fairly hard to arrive at a true assessment. Below are some basic principles of resistive testing: • The first time working with an individual, use very gentle force. If the client tolerates it well, next have her push a bit harder and then possibly with all her might •
Stabilize the joint properly when using this type of testing. For example, stabilize above the wrist at the styloid processes when testing the wrist. This allows for only the movement of the wrist without having to move the forearm
•
Always begin with the joint at neutral, if possible. If the client is stronger than you are, try beginning in a slight stretch position. This will increase the strain on the structure
•
If the client is very strong and can overpower you, place him as well as yourself into positions to give you the mechanical advantage
•
Always give equal and opposite force to the effort of the client, so there is no movement through space tak ing place
31
see how well they align with the various anatomical planes of the body. When a person is off of his anatomical planes, stress is being placed on certain structures, chronically shortening some muscles while overstretching their antagonists. Either of these extremes will create a condition that allows trigger points to occur, but mostly the trigger points will occur within the chronically shortened muscle fibers while the overstretched fibers feel tight and painful. The overstretched muscles are continuously microtearing, causing a feeling of discomfort. For example, in an anterior pelvic tilt, the pelvis is in too much flexion, causing overstretching of the ham strings and shortening of the quadriceps-especially rectus femoris, tensor fascia latae, and iliopsoas. The client will probably complain of pain and stiffness in his hamstrings; this will be due to the microtearing. There may be reports of pain or other sensation in the knee and thigh area, low back, and hips. If so, this will most likely be referral from trigger points within the shortened muscles. The therapist can treat the shortened muscles specifically using neuromuscular therapy to help lengthen the muscle fibers and alleviate the referral issue caused by the trigger points. The therapist can also help the overstretched muscle fibers to unlock and return to their normal resting length with some specific work there. As a neuromuscular therapist, you will see client who have slight postural distortion along with those who have whole body dysfunction-the "vertically ill" (Fig. 3-2). According to Bob King, "when looking at this person, it is easy to see how they can be compressed, repressed, oppressed, and depressed." The following is a list of some of the postural findings you will encounter during orthopedic assessment in clients who have whole body dysfunction: • Flattening of the arch of the feet •
Tibial torsion with improper patellar tracking (the patella is not riding properly within the condylar groove of the femur)
•
Anterior and lateral pelvic tilting (the pelvis has both too much flexion and is high on one side while being low on the other)
•
Functional leg length differences
•
Abdominal protrusion (the belly appears to be large, such as having a "beer belly")
•
Diaphragmatic compression (this person has a "banana back," with rounded shoulders, and his lower rib cage has dropped, placing pressure on the diaphragm) and intercostal adhesions (the intercostals muscles are being squeezed with this posture and the layers are now glued to each other)
•
Respiratory dysfunction (with the above posture of "banana back" and diaphragmatic compression
Postural Assessment
Another type of orthopedic testing of the body that is important for neuromuscular therapy is postural assess ment. This type of testing determines the extent of a client's postural dysfunction and how it is impacting this person. This involves a comparison of bony landmarks to
CLIENT ASSESSMENT
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N E U RO M U SC U LAR T H E RAPY BASICS
happening, the client may not be able to breathe cor rectly or very well) •
Abducted scapulae and internally rotated humerus
•
Pronated forearms and hands
•
Cumulative trauma disorders such as epicondylitis
•
Brachial plexus entrapment and radiculopathies
•
Lower erector shortening
•
Protracted head, upper cervical jamming, and TMJ instability (when our heads ride forward, there is quite a bit of pressure being placed upon our TMJ s and upper cervical vertebra)
•
Shortened sternocleidomastoids, scalenes, and poste rior cervicals
•
Mechanical pressure on d isks from j ammed osseous structures
•
Uncoordinated gait pattern
•
Chronic pain and/or depression along with drug dependence
•
Varicosities and poor circulation
•
Easily fatigued with frequent headaches
•
Self esteem issues and psychological manifestations
•
Energetic, sexual, and spiritual depletion
As this author likes to examine a person's core muscles first, we will begin with postural distortion of the pelvis (Fig. 3 -3 ) . Anterior Pelvic Tilt
•
FIGURE 3-2
"The vertically i l l."
Anterior pelvic tilt is a condition in which the pelvis is chron ically flexed too much. To check for this, consider the degree of difference by comparing the location of the posteriol' superior iliac spine (PSIS) against the location of the anterior superior iliac spine (ASIS) on each side of the body (Fig. 3-4). If balanced, there will be only a slight degree of angle there. For men, this will be approximately between 0 and 5 degrees; for women, this will be approximately between 5 and 1 5 degrees. Anything h igher than this is considered an anterior pelvic tilt. Consider learning how to use a goniometer, an instru ment that measures degrees of angles. If you do not have a goniometer, a visualization of the ASIS to the PSIS having a line linking them as well as a base l ine that is straight from the ASIS to somewhere inferior of the PSIS as being zero degrees will help. There will be several postural findings included with this condition, such as the following: • Pubis drops anteriorly •
Coccyx elevates posteriorly
•
Excessive lumbar lordosis
•
Distended abdominal contents
•
Weakened lower abdominals
CLI ENT ASSESSMENT
CHAPTER 3
A
B
1
i
(
)
D
c
Functional Scoliotic Strain Pattern The bony structure is involved. The cause of most cases of scoliosis is u n known i n the medical realm, however, some situations have been traced to polio, tuberculosis, tumors, or a birth defect.
F
E •
•
FIGURE 3-4
FIGURE 3-3
Postural d i stortion of the pelv i s.
Comparing ASIS versus PSIS for anterior pelvic ti l t
.
33
34
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Compressive loading on the lower body
•
Sacroiliac joint is jammed on high hip side
•
Hyperextended ( locked ) knees
•
Femur internally rotates on high h ip side
•
Flattening of the medial longitudinal arch of the foot
•
Femur abducts on low hip side
•
Indentation/groove in the iliotibial band
•
Trochanteric bursitis may occur on low hip side
•
Possible internal femoral rotation
•
N arrowing of the greater sciatic notch with sciatic
•
Tendency toward forward head postures
•
People who commonly exhibit an anterior pelvic tilt include the following: Pregnant women
•
People who are obese or have a "beer belly"
•
Gymnasts, dancers, and skaters
•
Hypermobile individuals
•
Children ages 3 to 8 (at this age it is normal )
•
Tho e who wear high-heeled shoes
•
Hyperkyphotic individuals
Lateral Pelvic Tilt
Lateral pelvic tilt is a condition in which a person has a high hip on one side and a low hip on the other side. To check for this condition, compare the two sides of the pelvis at the iliac crests, the ASISs, and the PSISs. Upon comparison, these three readings will confirm this condition ( Fig. 3 - 5 ) . If balanced, each of these three comparisons will b e level. If not level, one side will be higher than the mher and the postural findings will include the following: Body weight sways toward the h igh hip ( most obvi
Pelvic rotation causes L5 to rotate toward the low hip side (rotoscoliosis)
•
•
•
nerve impingement •
Lumbar vertebrae above LS compensate by laterally flexing ( scoliosis)
•
Disc compression at the level of L4-LS and LS-S 1
•
Hyperpronated foot more obvious on low hip side
•
Knee pain
People who commonly exhibit a lateral pelvic tilt include the following: •
Mothers of young children who carry them on their
•
Those with scoliosis
•
Those with a long torso and short humerus
•
People with flat feet and/or Morton foot structure
hips or those who tend to carrying weight one-sided
Shoulder Asymmetry
The ideal position for a person's shoulders is for them to be level when comparing the two acromions ( Fig. 3 - 6 ) . Simply looking a t the shoulders may give a false reading, due to the side with a low shoulder having a built up upper
ous fi nding)
trapezius. This side will appear high when, in reality, it is
Hip appear uneven and client tends to lean toward
low. Many massage therapists make this mistake. Always do
the high hip
an actual physical comparison of bony landmarks. There
•
PSIS is higher on side of high hip and pubis symphysis is uneven
will be certain postural findings that correspond to this pos
•
Leg on the side of the high hip appears shorter when
•
Tightness in lumbar erectors on high hip side
other when the person stands with the arms hanging at
•
Il ium rotates anteriorly on high hip side
the sides
•
the client is lying down and longer when standing
•
FIGURE 3-5
ture, such as the following: • One shoulder presents higher than the other •
The fingertips of one hand appear to be lower than the
Comparing both ASIS and then both PSIS along with the i l iac crests for lateral pelvic tilt.
C H AP T E R 3
•
FIGURE 3-6
•
CLI ENT ASSESSMENT
Comparing acromions for shoulder asymmetry.
One arm hangs closer to the side of the body than the other
•
The body appears to sway toward the low shoulder side
Scoliosis is the posture that will most l ikely develop shoulder asymmetry. This will most likely be the case if a person has a h igh h ip, low h ip situation. Thoracic Kyphosis
The word kyphosis is Greek, meaning humpback or hunch back. Thoracic kyphosis is an abnormally large posterior curve of the thoracic spine. This condition involves having certain weak muscles along with others being chronically shortened. We observe this condition by looking at a person from a side view ( Fig. 3 - 7 ) . There will b e certain postural findings with this condi tion, such as the following: • Abnormal fascial accumulation in the lower cervical and upper thoracic areas • •
Dowager's hump Depressed sternum with locked ribs inhibiting threedimensional breathing
•
Elevation and depression of the thoracic cage
•
Paradoxical breathing patterns
•
Hyperventilation from poor diaphragmatic function
•
Gasping or wheezing while speaking
•
Frequent yawning, sighing, or attempting to catch one's breath
•
Elevation of the first rib with a tendency toward tho racic outlet syndrome
•
Internal rotation of the humerus, scapular abduction and elevation
•
Hand position anterior to the thigh w ith palms facing posteriorly
•
FIGURE 3-7
Diagram ofthoracic kyphosis.
35
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•
Inclination toward rotator cuff tears, bursitis, and ten donitis at the shoulder
•
Clavicular angulation (v-shaped) , compression of the acromioclavicular and sternoclavicular joints
•
Restricted elongation of the longitudinal a x is of the body
•
Anxiety, panic attacks, often with indiscriminate use of medication due to paradoxical breathing patterns
•
Fascial binding of the esophagus and vagus nerve at the diaphragm
•
Fascial restriction of the aorta, vena cava, and the main lymphatic ducts
•
S tomach distress, reflux disease
•
Compressed organs
•
Exaggerated spinal curves that narrow the intervertebral foramen
•
Fascial pull on the dural tube and spinal nerve roots
•
Migration of disc toward the spinal tube
•
Memory loss
The type of postures exhibiting the above findings would be imilar to those of the anterior pelvic tilt postures along with roor occurational postures. There may be perpetuating factors involved with these postures in the form of chronic resriratory disorders such as asthma. Forward Head Posture
In ideal rosture, the ear should be vertically in line with the head of the humerus when viewing a person from the side. Forward or protracted head posture is a condition in which the head is out of alignment in a forward position. Postural findings associated with this condition are as follows: • Hyperextension of the atlantooccipital joint •
Imringement of occipital nerves
•
Chin poking out posture
•
Stretch strain on the interspinous and supraspinous ligaments
•
Radiculopathy in the cervical region
•
Increased cervical curve squeezing discs with risk of herniation
•
Cervical misalignment creates the possibility of arthritis
•
Loss of range of motion increases the possibility of fusion
•
A powerful fascial downward pull on the mandible
•
Mandible is pulled posteriorly and superiorly, forcing the temporomandibular joint (TMJ ) forward
•
Clicking and pain in the TMJ
•
Bruxism and/or malocclusion in effort to hold the jaw
in its prorer place •
Lateral pelvic tilt affects the jaw laterally
1X 2X 3X •
FIGURE 3-8
Diagram of the weight of a forward head posture.
•
Anterior pelvic tilt affects the jaw anteriorly
•
Anterior fascia of the chest pulls into the hyoid area
Postures that exhibit a forward head would be all descriptions of anterior pelvic tilt, lateral pelvic tilt, and thoracic kyphosis. Forward head posture and thoracic kyphosis perpetuate cervical hyperextension because of the righting reflex. For each inch the head migrates forward from an ideal position, the lower cervicals are compressed by one time the weight of the head, resulting in fatigued cervical extensor muscles. The lumbar musculature must then work very hard to maintain an erect posture (Fig. 3 - 8 ) .
PAL PATION After performing range of motion testing and postural anal ysis on your client to gain an understanding of the bigger picture, you will need to use palpation to fine tune your assessment. Palpation is examination of the skin and under lying structures using one's hands. Palpation can be used when assessing, warming, or treating a client. The palpation
C H A PT E R 3
discussed at this point is that used for locating trigger points on a body, that is, for assessment. Palpation is an art as well as a science. A refined and skill ful ability to apply knowledge of anatomy to hands-on palpa tion is necessary, especially in working with painful and sen sitive tissues. Be clear on what structures are to be accessed and be direct in that palpation. Also, use visualization and be gentle and sensitive with the work while using enough pres sure to get the job done. Ultimately, the client is in charge of how much pressure you use. It might be wise to explain the difference between pa in, which prevents the client from relaxing and benefitting from the work, and discomfort, which a client feels but is still able to relax. This approach working in the zone of discomfort without crossing over into pain-is known as the optimal therapy zone (OTZ). Note, however, that OTZ is different for each client. Pressure that is experienced as discomfort by one client may be experi enced as pain by another. Therefore, be sure to encourage and respond to clients' feedback regarding pain. According to Travell and Simons, there are specific recom mended criteria for identifying active and latent trigger points. 1.
Taut bands palpable in an accessible muscle
2. An exquisite spot of tenderness of a nodule in a taut band of fiber 3 . A spot of pain experienced by the client upon pressure on the tender nodule 4. Compromised range of motion with painful limits of
full stretch 5 . Either visual or tactile identification of local twitch
response 6. Altered sensation, as with referrals, upon compression
of the tender nodule Three types of palpation are useful in assessing for trigger points. They are flat palpation, pincer palpation, and snap ping palpation.
•
FIGURE 3-9
/
C L I E NT A S S E S S M E N T
37
Flat palpation. (Reprinted with permission from Simons
DG, Travell JG, Simons LS. Travel! & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 1 : U pper Half of Body. 2nd ed. Balti more: Lippi ncott Williams & Wilkins, 1 999; p. 1 20, Fig. 3.7.)
Pincer Pal pation
Pincer palpation is the examination of a muscle or a trigger point by holding the area in a pincer grasp between the thumb and fingers. The therapist may actually roll the tissue between the tips of the digits in order to detect any taut bands of fibers, identify tender points in a muscle, and elicit a local twitch response (Fig. 3 - 1 0 ) . This technique will best work with a muscle that can be lifted off of the body, such as the upper and sometimes middle trapezius, brachioradialis, and gastrocnemius, to name a few. Snapping Palpation
In snapping palpation, a fingertip is placed against the tense band of muscle at a right angle to the direction of the tight band. You then quickly press down while drawing the finger back in an effort to roll the underlying fibers under the fin ger. This motion is quite similar to plucking a guitar string, except that when "plucking" a muscle fiber, the contact with the surface is maintained. If a tight band is snapped at
Flat Pal pation
Flat palpation is accomplished by using one's fingers to apply pressure either across the muscle fibers or through the muscle fiber's length, compressing against a firm underly ing structure such as bone. Using this technique, you are feeling for tight bands of muscle or fascia, dense or thickened soft tissue (such as adhesions) , tenderness, trigger points, and possibly thermal information such as coolness from ischemia or heat from inflammation. Depending upon the depth of the struc ture one is trying to locate, the pressure may be anything from very superficial to extremely deep (Fig. 3 -9 ) . This tech nique for palpation can be used on muscles anywhere in the body and will be quite effective when used on the larger muscles.
•
FIGURE 3-1 0
Pincer palpation. Reprinted with permission from
Simons DG, Travell JG, Simons LS. Travel l & Simons' Myofascial Pain and Dysfu nction:The Trigger Point Manual. Vol. 1 : Upper Half of Body. 2nd ed. Baltimore: Lippi ncott Williams & Wilkins, 1 999; p. 1 20, Fig. 3.8.
38
PART I
N E U RO M U S C U L A R T H E RAPY BASICS
limb may be shorter than the other, for example, and the pelvis and face on this side will probably also be smaller. Simple observation might be the first step in assessing for leg length discrepancy. For example, you might see the cli ent walking with a slight tilt to one side or standing with his or her weight on one leg ( usually, the shorter leg) . If you observe such a condition in a client, it is likely that there will be trigger points set up in quadratus lumborum that must be eliminated. To confirm this suspicion, you must next palpate the cli ent. Kneel behind the client, who is standing straight. Palpate both iliac crests and then the posterior superior iliac spines ( PSIS; there may be dimples here ) . Once a discrepancy is discovered, correct it by placing an object beneath the entire foot of the shorter limb. Be sure this feels comfortable to the client. A legal pad of paper, a magazine, or something similar may be used for this. The client must relax at this point, so you may need to simply converse about something else with the client in an attempt to allow this to happen. Once it appears that the client's weight has settled onto both feet, the muscles will be relieved of their attempt to compensate for the limb length d ifference and they may release the protec tive control. It is then possible to accurately compensate for •
FIGURE 3-1 1
Snapping palpation.
a trigger point, there should be a local twitch response ( Fig. 3 - 1 1 ) . This technique will work well for almost anywhere in the body.
any remaining limb length inequality by adding correction under the foot until the pelvis appears level. This should also level out the shoulders and straighten the spine. In order to confirm accuracy of the correction, add a mil limeter or two of additional l ift under the person's foot to see whether the pelvis or shoulders tip the other way. This is
PREDISPOSING FACTORS In addition to the methods of assessment discussed thus far,
considered overcorrection. The cl ient will most likely become aware immediately, as this will be an unfamiliar strain on his body.
you can also predict the presence of pain and trigger points
It will then be useful to refer this client to a health care
in clients with certain predisposing factors related to skele
professional to have corrective, full foot lifts made. A half or
tal anatomy asymmetry and disproportion or structural inad equacies. These predisposing factors include leg length dis
toes and could end up leading to other pathologies setting in.
three-quarter length orthotics will place this person up on his
c repancy, short humerus, small hemipelvis, and foot hyperpronation. Leg Length Discrepancy
Leg length discrepancy, also known as lower l imb length inequality, is often an important perpetuating factor.
S h ort H umerus
According to Travell and S imons, shortness of the upper arms in relation to torso height is a rarely recognized but not uncommon source of muscle strain and perpetuation of trigger points in the shoulder girdle. A discrepancy of this
According to Travell and Simons, correcting this may be
sort places stress on the shoulder girdle elevators, perpetu
essential to inactivating trigger points that are overloaded by the length d iscrepancy as well as to maintaining a trigger
ating trigger points in upper trapezius and levator scapulae
point-free body.
ture is very common among Native Americans, but not
muscles. Travell and Simons mention that this body struc
Trigger points in the hip and torso muscles commonly
limited to this race. If the shoulder-elbow segment of the
cause back pain. There are many studies that show a strong correlation between the presence of leg length discrepancies
upper l imb is short in proportion to the torso, when 't his person is standing, the elbows do not reach the i liac crests;
and back pain. As Travell and Simons note, one side of a person is often slightly smaller than the other. One lower
armrests of a typical chair.
when this person is sitting, the elbows fail to reach the
C H A PT E R 3
I
CLIENT ASSESSMENT
39
This is an observation that may be important for you to
Morton further contends that when the first metatarsal is
not� as it predisposes this client to shoulder and neck pain on a chronic basis. This person must always hold her shoul
shorter and the second is longer than "normal," it is the second metatarsal head that bears more weight. In th is
ders up because she cannot rest d ue to her arms not reaching
case, the foot is balanced on the second metatarsal. In com
the armrests on a chair. The shoulder raising muscles must remain in a hypercontracted state.
pensation, most people mod ify their gait by placing more
Small Hemipelvis
This is a condition in which the pelvis is smaller on one side than the other. The sacrum will most l ikely be t ilted,
weight on the lateral side of the heel and the medial side of the ball of the foot, making their shoes wear in that same pattern. Usually, the foot is sl ightly toed outward during heel strike as well as during stance phase of the gait. The
producing a compensatory scoliosis during both standing
ankle then excessively pro nates ( rocks inward ) during stance phase, and, at the same time, the femur becomes
and sitting.
excessively rotated med ially.
A person with this condition will tend to sit in a crooked
This type of gait w i l l activate trigger points in the
position, leaning to the smaller side. Our ischial tuberosities
posterior portion of gluteus medius that will refer sensa
are weight bearing when we sit, and so magnify the tilt and
tion to the low back. There will also be strain in the
effectively compromise the spine and muscles of the torso,
peroneus longus muscle, activating trigger points in it
as occurs in the pelvic tilt caused by a lower-limb length
that refer sensation to the ankle . Taut bands of fibers
inequality.
here may entrap the peroneal nerve aga inst the fi bula
A small hemipelvis is more commonly overlooked than
j ust below its head, produc ing nu mbness and t ingling
leg length d iscrepancies as a source of chronic muscle strain.
across the dorsum of the foot and sometimes d ropsy of
Often a leg length discrepancy and a small hemipelvis occur
the foot due to motor weakness . There may be add i t ional
together, usually with the shorter leg and smaller hemipelvis
trigger points in g l u teus medius that cause medial knee
on the same side.
pain and might progress to buck l i ng knee syndrome.
To observe this condition, have the client sit up straight upon his ischial tuberosities on a straight, firm surface while you palpate the iliac crests posteriorly. If one side is smaller,
Trigger points may also set up in the posterior gluteus minimus, causing referral sensat ion to the posterior th igh
the crests will not be even. Refer this client to a chiroprac tor or possibly a physiatrist or osteopath for further assess ment and treatment. With the muscular effects being similar to those of leg
and ca lf. Travel! and S i mons c l a i m these symptoms m i m ic radicu lopathy, which explains why so often there is a wrong d iagnosis determined . To assess a client for this cond ition, have him stand bare foot while you check for a dropped arch and medial malleo
length d iscrepancies, the quadratus lumborum must be elim
lus. The client should then walk up and down a hallway or
inated of trigger points.
long room several times while you look for arch drop and toeing out. Refer this client to a professional for further
Foot Hyperpronation
assessment and orthotics casting.
Foot hyperpronation is known by several names: Dudley J . Morton or "classic Greek" foot configuration, Morton toe syndrome, or Morton foot syndrome. According to Travell
PERPETUATING FACTORS
and Simons, this condition is of special interest because it
In addition to the predisposing factors that can lead to pain
is likely to perpetuate myofascial pain in the low back,
and trigger points, there are also factors that can perpetuate
thigh, knee, leg, and dorsum of the foot, with or without
them. A perpetuating factor is any stress-inducing condi
numbness and tingling. A person with this condition will
tion that aggravates a trigger point and its referral pattern,
report ankle weakness, frequently sprained ankles, as well
leading to pain.
as report difficulty learning to ice skate due to having ankles that bend in medially.
identify their perpetuating factors and manage and reduce
Travell and Simons discuss this condition because prob
Part of your role as therapist includes helping cl ients
lems with the foot can produce asymmetries in the lower limb
stress in their l ife. Determining client's stress factors requires asking many questions of this individual rather than simply
that affect the posture of the upper torso. This sort of postural
looking over the health information form he filled out, as
stress will activate and perpetuate trigger points in muscles of
discussed above. Although the treatment of many perpetu
the trunk, neck, and shoulders along with the lower limb.
ating factors lies outside the scope of practice for massage
According to Morton, when weight bearing, the first
therapists, it is important for you to have an understanding
metatarsal head should carry half of the body weight.
of common factors. In some cases, it may be appropriate for
40
PA R T I
N E U RO M U S C U LA R T H E R A P Y BASICS
you to refer your clients to other health care professionals to
ing the hours after work, the cl ient is subject to biome
address these factors.
chanical stress due to overuse.
Some common stress factors include the fol lowing: overuse syndro mes, sleep/rest habits, nutrition, chem i
Sleep/Rest Habits
cals, disease, trau ma, psychoemotional d istress, exercise,
A second stress factor to consider is the client's habits while
and postural dysfunction. Each of these is discussed in
sleeping or resting. Ask the client how he or she sleeps. Is i t
detail below.
o n the back, stomach, o r side ? Is h e o r she using the correct pillow for the chosen sleep position ? If on the back, the pil
Overuse Syndromes
low should be a small cervical support for the neck. If the
An overuse syndrome is something that prolongs the
sleep position is on the side, the spine must be kept straight.
existence of a cond ition. For example, neck pain due to
Th is means that the pillow must be of adequate size to
improper workstation setup can cause neck strain dai ly.
maintain the cervical spine in a straight position. This pil
An overuse syndrome can also be some chronic condition
low must keep the head and neck from laterally flexing
or d isease that the person must learn to manage and work
toward the mattress. Hopefully the client does not sleep on
with, such as post-polio syndrome. One category of over
h is or her stomach. This is not a good position to sleep in, as one must have the head and neck turned to one side for
use syndromes is biomechanics. Biomechanics is the study of the forces exerted by soft t issue ( muscle) and gravity on
long periods of time, thus increasing stress to the srine
the skeletal system. We must also look at biomechanics in
every night.
reference to postural stress when working, driving a car,
Is this person's mattress a good one ? Old, worn-out mat
cleaning house, gardening, and so forth. When we allow
tresses will stress the muscles and prevent a good night's
our bodies to be in poor postural alignment, stress is being
sleep. I nqu ire about how long and how well this person
placed upon our body's tissues 24 hours a day, no matter
sleeps each night.
what activity we do. Biomechanical overuse syndromes and repe t i t i v e
Another factor here may be how the person rests while at home. Many people l ie on their couches watching television.
acti ons m a y occur at work, while driving, or at home.
What is the couch like ? It may be quite soft and not giving
Regarding the occupational setting, i t is important to
proper support. Also, is the client using pillows to help bol
consider what the cl ient does while at work. For instance,
ster and support, and are they the correct pillows as discussed
the c l i ent may work in a factory on an assembly line,
above ? Purchasing a better couch, a new mattress, and pil
stand i ng all day while bend ing forward using an electric
lows might be the best investment this person could make.
screwdriver to attach one obj ect to another as they glide past on a moving belt. Or, this person may sit at a desk all day working on a computer using a mouse. A therapist must look at the factors stressing this person's body from a
N utrition
A client's nutrition can also be a stress factor. Note that
biomechanical point of v iew. How is this repetitive action
although nutrit ion-related concerns are d iscussed here to inform you of the affect of nutrition on pain, you should
on the part of this indiv idual impacting his muscu lar, skel
be careful to stay within your scope of practice and refer
etal, and nervous system ? How is this person's workstation
the c l ient to his or her physic ian or a d ietician for nutri
set u p ? Is it possible for the cl ient to have a qual ified ergo
t ional assessment if you have a concern in this area. Avoid
nomic specialist make suggestions as to how to work using
making recommendations to your cl ients about nutrit ion or "prescribing."
better biomechan ics ? It may be important to take a short drive around the
Nutrition includes water, vitamin, and mineral supple
block with this person at the wheel of his car if there is a chance that this activity is impacting h is body in a negative
ments as well as eating habits. One must drink enough water to enable the flushing of toxins from the body. Now, if this
way or if his occupation involves much driving. Again, the therapist is considering any repetitive actions causing stress
person works out on a regular basis, he or she must add more water to their daily consumption due to losing moisture
along with simple biomechanical stress to the body, such as
through sweating and breathing heavily during exercise. If
sitting on a wallet all day long.
this person drinks alcohol, coffee, soda, and so on, he or she
Finally, evaluate activities that the client performs at home. Does this person participate in sports or garden, for
must add that much more water into the diet to help flush out the added toxins.
instance ? Both of these activities include repetitive use of
Natural vitamins and minerals from a food source can
certain muscles. When pulling weeds, throwing a Frisbee, or hitting a golf ball repeatedly each weekend and possibly dur-
also help a client in chronic pain. A person with an unhealthy diet w i ll be producing toxins as a byproduct of
CHAPTER 3
CLI ENT ASSESSMENT
41
digestion. Eating healthy foods that provide nutrition will
Trauma
make it so that this person's system is less toxic in general.
A l l traumas to a client's body must also be considered, as they, too, are stress factors. While most therapists under
Eating processed foods, refined sugars, and excess proteins makes it so that we need extra minerals stored in our bodies to be able to digest and elim inate them. If the body is defi cient in minerals, toxins build up in the digestive system from unhealthy foods not d igesting entirely and not being eliminated. They are staying in the digestive tract putrefy ing. A lso, dairy products, alcohol, and h igh-fiber foods inhibit mineral absorption. These form mucus l ike plaque onto the lin ing of the colon preventing minerals and water from being reabsorbed by the body, according to Stewart Hare, C.H. Ed . DIP Nt Th . Avoid, however, vitamins pro duced from chemicals and heavy metals, many of which are not absorbed effectively in the d igestive tract. Different minerals have different absorption rates. In general, mineral absorption rates are affected by unhealthy d i ets, by the con dition of the intestines, as well as by the form of the mineral as it is taken into the body. The human body cannot effec tively break down heavy metals to convert them to an absorbable mineral form. Chemicals
Another stress factor that can aggravate trigger points and contribute to pain is exposure to chemicals such as caffeine, alcohol, tobacco, and so on. Such substances dehydrate the body's tissues, which can contribute to chronic pain. Avoiding such substances can help prevent dehydration and promote cleansing at a cellular level. These lifestyle changes that you may suggest to a client
stand to ask about inj uries and accidents, many do not th ink to ask about recent surgery. Surgery shou ld always be considered as having added stress to a body. If the cli ent has had surgery recently, be sure to acqu ire written permission from the client's doctor before beginning mas sage in the affected area. You m ust be certain that it will be doing no harm. Psychoemotional Distress
Psycboemot ional distress can, of course, be a maj or stress factor. As you work with cl ients, you may learn of specific stressors that affect tbem at home or at work. Perhaps they have to drive to and from work in te rror due to bad memor i es of an au tomob i l e accident that previously occ ' lrred. Maybe they do not get a long with their boss at work and l i ve in fear of losing their job. They cou ld be considering or in the middle of a d ivorce. These types of constant emotional stress will help maintain chronic pain at bigher levels. If you have a client w i th signifi cant psy choemot ional d istress, you may want to refer him or her to counsel ing by a qual i fied counselor or therapist. Again, remember to stay within your scope of practice as a mas sage therapist. Exercise
Exercise-either the lack of it or the improper practice of
could be phrased in such a way as to not sound j udgmental.
it-can also be a stress factor. For instance, a cl ient who
This is not about judging a person's life, it is about providing
does not have a proper understanding of biomechanics may
information that can help him begin to fee l better, and
injure himself repeatedly while exercising. [t might be wise
there are times when the information to be conveyed is not
to develop a professional relationship with one or two very
what he wants to hear.
well-trained personal trainers so that you can refer cI ients who have need of assistance with establishing or modifying
Disease
an exercise program.
Any type of disease is also adding stress to a person's body and life. In fact, it is critical that you rule out pain stemming
Postural Dysfunction
from a disease before you begin working on a client, as there
Our final category of stress factors is postural dysfunction.
may be risks involved with working on a client with certain
Postural dysfunction equals stress on the body, pure and
conditions. For example, a client complains of pain in the
simple! One postural dysfunction is having a forward bead,
lower legs. Could he have diabetes ? Or might he have devel
rounded shoulders, and collapsed chest. A person with such
oped phlebitis and have a blood clot somewhere in h is legs ?
posture will likely feel tightness and/or pain in his upper
[n either case, massage would be contraindicated, at least
back and neck areas, with possible headaches. This constant
locally. Another example would be a cl ient feeling pain in
d iscomfort is considered stress to the body. If we can get a
the anterior/lower rib area as a result of gall bladder d isease.
body back on its anatomical planes and help it maintain
[n any situation in which you know or suspect that the cli
that posture, we will have taken away this huge stress factor.
ent m ight have a condition for which massage would be
Note, however, that poor posture often develops over a life
contraindicated, you should stop work immed iately and
time and correcting it takes time and hard work from both
refer the client to his or her physician for evaluation.
tbe client and the therapist.
42
PA R T I
N E U RO M U S C U LA R T H E R A P Y B A S I C S
C H A P T E R S U M M A RY This chapter equips you w ith vital information regarding the assessment of the client. The more thorough the
analysis, palpation, and predispos ing and perpetuating factors. Developing a network for referral with competent
assessment is, the faster the rehab i l i tation w i l l be for
medical personnel such as occupational therapists, physi
the client. The key components of assessment that we have covered include the health information form, inter
cal therapists, and physiatrists will also become impera t ive for the neuromuscular therapist. The next step is the
viewing the client, range of motion testing and postural
actual treatment of the client.
C H A PTER 3
CLIENT ASSESSMENT
43
� R EV I EW QUESTIONS
Short Answer Questions 1 . Orthopedic tests were developed to assess what? 2. Besides the pelvic tilting, what dysfunction can a lat eralpelvic tilt lead to? 3. A person with severe thoracic kyphosis will most l ikely demonstrate what sort of breathing patterns/condi tions? 4. According to Travell and Simons, what are the specific recommended criteria for identifying active and latent trigger points? 5. List some perpetuating factors of trigger points. Multiple Choice Questions 6. It is the responsibility of a neuromuscular therapist to do what as the initial portion of assessment with a new client ? A. Gain a comprehensive health history B. Do a postural stress analysis C. Gain payment D. Provide home care instructions 7. To form a well-rounded, comprehensive treatment
1 0. When performing a n active against-resistance test, what exactly is being tested ? A. An extremity B. Passive or inert structures such as joint capsules C. A specific muscle or muscle group D. Arthritis True/False 1 1 . If there is inflammation stemming from inj ury, then there will most likely be loss of function as well. 1 2. Passive testing gives us information about the state of inert tissues. 1 3 . I nert tissues refer to structures such as large muscles. 1 4. With active testing against resistance, there is no move ment of a l imb through space. 1 5 . A joint need not be stabilized when using active testing against resistance. Matching a. Bruxism b. Inert tissue
g. Rotoscoliosis
c. Informed consent
h. Thoracic kyphosis
plan, the therapist must use
d. Malocclusion
A. all of his intuition
e. Isometric contraction
B. tools of measurement C. the client's report of symptoms along with various assessment methods D. a medical model 8. When comparing a client's acromions, what postural dysfunction is being considered ? A. H igh hip/low hip B. Posterior pelvic tilt C. Shoulder asymmetry D. Leg length discrepancy 9. When comparing a client's two ASIS to each other, what postural dysfunction is being considered ? A. Shoulder asymmetry B. H igh hip/low hip C. Anterior pelvic tilt D. Leg length discrepancy
f. Malingerer
i. Active Testing
1 6. Clenching the j aw and grinding the teeth. 1 7 . Vertebrae that rotate to one side. 18. I mperfect contact of the mandibular and maxillary teeth. 1 9. A competent and voluntary permission for procedure, test, or medication based upon ful l understanding by the client. 20. Contraction of a muscle's tension without shortening its fibers.
THIS PAGE INTENTIONALLY LEFT BLANK
BAS C NEUROMUSCULAR THERAPY TECHNIQUES AND BODY MECHANICS Anesthetize: to induce loss of sensation
Local twitch response: a transient contraction of a group of
Carpal tunnel syndrome: soreness, tenderness, and weakness
tense muscle fibers that traverse a trigger point in response
of the muscles of the thumb caused by pressure on the
to stimulation of the trigger point
median nerve at the carpal tunnel of the wrist
Muscle energy technique: a form of proprioceptive neuromus
Cryotherapy: the therapeutic use of cold
cular facilitation designed to promote or hasten the response
Hypoxia: deficiency of oxygen Jump sign: a general pain response of a client in the form of wincing, crying out, or withdrawing in response to pressure applied to a trigger point
Juxtaposition: a position that is adjacent or side by side
After studying this chapter and then practicing the techniques
of the neuromuscular mechanism to lengthen the muscle in question through stimulation of the proprioceptors
Thoracic outlet syndrome: a condition in which nerves and/or vessels are compressed in the neck or axilla area. Usually, it is the first rib pressing into the clavicle, pinching the brachial plexus
TREATMENT TECHNIQU ES
along with the body mechanics necessary to the longevity of a neuromuscular therapist, you will begin to develop the skills of
The use of massage strokes is an art along with a science. To
effective treatment. Not only is it important to practice each type
be refined and skillful in ones ability to apply knowledge of
of technique, but to practice while using proper body mechanics.
anatomy to hands-on massage is important when working
The effectiveness of each technique depends upon your doing it
with painful and sensitive tissues. When treating, to be clear
correctly, at the exact level of tissue necessary, and on using the
on which structures are being accessed, you must be able to
correct body mechanics. This way, you will not hurt yourself
visualize that structure correctly. A lways be gentle and sen
while applying the appropriate pressure to influence and treat
sitive while applying this knowledge and art. Specificity is
even the deepest layer of muscle effectively. Remember that deep
essential to being refined and skillful .
work does not mean rough work. Deep work done artfully is gentle yet effective, while being anatomically precise.
Presented below are some general guidelines o n treat ment along w ith two types of massage strokes: warming
In addition to treatment techniques and body mechanics, this
and direct. A lthough these strokes are basic and not spe
chapter also covers neuromuscular therapy tools, the importance
c ific to neuromuscular therapy, they are reviewed here
of a referral network, home care assignments you can give to
because they may be effectively integrated into neuromus
your clients, and reassessment.
cular therapy.
45
46
PART I
N E U R O M U S C U L A R TH E R APY BA S I C S
Most techniques effectively used with neuromuscular therapy are strokes you have been using for relaxation mas sage. Now you will be using them while providing more pressure and specificity. These strokes will be the ones you use leading up to applying trigger point release.
General Guidelines for Treatment
Warming Strokes Warming strokes are used to quickly yet gently warm and bring about hyperemia to the tissues of both the superficial and deep structures. These strokes are needed to prepare the client for the more focussed trigger point treatment later. Note, however, that with a c l ient in pain, there is quite a bit of trigger point work to be done, so the warming phase of
Three essential components to consider when performing
the session must be kept brief yet effective. The following
neuromuscular therapy are pressure, contact, and direction/
strokes are the most efficient for the purpose of thorough
location. These are discussed below.
warming while examining.
Pressure
Skin Rolling
The use of appropriate pressure is very important in working with chronic pain. The sensitivity of ischemic t issues creates reduced receptivity, which requires that you be careful not to use too much pressure at first, but it still needs to be enough pressure to bring up hyperemia and allow you to be able to palpate the deeper t issues. This tissue must be warmed quickly and worked with using integrated techniques before the trigger points may be addressed.
In skin rolling, the therapist lifts, compresses, and rolls the skin between his thumb and fingers to free it from adhering to the superfiCial fascia and bring about extreme hyperemia very quickly at the same time. This technique may be used on the back, arms, legs, and abdomen ( Fig. 4-1). Effleurage Just as when doing a relaxation massage, we will begin with
As with any massage, the client is in charge of how much
effleurage in general to apply the lubricant (for neuromuscu
pressure may be applied. You must always work within the
lar therapy we use very small amounts) and get the person
client's tolerance to be effective. The more varied the pres
used to our touch while initiating the warming of the body's
sure, the more that gets done by way of building the c lient's
tissues, yet done a bit deeper than when used for relaxation
tolerance to pressure. The pressure for warming strokes can
massage. For this we may use two hands, hand over hand,
vary greatly. As you become more focused with the work
forearms, etc. This portion will last only a short time before
and become more direct with your techniques, the pressure
we continue on with other strokes designed to warm quickly.
will most likely become deeper. Contact The manner of establishing contact will definitely affect the results obtained, especially when working with hypersensi tive tissues. To increase receptivity to deeper work, thorough warming is necessary. This is done quickly by using forearms and heels of hands to effleurage and using thumbs to muscle strip while increasing pressure with each stroke. Another key concept is tissue engagement . The effect iveness of Neuromuscular Therapy comes from its d irectness in isolat ing the muscle or tissue in question. This is a combination of pressure and direct contact in a refined and sensitive way. We will be looking for and then treating an epicenter in each nodule we find within the taut bands in the soft tissues. Direction/Location The proper direction of pressure in palpation and in apply ing a particular technique is crucial to its effectiveness. One's intention must be clearly in mind and at hand, for example, to arrive at a particular layer or level of tissue, to increase c irculation, to lengthen muscle, to free tissue bind ing, or to lengthen fascia. Knowledge of anatomy, body mechanics, and hand positioning become very important in effecting proper direction and effectiveness.
•
FIGURE 4-'
Skin rolling.
C H A PT E R 4
B A S I C N E U RO M U SCU LA R THERAPY TEC H N I Q U E S A N D BODY M EC H A N I C S
47
Direct Strokes Once warmed quickly yet thoroughly, we must begin treat ment. We w i l l want to use techniques that are specific and direct while we treat sensitive and tender areas, taut bands of muscle fiber and fascia, fibrotic areas, and trigger points. Below are some very direct techniques.
Thumb Strlppmg Thumb stripping, a type of effleurage, is the use of both thumbs together applying pressure in a g l id ing motion spec ifically in the direction of the fibers of each muscle. When influencing smaller areas or muscles, one thumb alone may be used . With each pass, the pressure becomes increasingly deeper to examine and treat each layer of tissue/muscle. It is important to use proper thumb and wrist mechanics, as shown in Figure 4-3, along with good body mechanics i n genera l . Wrists are to be held straight along with the metacarpophalangeal j o ints and the inter phalangeal j oints of the thumbs. A lso, keep the thumbs i n an abducted position. A l l of these suggestions of hand and wrist mechanics w i l l help you i n keeping your thumbs and wrists healthy and rel a t i v e ly strain free. If poor •
FIGURE 4-2
Use of opposing thumbs for petrissage.
Petrissage
mechanics are used, the c l ient w i l l notice less and less pressure as the therapist becomes increasingly fatigued or inj u red ( Fig. 4-3).
The petrissage strokes discussed here are very similar to those learned for relaxation massage, except we will use them more specifically. Remember that the definition of petrissage is to l ift the muscle and pull it away from the bone. For a relaxa tion massage, this is done in a very superficial way. For neu romuscular therapy, we wish to impact each muscle directly, so we must be precise with this technique. Kneading, a type of petrissage, is the use of one or both hands to loosen a muscle. This movement is similar to knead ing bread dough. This stroke can be quite specific to a muscle. Using opposing thumbs to get underneath certain mus cles is also specific. With this technique, we w i l l use one thumb in juxtaposition to the other thumb to l ift long mus cles up off of the body. A good place to practice this is on longissimus ( Fig. 4-2). Circular Friction This, again, is a stroke that is used for relaxation massage. We will be using it specifically to warm the areas around joints and possibly into long muscles, as well. This stroke has a good circulatory quality to it and works to warm quickly and efficiently. We can use thumbs or fingertips to move the deeper t issues i n a circular motion while not mov ing across the skin. We w i l l be taking the skin along with our thumbs or fingertips.
•
FIGURE 4-3 Thumb stripping.
48
N E U RO M U S C U LA R T H E RAPY B A S I C S
P A RT I
Cross Fiber Friction Cross fiber friction , also known as deep transverse friction or Cyriax movement, is a stroke in which we friction across the fibers of deeper muscles using thumbs or fingertips. The fin gert ips or thumbs do not glide across skin, the skin moves with the thumbs
or
fingertips as the deeper tissue is being
frict ioned against the bone beneath the area ( Fig. 4-4). This is an extremely d irect stroke and may possibly be the most effective stroke available to help a client. Make friction your friend. As with thumb stripping, it w i l l be important to use proper hand and wrist mechanics while allowing your body to do the work rather than using your shoulders and arms to
create the motion. Longitudinal Friction Longitudinal friction is simi lar to the above cross fiber fric tion, except the movement is in the d irection of muscle fiber rather than across it ( Fig. 4-5). Pincer Technique Pincer technique makes use of the pincer palpation, d is cussed in Chapter 3, for treatment. I n using this technique, we pincer grasp a muscle or port ion of a muscle and roll the tissue between our fingertips and thumbs exam ining it for a trigger point
or
t ight, sore area. Once located, we press it a
•
FIGURE 4-5
Longitudinal friction.
bit harder and hold. Within a few seconds, the soreness and/ or referral sensation lessens. With practice, this will become obvious to you, but as always, be sure to ga in confirmation from the client before moving on to another area by asking him to let you know when the sensation changes ( see Fig. 3-11).
TREATMENT OF TRIGGER POINTS After warming the area and using more d irect techniques to find the t ight bands and trigger points within the muscles, we then begin to use the techniques best designed to allevi ate the trigger points. Below is a description of trigger point treatment. There was a t ime when trigger point pressure was known as ischemic pressure. Travel and Simons replaced the term ischemic pressure w i th the term trigger point pressure owing to clinical evidence indicating that when applying d igital
pressure to a trigger point, there is no need to exert the type of pressure necessary to produce ischemia. They go on to say that because the area w i th a trigger point is already suffering severe hypoxia, there is no reason to think that add i tional ischemia would be helpfu l . The idea of trigger point release is really a release of the contractu red sarcomeres of the·nod u les in the trigger points. The actual technique now known as trigger point release •
FIGURE 4-4
Cross fiber friction.
is far less vigorous than ischemic compression and involves
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49
what is known as the barrier release concept. This tech
to influence it, the client will wince, cry out, or possibly try
nique will not produce additional ischemia in the area and
to pull away from the pressure as confirmation-in other
seems to be more effective clinically. The client will learn
words, give a jump sign. Again, remember to always work
what optimal pressure feels like for self-treatment. This
within the client's tolerance. With strong wincing or with a
approach is far more client friendly, according to Travell
major j ump sign, chances are that the more superficial tissue
and Simons.
needs to be massaged to a l leviate the soreness before you
The first step when using this technique is to work with
can successfully apply trigger point pressure to the underly
the intent to lengthen the muscle in question before apply
ing tissue in question. If the client cannot tolerate the pres
ing trigger point pressure. The trigger point pressure is
sure, he will tense up against the work and you will get
applied gradually while increasing pressure until the finger
nowhere with this treatment.
pressing into the tissue encounters a definite increase in
You should apply trigger point pressure directly to any
resistance. This is called "engaging the barrier" by Travell
suspected trigger point found, using either a finger or a
and Simons. The client will feel a degree of discomfort, but
thumb. This pressure should be as pin-pointed as possible:
not pain. The pressure is maintained until there is a sense of
find the exact site of the trigger point and apply pressure
relief of tension under the finger that is applying the pres
with one thumb only. As your thumb tires, begin to use a
sure. Pressure then is increased to engage a new barrier. This
finger, and then back to the thumb, and so on. This pressure
pressure is still somewhat light, waiting for the muscle ten
will take practice. Again, as stated above, the amount of
sion to let go. During this time, you may change the direc
pressure applied depends on the depth of the trigger point.
tion of the technique if necessary to achieve better results.
Hold this pressure for the 10 to 18 seconds, gain confirma
When working with trigger points, use enough pressure
tion that the referral sensation has changed/decreased , and
to effectively release the facilitated reflex arc. The pressure
then let go. Then it is effective to use a couple of strokes of
must not be too light or too heavy as previously mentioned,
thumb stripping through the muscle at the proper depth to
and the time the trigger point pressure is held must also be
see how different it feels to the client. It is important that
correct. Insufficient pressure will not be effective. On the
the client be able to feel the change in that area.
other hand, too much pressure will add excessive stimulus to
You may go back to that same trigger point several times
an already overloaded system, thus aggravating the trigger
using trigger point pressure to gain more change from it. To
point and exacerbating the chronic pain pattern. Also, with
be sure not to fatigue the area, work elsewhere for a few
too much pressure, the client will most likely tense up
moments, then go back to it. This may be done again and
against the pain. Therefore, the amount of pressure used
again with a trigger point. J ust remember that it may take
along with the amount of time held is critical to the success
more than one session to completely a lleviate a trigger
of the therapeutic release and normalization of the reflex
point, especially one that has been active for a long time.
activity of trigger points. The time duration for applying trigger point pressure to
Active Range of Motion of Involved Muscles
trigger points is around 10 seconds. If it goes beyond 18 sec
Trigger points are more likely to decrease referral sensation
onds or so without deactivation occurring, let go and then
once some flexibility has been restored and range of motion
return in a few minutes and try again after adj usting your
has begun to improve. A lso, some trigger points only prove
pressure. You can continue to come back to this trigger
active during motion of a certain muscle or group of mus
point several times during a session to gain further release. If
cles. There may be times during a treatment session when
you were to hold trigger point pressure on a trigger point for
asking the client to demonstrate certain range of motion
longer periods of time, you may cause a fatiguing of the
exercises ( as described in Chapter 3) is essential to the suc
nerves or possibly over stimulate them. ReleaSing a trigger
cess of the treatment. These range of motion exercises, done
point is not similar to myofascial release work.
speCifically, will confirm that the trigger point is still firing
Along with the pincer technique mentioned above, we
during motion as well as how strongly it is firing. This infor
will be using trigger point pressure to a lleviate any type of
mation a l lows you to know when more work is necessary at
trigger point we find. The deeper the muscle in question, the
the site of that particular trigger point.
more difficult it is to influence, so the therapist must use a
Another goal to increase the range of motion of an
deeper palpation to find and then treat. To be able to use
involved muscle is to gain a balanced movement of a par
trigger point pressure successfully with deeper structures, the
ticular j oint. If a muscle loaded up with trigger points stops
pressure used must be deep enough to influence the correct
being used for a certain movement, its synergists will have
layer of tissue, yet extremely specific to the trigger point. If
to take over for it. These synergists are not large enough to
there is a deep trigger point and the pressure is great enough
be competent at this j ob and so become overloaded and may
50
PA R T I
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N E U RO M U SC U L A R T H E R A PY BAS I C S
also set in trigger points. Meanwhile, the prime mover that is loaded with trigger points may become adhered to other structures, causing further dysfunction in the area. Now,
There are precautions to take when applying ice accord ing to Marybetts Sinclair I ; they are as follows: •
more and more muscles begin to set in trigger points.
applying ice by using a hot pack, blankets, hot water
To avoid these issues, take the affected joint through pas sive range of motion after performing soft tissue manipulation
bottles, and so on •
( see Chapter 3 for details). A lso, have the client perform the
chilled •
too cold; be cautious here •
ment you provide in your office or as a self-care treatment
Be extremely cautious when applying cold over super ficial nerves; never apply pressure there with a cold
that the client performs at home. Moist heat is very simple to use. For example, the client could stand in a shower, letting
Children, especially preschoolers, have a d ifficult time letting someone know if something is causing pain or
Using hydrotherapy in the form of moist heat as well as cryo
therapy can facilitate the client's recovery, either as a treat
For clients older than 60 years, be especially sure to keep them warm as it is easier for them to become
exercises actively at home.
Moist Heat and Cryotherapy
If a client is cold, be sure to warm him or her before
pack and never exceed the recommended time •
Caution clients not to exercise immediately after ice
warm water strike a particular area such as the back of the
application, as they may have decreased muscle
neck, or sit in a hot tub or even a bathtub with warm water
strength because of the cold treatment and could injure
covering the area in question. Electric moist heating pads are available, or one could wet and wring out a small bath towel and heat it in a microwave. Be sure to use oven mitts or thick
themselves •
to an area
rubber gloves to remove the towel from the microwave. Then, fold it to the correct size for placement and cover it w i th sev eral layers of dry towels or blankets. The towel may be
Periodically check for cold damage when applying ice
There are also contraindications according to Sinclair; these are as follows:
reheated after it has cooled, so that the moist heat application
•
Aversion to cold applications
can last up to 20 minutes long ( Fig. 4-6).
•
Sensitivity to cold ( this may be the case with one who has fibromyalgia)
• •
If cold applications cause headaches Any impaired sensation in the area being iced such as with one who has a spinal cord injury or diabetic neuropathy
•
Poor circulation as cold will further decrease circulation
•
Raynaud syndrome
•
Areas that have previously been frostbitten
•
Peripheral vascular disease such as diabetes, Buerger disease, and arteriosclerosis of the lower extremities
• •
Malignancy in the area Heart disease: never apply over the heart due to reflex constriction of the coronary arteries
•
If there is an implanted device present in the area, such as cardiac pacemakers, stomach bands, or infusion pumps
•
Any marked hypertension, as the ice will change the blood pressure to a certain degree
•
If an analgesic has been applied to the skin in that area
•
Any open wound
•
Lymphedema
Cryotherapy is the use of ice or very cold water for treat ment of sore muscles. This type of therapy can be used after •
FIGURE 4-6
Application of moist heating pad.
treatment to help relieve soreness from deep massage if
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51
necessary, but a lso to help muscles recover more quickly in general. The d i fferent forms of cryotherapy used might include ice massage, ice pack or cold compress, and immer sion in cold water. In using cryotherapy (or in recommending it to your cli ents) , keep in mind that there are stages the client will go through when using ice. They are as fol lows: first, the area being iced feels cold; second, the area begins to warm and the client even experiences a burning feeling; third, the client feels pain and/or aching; and, finally, the area feels numb-- the nerve endings have been successfully anesthetized. lee massage is easy for you to perform on a client or for the client to perform on himself. Simply freeze water in a paper cup fi lled to two-thirds full. Tear off the upper por tion of the cup once the water is frozen; the lower portion of the cup then may be grasped for massaging. The client, or you, w i l l massage the muscle in question for about 15 to 20 minutes. There are commercial ice rol ler you can pur chase too ( Fig. 4-7). An ice pack or cold compress is ice in a bag designed for this purpose or a disposable zipper closure bag. It can be used directly on an area or wrapped up in a thin towel before placement, depending on how sensitive the client is to the cold. Place the pack or compress on the area and leave for
•
FIGURE 4-8
Cold compress application.
about 20 minutes ( Fig. 4-8). Immersion is ideal for certain areas, such as the legs/feet and forearms/hands. Such treatment requires a container that will hold water, such as a clean waste basket or bucket of the correct depth to be able to place a foot and leg into, as an example. Simply pour ice cubes into the container, filling it to approximately one-third, and then add enough water, so the entire leg is immersed up to the knee. This will be effective for the deeper muscles in the leg, such as tibialis posterior. A simple ice pack will probably have very little impact on a deep muscle, whereas immersion will have far more influence ( Fig. 4-9). Often, there is confusion as to whether to use ice or moist heat with a client. When in doubt, choose ice. lee docs cer tain things that heat w i l l not. lee will anesthetize the nerve endings, help decrease inflammation, and lower the metab olism of the surrounding healthy tissues, so the oxygen and nutrients carried i n the blood can safely go to help the inj ured area without causing hypoxia. Both heat and ice w i l l bring about hyperemia. A lso, if there is any sign of inflammation at a site of inj ury, the heat will increase this. Once there is no inflammation present and it seems that the ice application is decreasing in effectiveness, the client can be taught to use contrast therapy. Contrast therapy is the use of both moist heat and ice together. This is done by alter •
FIGURE 4-7
Ice massage with an ice roller.
nating the placement of heat and cold applications on the
P A RT I
52
N E U RO M U S C U LA R T H E R A PY BAS I C S
icing/heating at home, after the session . Be sure the client is really following through on this treatment, though, as it is important to the overall success of the work.
Stretching Involved Muscles The cl ient should actively stretch all involved muscles at home regularly. Moreover, you should be passively stretch ing and/or using muscle energy technique for the same muscles after performing soft tissue manipulation and trig ger point therapy. Again, trigger points and tight areas are more likely to be alleviated once the muscle in question begins to regain its flexibility. As an example of passively stretching a muscle after treatment, consider rectus femoris, one of the muscles of the quadriceps group. During treatmen t, the client would most l ikely be supine on the table. You would then assist the cli ent in turning to the prone position on the table. While stabilizing at the client's posterior superior il iac spine area of the pelvis to help prevent hyperextension at the low back, lift the lower leg by holding above the malleoli and bend the knee until the client experiences a stretch of the muscle. Using this same muscle for an example of muscle energy technique, when the muscle is in a stretched position, ask •
FIGURE 4-9
Immersion as cryotherapy.
area in question, leaving each application on for about 20 minutes before moving to the next. There are many opin ions out there as to the t iming when it comes to contrast therapy, with the alternating bouts being as short as 2 to
5 minutes each. You must decide how to most effectively use this so that your client receives the most benefit. The client can begin with either the heat or the ice. For comfort, possi bly begin with the ice and end with the heat in winter months and reverse it during the summer.
the client to push his lower leg back down toward the table. Do not allow the lower leg to actually move, turning the client's muscular contraction into an isometric contraction. Hold this for 5 to 8 seconds. Then ask the client to relax the muscle, so you may take it into an even greater stretch. This procedure is to be repeated two or more times until it seems the muscle has successfully lengthened .
NEUROMUSCUlAR THERAPY TOOlS Besides your own hands, there are many massage tools avail
All of the above thermal therapies can be used all day long
able commercially that you can use in treating your clients.
if the client waits 1 hour between bouts. This wait will give the
These tools include Theracanes, Backnobbers, T-bars,
body time to recover from the cold and/or hot treatment.
Thumbbys, molded foam rollers, Ma Rollers, footsie rollers,
Regarding a general application of moist heat, there are a few contra indications here as well: •
Diabetic neuropathy
and icing roller tools ( Fig. 4-10). Theracanes and Backnobbers are made specifically to allow a person to use on themselves to release trigger points
•
Local inflammation in the area
anywhere on his or her body. The design of these tools allows
•
Open wounds, rashes, and eczema
for this by providing leverage for the work. A T-bar with a
•
Tumors
beveled edge is used by a therapist to apply friction to mus
•
Lower abdomen in pregnant women
cle attachments to bony landmarks, whereas a round headed
•
Heat-sensitive skin
•
Spinal cord injury
You can also use cold or moist heat therapies as part of
T-bar is used for effleurage. A Thumbby can be used by a therapist or as a self-help tool. It is made of silicone and so has the feel of your thumb to it. It can be used for effleurage, friction, and trigger point pressure. At home, it will stick to
each session. You may apply ice or heat to an area while
the wall and provide pressure if one presses into it. It can
working on another area, for instance. You may fi nd it to be
also be used on the floor to provide pressure when lying on
a better use of treatment time to have the client do her own
it. The molded foam rollers are another self-help tool that a
CHAPTER 4
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53
satisfaction of helping your clients and, most likely, by refer rals from these professionals, as wel l .
•
HOME CARE
In addition to the work you perform on the client during his office visits, you can further help your client recover by pro viding him with home care assignments that he can com plete on his own. Furthermore, these assignments can address some of the perpetuating factors the client may have ( di cussed in Chapter 3) and help eliminate the source of some trigger points. In addition to thermal therapies, which are discussed above, home care assignments may include the following: work station rearrangement, development of proper postures, stretching, and self-trigger point release. Remember that the goal here is to help eliminate perpetuat ing factors and minimize predisposing factors. Also remem ber to stick to your proper scope of practice as a massage therapist and refer your cl ient to other professionals as needed and appropriate ( Fig. 4-11).
Work Station Rearrangement If a client appears to have a perpetuating factor related to •
FIGURE 4-10
Various massage tools.
his or her work station, learn as much as you can concern ing the work he or she does each day. Ask the following
client can actually roll his iliotibial bands on along with using to do core balancing and strengthening exercises with. A Ma Roller is a wooden object used for self-help. A client would usc it to melt the tension out of his back by lying on it while incrementally moving it up the paraspinals. Then, the client can actually roll himself or herself up and down the roller against the floor. A foot roller is another self-help tool that a client places on the floor and then rolls the plantar surface of the foot against it. The icing roller tool is used by the therapist to provide cryotherapy while applying effleurage. Often, you can find these tools at the small book and sup ply store of a massage school. Usually, this type of store offers this sort of tool at a better price than you would find at an online store, because of the cost of shipping.
THE IMPORTANCE OF A REFERRAL NETWORK Being a massage therapist, you will not have all of the infor mation necessary to address all of client's treatment needs. This is why it will be important to have a referral network available. Development of relationships with physiatrists, occupational therapists, physical therapists, Fe ldenkrais practitioners, ergonomics experts, and personal trainers will be of great value to you and your client. While this will take time and effort on your part, you will be rewarded by the
•
FIGURE 4-11
Client performing stretch of rectus femoris.
54
PA R T I
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N E U RO M U S C U L A R T H E RAPY BASICS
questions: What is i t you do exactl y ? Can you demonstrate
s t retch b e i ng performed a long w i t h s i m p l e written
the repetitive movements you make ? How is your worksta
instructions to the c l ient, which w i l l help this person
tion arranged ?
remember how to do the stretch as well as remember to
Regarding the workstation itself, you will want to know
actually do the stretch.
about each component of equipment and its placement,
Begin by teaching a c l ient j ust two stretches, as this may
such as the height of the desk and where the computer
be a l l she can learn at once. At the next session, ask her
monitor is along with where the keyboard is placed. For
how the stretches are going. You may need to encourage
example, a client may have his keyboard in front of him
her to actually do them daily. Have her quickly demon
while his monitor is to the side, forcing him to have his neck
strate that she still knows how to do them. If it appears
turned to one side a l l day long. Sometimes a simple sugges
incorrect, do not demonstrate other tretches; work with
tion about how to rearrange a workstation can be helpfu l .
her to perfect the two she is supposed to be doing. Once you
For example, you may suggest that the client place the mon
are confident that this person is doing the stretches cor
itor on a telephone book or bring it to eye level . Sometimes,
rectly and daily, it is time to add one or two more into the
it is the simple things that can make an impact on a person's
client's routine. Once this client is ready for some strength
health and well-being. If the c l ient has more complex issues, you may want to
ening exercises, you can use this same recipe. Remember that the goal here is to help the client increase his stress
refer him or her to a speci a l ist in ergonomics. If you are
tolerance of the involved muscles. Again, only instruct the
intere ted in learning more about this subj ect, consult
client in stretches that you are trained in and that are
the fol lowing books: Ergonomics of Workstation Design by
within your scope of practice.
T. O . Kvalseth and Industrial Ergonomics by R . T. L i n and C. C. Chan.
There are excellent books available on stretching that can be used by both the therapist and client, and several are
Development of Proper Postures As a neuromuscular therapist, you must help clients under stand why it is important for them to begin to develop proper
listed below. •
Stretch to Win by A. Frederick and C. Frederick
•
Stretching Anatomy by A. N elson and J. Kokkonen
•
postures when sitting, standing, l ifting, sleeping, and so on. You must al
0
help them find these postures. It may be a
good idea to get to know an Alexander technique practi tioner or possibly read a book or two on that subject, as it is a l l about adopting proper postures for whatever it is you do in life. As an example of the above, to help a client when sit
The Whartons' Stretch Book: Active-Isolated Stretching by J . Wharton and P. Wharton
•
Facilitated Stretching by R. McAtee and J. Charland
•
Stretching by B. Anderson
Trigger Point Release Another home care treatment a cl ient may be taught is to
ting, for instance, he must be in a good chair with a back to
apply his own trigger point pressure to any active or latent
it sitting upright while resting his back against the chair
trigger points he can reach. Having the abil ity to actually
back. H is thighs at the hips should be in about a 90-degree
reach these trigger points is important. If there are trigger
angle. The knees should also be at a 90-degree angle, with
points in muscles of the back, this person might need to
the feet flat on the floor directly under the knees. The c l ient
purchase a tool to use such as a Backnobber. If you do
must be told to use his abdominal muscles to remain in that
encourage the c lient to purchase such a tool, be sure to
position rather than using back muscles. This is the sort of
carefu l ly instruct him or her in how to safely and properly
help most folks need; j ust something simple like this can
use the tool.
make a huge difference in their lives. As the c lient practices his new, proper postures each day
The procedure for the cl ient w i l l be simi lar to what you do. Let us consider a trigger point in the rectus femoris.
while continuing his neuromuscular therapy sessions, he
For a warming stroke, the cl ient can sit down and do some
w i l l begin to experience better quality of life-a l ife with
simple compression on the muscle to bring about hypere
les and less pain each week.
mia. Next, he w i l l begin to apply trigger point pressure to the actual area with the trigger point. Once he feels the
Stretching
barrier, he w i l l stop pressing and simply hold the area with
Stretch i ng is another area in which you can provide
steady pressure, waiting to fee l a release in tension i n · the
home care assignments to your client. It is probably w ise
soft t issue. As this tension l essens, he wi II press a bit
to demonstrate a stretch fi rst, and then help the person
harder to find the next barrier. He w i l l continue this for
d o the stretch properly. If possible, provide a photo of the
up to 18 seconds. I f nothing happens in L O seconds or so,
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BASIC N E U RO M U S C U L A R T H E R A P Y T E C H N I Q U E S A N D BODY M E C H A N I C S
he should let go, wait a couple of minutes and try again
•
with different pressure, ei ther l ighter or harder. On suc cessful release of the trigger point, he w i l l then do a stretch specific to that musc le.
Client Compliance It will be crucial for the client to be compliant with her home care. The person who chooses to ignore her part in recovery will most likely not recover fully and certainly will not recover as quickly as the person who is compliant. Therefore, d iscuss this with the client. For the person who forgets to do her home care, suggest that she place large notes about home care in places where she will see them daily. If whenever she sees a note she does some of her home care, she will not forget. Pretty soon, it will become a habit for her.
REASSESSMENT
•
55
BODY MECHANICS FOR THE NEUROMUSCULAR THERAPIST
Using correct body mechanics is important to the longevity of your career. Using proper body mechanics means working smarter rather than harder; it means using your body in uch a way as to ease your work. Many massage therapists wind up injuring themselves repeatedly by using poor body mechan ics and have a very short career consequently. One of the goals of this textbook is to bring about an awareness and interest in the use of proper body mechanics by massage therapists. There are textbooks solely devoted to this sub ject that you may purchase and study. One in particular is
Body Mechanics for Manual Therapists, A Functional Ap/)roach to Self-Care by Barbara Frye. You not only use your fingers, hands, and forearms when working on a body, you use your entire body. Your fingers are simply the tools at the end of your body. So many ti mes
Reassessment of the c lient must happen at regular intervals.
a simple adjustment of your body placement w i l l make a
There will be several things to take into consideration at
technique much easier to apply. These adj ustments are
each session. Following is a list of some of the considerations
things such as changing which foot is in front while lung
for rea sessment. •
ing into a technique or even the simple act of performing
The client's level of pain experienced in general. Has
a lunge while working rather than bending at the waist
the client been feeling better with each session ? If so,
( Fig. 4-12). Strive to save your back, neck, shoulders, arms, and hands
by what percentage ? •
The client's level of tolerance for the work. This should
from strain when working. When at all possible, keep your
also have been changing with each session, allowing for the therapist to get deeper and deeper into the work •
Each trigger point must be checked. Are trigger points sending out less and less referral sensat ion ? Are they al leviated completely ?
•
The specific muscles with trigger points must also be checked. Is the muscle more flexible? Is it softer to the touch, allowing for deeper work ?
•
Range of motion must also be considered during a reas sessment. Has the range of motion improved in a given joint? Because using a muscle to provide active range of motion can make a trigger point refer, we also need to ask if the referral stopped happening while doing that exercise
•
Coordination and ease of movement in general. Has the client's ability to move with ease and in a coord i nated way improved ? Does he or she have more energy in general ?
•
And, of course, reassessment of home care must always be included here
You might consider charting each of these above catego ries along with anything else you can think of with each reassessment. Also, remember that the course of treatment will most likely change as a result of reassessment.
•
FIGURE 4-12
Lunging posture.
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NEUROMUSCULAR TH ERAPY BASICS
back and neck straight while your hips and legs hold you in
far more pressure on a body than relaxation massage. Keep
a lunge position.
your wrists as straight as possible, using hyperextended wrists
Your shoulders must also be held straight, not internally rotated. This helps you to keep a straight neck. If you con
as little as possible. Overuse of wrist movement may lead to conditions such as carpal tunnel syndrome.
stantly work with internally rotated shoulders, you are at risk
When performing thumb stripp ing, keep your thumbs
for developing thoracic outlet syndrome. Also, avoid keep
in a position to be able to push forward through musc le
ing your neck flexed toward the work; you can see what you
t issue deeply. For this technique, the thumbs must be
are doing ju t fine from a straight position. A common mis
held c lose to the fingers, not out away from the hand,
take made among massage therapists is flexing the upper body,
dragging along while straining the thumb adductor mus
shoulders, and neck forward to be close to the work. This
c les ( Fig. 4-4).
author has observed massage therapists with their face so
If you have weak flexor muscles and tendons in your
close to the client's body that their nose is only two or three
hands along w ith lax l igaments at the carpometacarpal
inches away from where they are working! If poor eyesight
joints and interphalangeal joints, consider regularly squeez
causes you to use improper body mechanics as you strain to
ing a rubber ball in your hands to help strengthen your fin
see your work, consider having your vision checked and get
ger flexors.
ting glasses or contacts or having your prescription strength ened so you can move back into proper body mechanics.
A l l of this information regarding body mechanics is merely an overview. As mentioned above, consult other
Most important are your wrist and hand mechanics.
sources on this topic and take a seminar devoted to the sub
N euromuscular therapy is deeper work and requires placing
ject of body mechanics as part of your continued education.
C H A PT E R S U M M A RY In preparing to treat clients, you must understand how to
ments to your c l ients to further faci l i tate their health and
apply warming and direct massage strokes and treat trigger
following up with them to ensure their compliance. Finally,
points with d igital pressure, as well as with tools designed
to avoid inj uring yourself and to improve the effectiveness
espec ially for this purpose. It is also important to know
of your treatments, it is critical that you learn to use proper
your treatment l imits and develop a network of healthcare
body mechanics while work ing w i th clients. Once you
profes ionals to whom you can refer your c lient for help
have become proficient in all of these areas, you are pre
with issues beyond your scope of practice. Another impor
pared to successfully perform neuromuscular th�rapy on
tant element of treatment is provid ing home care assign-
your cl ients.
C H A PT E R 4
-
--<
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BASIC N E U RO M U S C U L A R TH ERAPY TEC H N I Q U E S A N D BODY M E C H A N I C S
57
REVIEW QUESTIONS
Short Answer Questions
C. Friction
1 . When performing neuromuscular therapy, why would a
therapist not want to use much wrist movement ?
2. What might happen to a therapist who works with shoulders that are constantly internally rotated ?
3. How could a therapist help strengthen his hand and finger flexors ?
4. Why are proper body mechanics important
to a neu
1 0. Cryotherapy is the therapeutic use of wha t ? A . Water B. Steam C. lee D. Heat
True/False
1 1 . lee massage is easy for c l ients
romuscular therapist ?
5. What are the various areas of consideration for reassess ment of a cl ient's progress?
to perform on them
selves.
1 2. Use of moist heat will anesthetize an area. 1 3 . The use of either heat or ice will bring about hyperemia.
Multiple Choice Questions 6. Examination of deeper tissues using finger pressure
moving acros the muscle fibers at a right angle while compressing against a deep structure is called: A. pincer palpation
1 4. The c lient should be actively stretching all involved muscles at home regularly.
1 5 . A neuromuscular therapist should be able to do gait training with a cl ient rather than refer him to a physi
B. cross fiber friction
cal therapist.
C. flat palpation
Matching
D. longitudinal friction
7. Use of opposing thumbs is a technique that fal ls into which category ? A. Effleurage B.
D. Effleurage
a. Carpal tunnel syndrome
d. Local twitch response
b. Hypoxia
e . Anesthetize
c. J ump sign
f. Cryotherapy
1 6. Sorenes , tenderness, and weakness of the muscles of
Petrissage
the thumb caused by pressure on the medial nerve at
c. Vibration
the carpal tunnel of the wrist.
D. Tapotement 8. Thumb stripping is a technique that fal ls into which category ?
1 7. A transient contraction of a group of tense muscle fib ers that traverse a trigger point in response to stimu la tion of the trigger point.
A. Effleurage B. Vibration
1 8. A general pain response of a c lient in the form of winc
C. Friction
ing, crying out, or withdrawing in response to pressure
D. Petrissage
applied to a trigger point.
9. Mostly trigger points
are al leviated with which
technique ? A. Trigger point pressure B. Petrissage
REFERENCE 1 . Sinclair
M. Modern Hydrotherapy for the Massage Therapist.
Baltimore: Lippincott Will iams & Wilk ins, 2008.
1 9. A deficiency of oxygen. 20. To induce anesthesia.
THIS PAGE INTENTIONALLY LEFT BLANK
PART II Muscles and Neuromuscular her:apy Routines by Body Region
THIS PAGE INTENTIONALLY LEFT BLANK
HEAD AND NECK Note that common conditions encountered in this region
Headaches: pain inside the head, including tension headaches,
are includec among the key terms
migraines, dome headaches, etc.
.
•
Bilateral: affecting or related to two sides of the body
Hypoesthesia: dulled sensitivity to touch
Bruxism: clenching of the jaw and grinding of the teeth
Ipsilateral: affecting or related to the same side of the body
D ysesthesia:abnormal sensations on the skin, such as numbing, tingling, prickling, burning, or cutting pain
Eagle syndrome: an elongated styloid process of the temporal bone that punctures the sternocleidomastoid muscle and may cause dizziness and pain
Entrapment of the brachial plexus: an endangerment site
lamina groove: the flattened part of the vertebral arch, which extends between the vertebral spinous processes and the transverse processes
Occlusal imbalance: an uneven bite causing the muscles of the jaw to be in disharmony
Stiff neck: tight cervical muscles that cause pain and/or
that lies between anterior and medial scalenes and can
stiffness
become entrapped if the scalene muscles are chronically
Temporomandibular joint dysfunction (TMJ syndrome): symp
shortened
toms of pain and discomfort in the temporomandibular joint
Entrapped supraorbital nerve: pressure on the supraorbital
usually caused by a combination of poor posture along with
nerve caused by a tight frontalis muscle
tight muscles and malocclusion
Forward head posture (protracted head syndrome): poor posture
Tinnitus: a subjective ringing or buzzing sound in the ear
that includes the head being forward in relation to the
U nilatera l:affecting or related to one side of the body only
coronal plane
Whiplash injury:an injury to the cervical vertebrae and
Glaucoma: disease of the eye characterized by increase in
adjacent soft tissues produced by a sudden jerking of the
intraocular pressure, which atrophies the optic nerve,
head either backward, forward, or to the side with respect
causing blindness
to the vertebral column
OVERVIEW OFTHE HEAD AND NECK REGION
the temporomandibular joint (TMJ) area. Information pre sented will include trigger points and referrals along with anatomical and treatment considerations. This information
In this chapter, we will concern ourselves with the muscles
will be helpful
of the head and neck, both anterior and posterior, including
body's tissue and regaining integrity for the client.
to
you in meeting the goal of normalizing the
61
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POSTERIOR CERVICAL MUSCLES The first portion of this chapter presents the muscles of the posterior cervical region in detail. Routines for working these muscles are provided at the end of the chapter for cl ients in both prone and supine positions.
Posterior Suboccipital Muscles The posterior suboccipital muscles are four pairs of very short and small muscles. They can create severe headaches, usually due to mechanical overload on a chronic basis.
Rectus Capitis Posterior Major and Minor, Obliquus Capitis Superior and Inferior:The Rock and Tilt Muscles Three of these short suboccipital muscles connect the first two cervical vertebrae to the occiput, whereas the fourth, the obliquus capitis inferior, connects the upper two cervi cal vertebrae with each other ( Fig. 5-1). ORIGIN • Rectus capitis posterior major: spinous process of the
axis ( C 2 ) • Rectus capitis posterior minor: tubercle o n the poste
rior arch of the atlas (C l ) • Obliquus capitis superior: transverse process of the
atlas ( C l ) • Obliquus capitis inferior: spinous process of the axis
Minor
(C2) INSERTION • Rectus capitis posterior major: lateral portion of the
Major
Oblique capitis i
inferior nuchal line of the occiput • Rectus capitis posterior minor: medial half of the infe
rior nuchal line of the occiput • Obliquus capitis superior: between the superior and
inferior nuchal lines of the occiput • Obliquus capitis inferior: transverse process of the
atlas ( Cl)
• FIGURE 5-1 Attachment sites for the suboccipitals. Rec tus capitis posterior major: spinous process of the a xis, lateral portion of the inferior nuchal line of the occiput. Rectus capitis pos terior minor: tubercle on the pos terior arch of the atlas, medial half of the inferior nuchal li ne of the occiput. Obli quus capitis superior: transverse proc ess of the a tlas, between the superior and inferior nuchal lines of the
ACTION • Control movements of nodding, side bending, and
rotation of the head (nodding: rocking; looking upward with a rotation: tilting) TRIGGER POINTS AND REFERRAL ZONES
These muscles are deeply placed at the upper posterior neck area, j ust below the skull bilaterally. The trigger points are found in the belly of the muscles. The referral sensations . will be strongly felt behind, above, and in front of the ear, with quite a bit of spillover extending further in those d irec tions ( Fig. 5-2 ) . I t i s often difficult to distinguish the difference between referrals from trigger points in these muscles and those from semispinalis. It is rare that the suboccipital muscles develop trigger points without associated involvement of other major posterior cervical muscles.
occiput. Obli quus capitis inferior: spinous process of the axis, trans ve rse process of the atla s . (Reprin ted with permission from Oa tis CA. Kinesiology. Baltimore, MD: Lippincott Williams & Wilkins, 2 004.)
Trigger points in these muscles are one of the most com mon sources of head pain. The pain seems to be inside the head but is diffic ult to isolate. A person with these trigger points will most likely describe a headache as hurting all inside the head. If questioned further, the client will likely describe pain extending forward unilaterally to the occiput, eye, and forehead. The sensation typically does not have clearly definable limits, however. It will not be the stra'ight through-the-head quality, such as that from the splenius cervicis muscle. These muscles are usually quite tender to the touch, especially considering the depth of tissue one must press through to palpate.
CHAPTER 5
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HEAD AND NECK
63
• FIGURE 5-2 Trigger points and referral zones for the subo ccipitals. Noti ce that Travell and Simons have only noted trigger points on the obl i que
muscles.The trigger points occur within the belly of each muscle with very strong referral across the latera l head beginning just in front of the ear and completing well behind the ear.There is spil lover surrounding the strong referral all the way to the eye and above it in front and to the midline of the posterior head behind. (Repri nted with permission from Simons DG, Travel l JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore: Lippin cott Williams & Wil kins, 1 999. Travell & Simons'Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1 . p. 4 73, Fig. 1 7. 1 .)
Clients experiencing trigger points in these muscles often complain of horrible headaches when their head rests on their pillow at night. The weight of the head presses the pil low against the occiput, placing pressure on these muscles. Such a client might be able to locate the sore spot by palpat ing the base of the skull. If obliquus capitis inferior is involved, the head may not be able to rotate completely to the rear, as when necessary in trying to back up when driving a car. TRIGGER POINT ACTIVATION
As these muscles are mostly responsible for moving the head at the top of the spine, they will probably develop trigger points when trying to control flexion, when held in a short ened position maintaining extension looking upward for long periods of time, or when held in a shortened position looking to the side for prolonged periods of time. Often a person with forward head posture will also have the head in hyperextension (chin poking up and out). This accommodates the line of vision for the person. This will likely activate trigger points in the posterior suboccipitals along with other posterior cervical muscles. These muscles are a very common source of posttraumatic headache trigger points.
• Uncorrected nearsightedness • Lenses with too short a focal length • A chill or draft to the back of the neck while maintain
ing the head to the side • Whiplash injury
PRECAUTIONS • Avoid working too deeply too quickly • Initial warming should include the location of the
bony landmarks in the area • Palpation should be gentle: avoid poking or jabbing
movements. This is a very sensitive area for most people MASSAGE THERAPY CONSIDERATIONS • Be sensitive to the client's pain threshold, yet apply
appropriate pressure to allow the tissue correctly
to
respond
• Treatment of the suboccipital tissues between C l and
the occiput will ensure that the head will be able move without restriction
to
• Treatment between Cl and C2 will ensure that the
head will be able to rotate fu lly STRESSORS AND PERPETUATING FACTORS •
Lying on the floor propped up on elbows watching television
• Looking to the side or reading copy from a flat surface
while keyboarding when doing computer work •
Sustaining an upward gaze with head tilted up (paint ing a ceiling or using binoculars)
•
Any sustained awkward head position
•
Maladjusted eyeglasses or use of trifocals
• This is a common area for the therapist to overwork
using friction and pressure • An effective technique for warming with the suboc
cipitals is to use a wave-like motion utilizing fingertips at the base of the skull while resting the head on the palm of the hand (please see the online video for this technique) • Be sure not to push the atlas forward but to make the
direction of pressure upward under the occipital ridge
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Levator Scapula:The Stiff Neck Muscle Interestingly, the scapular attachment of levator scapulae inserts in two layers, with fibers attaching to both the ante rior and posterior surfaces of the medial border of the scapu lae for most people. l Often, there is a bursa between the two layers. There might be another bursa between the attach ment of levator scapulae and serratus anterior at the supe rior angle of the scapulae. These bursas will most likely be very tender (Fig. 5 -3). ORIGIN • Transverse processes of CI-C4 (C3 and C4 attach
ments are actually at the posterior tubercles of the transverse processes) INSERTION • The vertebral border of the scapulae between the supe
rior angle and the root of the spine of the scapulae ACTION
• FIGURE 5-3 Atta ch ment sites for the levator s capula. Transverse pro cesses of C1 to C4. vertebral border of the s capulae between the
• Elevation of the scapula
superior angle and the root of the spine of the s capulae. (Reprinted
• Downward rotation of the scapula
with permission from Life Art, Lippin cott Williams & Wilkins.)
• Ass ists rotation of the neck to the same side when the
scapula is fixed • Assists extension of the neck while helping to control
neck flexion TRIGGER POINTS AND REFERRAL ZONES
Trigger points commonly occur in the belly of this muscle, one in the middle portion and another near the scapular attachment (Fig. 5-4) . From both of the commonly found trigger points i n this muscle, referral sensation projects to the angle of the neck/ shoulder (crook of the neck area) , with a spillover zone next to the vertebral border of the scapula and across the poste rior shoulder. Referrals from these trigger points are some of the most important causes of neck pain and, at times, shoulder pain. This muscle is often involved in a shoulder girdle issue. In a study done by Sola et al } latent trigger points were found in 20% of 200 normal young adults. More trigger points are found here than in any other muscle except for the upper trapezius. In a clinical study of active trigger points, } the levator scapulae was found to be harboring the most. When the trigger points are severe, a person will com plain of pain at the angle of the neck and/or a painful, stiff neck. Symptoms of these trigger points may mimic torticol lis. Other clients experiencing these trigger points may have diagnoses of stiff neck syndrome, levator scapulae syndrome, or scapu locostal syndrome, according to Travel and Simons.
• FIGURE 5-4 Trigger points and referral zones for the levator s capula. The trigger points usually o ccu r within the m u s cle belly at the angle of the n e ck and just below with very strong referral around them . There is often spil lover down the med ial border of the s capulae and a cross the posterior shoulder. (Reprinted with permission from Medi Clip, Lippin cott Williams & Wilkins.)
C H A PT E R 5
With extremely activated trigger points, a person may be unable to turn the head fully to the same side because of pain upon contraction and not fully to the opposite side because of painful increase in muscle tension. To look behind, he or she must turn the body rather than the neck. Pain from the trigger points actually limits neck rotation, and so it is named the "stiff neck" muscle. If active enough, the trigger points will refer extreme pain even when at rest.
H E AD A N D N E C K
65
•
Sitting in a chair with armrests that are too high
•
Sleeping with the head tilting backward or to one side, such as when in an airplane seat or on one's stomach
• Whiplash from any direction •
Asymmetries in the lower part of the body providing an uneven gait
PRECAUTIONS •
When working with a client in the prone position, take care not to mistake the lateral border of trapezius for the levator scapulae
•
Be sure to observe the bony landmark of the transverse process of C l and apply techniques to the lateral aspect of the neck, not at an oblique angle toward the occipi tal ridge
TRIGGER POINT ACTIVATION
Postural stress is the main activator here. Trigger points are most likely to develop because of occupational stress or sleeping position. Psychological stress that creates tense, hostile, aggressive posture of the shoulders can also activate trigger points. Activities that keep the levator scapulae in a shortened position can activate latent trigger points. Specific examples of these postures and activities are discussed in the next section.
/
MASSAGE THERAPY CONSIDERATIONS • A strain in levator scapulae will restrict range of motion
to the opposite side and will be painful upon rotation to the same side
STRESSORS AND PERPETUATING FACTORS •
Overexertion in sports such as tennis or swimming, particularly when out of shape
•
Rotating the head back and forth repeatedly, such as when observing a tennis match at center court
•
Keyboarding with the head and neck turned to one side or with the keyboard too high
•
Talking for long periods of time to a person sitting to one side
•
Carrying a purse on the shoulder by a long strap
•
Looking ideways for long periods of time
•
Cradling the telephone between the shoulder and the ear
• This muscle should always be examined during any
•
Using crutches or a cane that are too long
•
•
Tense or aggressive postures, such as occurs when hold ing one's shoulders up high when driving aggressively
• The attachment on Cl transverse process requires spe
cial attention due to its hidden location deep to sterno cleidomastoid; this will also treat the splenius cervicis attachment there •
The tendonous attachment at the superior angle of the scapu l a is often fibrotic and easy to locate. Stand at the head facing the scapula to work on this attachment
•
Be sure to use muscle stripping and friction to work on the transverse process attachments work for the cervical area Use of forearm compression into the belly of the mus cle at the angle of the neck is a nice way to give a bit of a stretch when completing work here
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ANTERIOR CERVICAL MUSCLES The anterior cervical muscles should be worked with the client in a supine position. As most people have never had their anterior cervical muscles work on, be sure to explain what will be going on during this work and why it is neces sary. Especially when a person has had any whiplash inj ury, the anterior cervical muscles will be involved. Most massage therapists avoid doing this type of work as it frightens them due simply to the area being worked and the fact that to work in this region a therapist must really know their anat-
omy and be able to visualize it. To eliminate risk as you work, be sure to be gentle. Also to be safe with this work, you must be precise with your positioning. When a person has had a whiplash injury and the only muscles being dealt with are in the posterior neck, pain in that area will actually increase. Because the t.herapist is giv ing this person a muscle imbalance by loosening the poste rior musculature while leaving the anterior musculature tight, this person may begin to lose the curve of their cervical spine and end up with what is called a "military neck." This is why it is so important to be able to do this work well.
Sternocleidomastoid: Amazingly Complex The sternocleidomastoid is a fascinating muscle that should be considered when doing any neck, shoulder, or head work with a client. ORIGIN •
Manubrium of the sternum
•
Medial clavicle (posterior to the sternal attachment)
INSERTION •
Mastoid process of the temporal bone
ACTION •
Rotation to opposite side and tilting upward (unilateral)
•
Flexion of head and neck (bilateral)
•
Auxiliary muscle for inhalation (bilateral)
•
Control of posterior head and neck movements (bilateral)
TRIGGER POINTS AND REFERRAL ZONES
The sternal and clavicular portions of this muscle each have their own referral patterns. Mostly, however, both refer pain to the face and the head, not the neck. The referrals often mimic the symptoms of atypical facial neuralgia or tension headaches. Often dentists recognize these referrals as a com ponent of facial pain complaints. From the sternal portion of this muscle, the referrals usually present as pain. Typically, the trigger points themselves are all along the length of this division, with the referrals being strongly felt at the attachment on the mastoid process and occipital ridge and arcing around the medial, lateral, and supe rior aspect of the eye and the eyebrow. There may be spillover referral to the top of the head, behind the eye, and to the max illa and mandible, throat, chin, and sternal attachment. There may be symptoms of the eye such as excessive lac rimation, reddening of the conj unctiva, or visual distur bances such as blurred vision or a dimming sensation. There
.. ..... .,. ...-.-.. :
:
• FIGURE 5-5 Trigger points and referral zones for the sternal head of
the sternocleidomastoid. There wi ll most likely be trigger points set into this portion of the muscle along its entire length. There will be strong referral arcing from the temple up and over the eye to the bac k of the head and into the sternum. There may be spil lover to the top of the head, from the ear to the eye and entire maxilla as we ll as lateral to the strong referral at the stern um. (Reprinted with permis · sion from Medi Clip, Lippi ncott Williams & Wilkins.)
may even be sinus congestion present. Occasionally, there may be unilateral deafness occurring without tinnitus or a crackling noise (Fig. 5-5). From the clavicular portion of this muscle, the referrals are pain with the actual trigger points all along the length of this division. The referrals will be felt mostly into the fron tal area of the head and behind and deep into the ear. Occasionally, there is spillover referral to the cheek and the molar teeth on the same side.
C H A PT E R 5
/
HEAD AND NECK
67
positioning wil l have active trigger points in sternocleido mastoid, as well. Another source would be a structural inadequacy, such as a high hip/low hip, short leg, or small hemipelvis, because these conditions cause functional sco liosis and shoulder girdle tilting. These conditions over load the muscle by making it work hard to maintain a normal head position to level the eyes. Any limping gait can activate trigger points here because the sternocleido mastoid will try to either help the movement and/or main tain equilibrium. A tight pectoralis major may activate trigger points in sternocleidomastoid by pulling on the clavicle. Also, para doxical breathing or chronic coughing can overload this muscle. STRESSORS AND PERPETUATING FACTORS • FIGURE 5-6 Trigger points and referral zones for the clavicular head
of the sternocleidomastoid. As with the sternal head, the trigger
• Hyperextension of neck, as when painting a ceiling,
writing on a blackboard, hanging curtains, or sitting in a front-row seat at a theater with a high stage
po ints set into the muscle along its entire length. The strong referrals are to the forehead, into the ear, and behind the ear. There may be a b it of s p illover surrounding those sites. (Rep r inted w ith permiss ion
•
Reading while lying on the back with the book held to the side
•
Protracted head, slouched posture
from Medi Clip, L ippi n cott W illiams & W ilkins.)
A person may complain of proprioceptive difficulties such as spatial disorientation, dizziness, and/or vertigo. Mechanical stimulation of active trigger points in the cla vicular division can refer autonomic phenomena of local ized sweating and vasoconstriction to the frontal area of referral (Fig. 5-6). Interestingly, there usually is no neck pain or stiffness reported from trigger points in sternocleidomastoid. However, there may be complaints of soreness in the anterior neck area, which mimics the symptoms of tender lymph glands. Extreme referrals into the head and face from these trigger points will also resemble a tension headache. It is rare that this person will complain of restricted neck motion. Mostly complaints will be of vision blurring, dizziness, profuse tearing of the eye, frontal headaches, and nausea.
• Forward head posture while driving •
Wearing collars or ties that are too tight
•
Drooping shoulders (wearing too heavy of clothing or feeling "down")
PRECAUTIONS • When working on the sternocleidomastoid, avoid the
carotid artery, which lies medial to the sternal fibers. MASSAGE THERAPY CONSIDERATIONS • Rotating the head slightly toward the side being worked
will slacken the muscle fibers and make it easier pincer grasp this muscle
• Using a pincer compression is very effective for this
problematic muscle • It may be necessary to use a tissue or paper towel to be
able to grasp the muscle securely if lubricated
TRIGGER POINT ACTIVATION
Any posture or activity that activates these trigger points will also perpetuate them if not corrected. Excessive forward head posture will shorten this muscle and activate trigger points there. Also, having the head turned to one side for long peri ods of time will activate trigger points, along with sleeping on one's back using two or more pillows to keep the head up. Mechanical overload is a frequent cause of activation, such as when the neck is hyperextended for a prolonged period dur ing an activity. Activation could also be induced accidentally by injuries such as falling on one's head, or whiplash. A person with a deformity or injury that restricts upper limb movement requiring awkward compensatory neck
to
• Stretching and range of motion exercises may be
effectively done by rotating the head without lateral flexion • Sternocleidomastoid is the most superficial of the three
muscles that attach at the mastoid process •
The referral pattern of the sternal division of sterno cleidomastoid mimics the classic migraine arc
• Thorough treatment of this thick upper half of the
muscle, including the tendon at its attachment at the mastoid process, is extremely important • Always note the location of the stylOid process prior to
treatment so as not to intrude onto it
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Scalenes: Anterior, Medius, and Posterior: The Entrappers Scalene muscle trigger points and their associated thoracic outlet entrapment syndrome are often overlooked sources of pain in the shoulder-girdle region and upper limb. Scalene trigger points are among the more difficult to identify and treat effectively but are also the most important of the myo fascial trigger points. All of the scalene muscles are variable in their attach ments. The most variable is scalene minimus. This muscle exists in approximately 50% to 7 5 % of people on at least one side of the body. ORIGIN • Anterior: transverse processes of C3-C6 • Medius: transverse processes of C2-C7 • Posterior: transverse processes of C5-C7 • Minimus: transverse processes of C6-C7
INSERTION • Anterior: rib 1 • Medius: rib 1 • Posterior: rib 2 • Minimus: rib 1
ACTION • Forward flexion of the neck • Lateral flexion to same side • Stabilize cervical spine against lateral movement • Assist in elevating first two ribs for forceful inspiration
the scalenes rarely refer to the head, they are associated with trig ger points that do refer to the head. Travell and Simons quote a study4 that shows that more than half of those in the study who had celvicogenic headaches also had associated active scalene trigger points that were contributing to their pain. Scalene muscles are among the most common sources of back pain. Pain from these trigger points is usually described as being persistent and aching, coming in two finger-like proj ections over the upper chest area. If on the left side, it may be mistaken for angina pectoris and will most likely be associated with muscular activity. The less common referral into the thumb will usually be described as numbness and may or may not include hypoesthesia with or without a thermal sensitivity (usually this will be cold). TRIGGER POINT ACTIVATION
Often trigger points in the scalene muscles are activated sec ondary to trigger points in the sternocleidomastoid. This ster nocleidomastoid forms a functional unit with the scalenes. Also, a severe stiff neck syndrome from trigger points in levator scapulae will sometimes include trigger points in the scalenes. STRESSORS AND PERPETUATING FACTORS • Accidental trauma • Pulling or lifting heavy items (hauling on ropes when
sailing) • Playing a game of tug-of-war
TRIGGER POINTS AND REFERRAL ZONES
• Competitive swimming
Mainly the trigger points occur along the bellies of the mus cles. With medius, however, the trigger points are usually found in the lower portion of the belly. Active trigger points in the anterior, medial, or posterior scalenes may refer sensation anteriorly to the chest, laterally to the upper arm, and posteriorly to the medial scapular border and interscapular area. It could be all of this area referred to or any portion of it. The posterior referral is usually from scalene anterior, especially along the border of the scapula. Anteriorly, there may be referrals into the pectoral region coming from sca lene medius or posterior. Also, referral may be down the front and back of the upper arm, skipping the elbow, and then into the radial side of the forearm, the thumb, and the index finger. This refer ral usually comes from trigger points in the upper scalene anterior along with medius (Fig. 5-7). Trigger points from the scalenes are commonly overlooked sources of back, shoulder, and arm pain. As trigger points from
• Holding awkwardly large objects • Playing certain musical instruments • Overuse as with paradoxical breathing • Coughing hard very often (asthma, bronchitis, etc.) • Sleeping with the foot of the bed higher than the head
of the bed • A tilted shoulder girdle when standing • A small hemipelvis when seated • Loss of an upper limb or surgical removal of a heavy
breast • Scoliosis • Having to lean awkwardly when seated because of
short upper arms not reaching armrests of a chair • A whiplash-type injury • Carrying heavy shoulder bags • Upper chest breathing (asthma, etc.) • Reading in bed with head tilted forward • Limping
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B
• FIGURE 5-7 Trigger poi n ts and referral zones for the s calenes. l n ea ch o fthe four po rt ions of this mus cle, the trigger poin ts appear wi thin the belly of the mus cle. There may be s trong referral to the area just medial to the s capulae, down the pos terior and la teral forearm, i n to the pos terior hand, and i n to the ches t.There may be spillover a cross the shoulder both a n terior and pos terior, down both anterior and pos terior areas of the forea rm and i n to the palm, and i n to the ches t above the s trong referrals there. (Repri n ted wi th permission from Simons DG, Travell JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore: Lippi n cot tWilliams & Wilkins, 1999. Trave" & Simons' Myofascial Pain and Dysfunction.' The Trigger Point Manual; vol 1 . p. 5 06, Fig. 2 0.1.)
PRECAUTIONS • Avoid direct pressure on the brachial plexus, an endan
germent site, which lies between anterior and medius MASSAGE THERAPY CONSIDERATIONS • Very tight scalenes will cause entrapment of the bra
chial plexus • When using gliding thumb strokes with the head
rotated to the side, avoid direct contact with the clavi cle by engaging thumb posteriorly and inferiorly toward the first rib attachment (area of brachial plexus) •
Tightness of scalenes will e levate the first two ribs. Tightness of pectoralis minor will cause the clavicle to
depress. This combination can close the thoracic out let and cause the brachial plexus to become entrapped, which is thoracic outlet syndrome • If there is ulnar pain, tingling, numbness, and dys
esthesia along with hand edema, then the client likely has thoracic outlet syndrome • Trigger points here may cause symptoms similar to
those of carpal tunnel syndrome • Because the brach ial plexus and a x i l lary artery
emerge above rib 1 while between the anterior and medial scalene, be careful not to intrude into it. The person w i l l fee l an e lectric- like shock if this happens
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Anterior Suboccipitals The anterior suboccipitals are made up of two muscles, rectus capitis anterior and rectus capitis lateral is. Even though they are relatively difficult to get to, they are palpable and workable. Rectus Capitis Anterior and Rectus Capitis Lateralis Although these two muscles are quite short, they can play a major role in head and neck pain, especially when injured. Rectus capitis anterior lies deep to the upper portion of lon gus capitis.
cles are a very common source of posttraumatic headache trigger points. STRESSORS AND PERPETUATING FACTORS •
ORIGIN
Lying on the floor propped up on elbows, watching television
•
Anterior: anterior transverse process of atlas (Cl)
•
Maladjusted eyeglass frames
•
Lateralis: transverse process of atlas (Cl)
•
NearSightedness that goes uncorrected
INSERTION •
Anterior: occipital bone, anterior to foramen mag num
•
Lateralis: j ugular process of occipital bone
ACTION •
Anterior: flexes head
•
Lateralis: laterally flexes head
TRIGGER POINTS AND REFERRAL ZONES
Actual locations for trigger points as well as specific referral patterns for most of the deeper anterior neck muscles have not been established yet. Most agree, however, that trigger points can refer to the laryngeal area, anterior and posterior neck, and sometimes into the mouth, as well. A person with trigger points in this area may complain of anterior and neck pain or possibly a lump or tickle in the throat or difficulty with swallowing. TRIGGER POINT ACTIVATION
As these muscles are mostly responsible for moving the head at the top of the spine, they will probably develop trigger points when trying to control flexion, when held in a short ened position maintaining extension looking upward for long periods of time, or when held in a shortened position looking to the side for prolonged periods of time. Often a person with forward head posture will also have his or her head in hyperextension (chin poking up and out). This accommodates the line of vision for the person. These mus-
• Lenses with too short a focal length •
Use of trifocal lenses that require frequent and/or sus tained fine adjustment of head position to see properly
•
A chill or draft to the back of the neck while maintain ing the head to the side
•
Whiplash injury
• Sustaining an upward gaze with head tilted up (paint
ing a ceiling or using binoculars) •
Any sustained awkward head position
•
Prolonged typing while reading copy from a flat surface or reading to the side
PRECAUTIONS •
Palpate the styloid process to ensure knowledge of its exact location; never press on it as it is quite sharp and could cause trauma to the stylopharyngeus muscle and the glossopharyngeal nerve. Also, the styloid process is small enough to fracture or snap off completely
•
Palpation should be gentle; avoid poking or jabbing movements. This is a very sensitive area for most people
MASSAGE THERAPY CONSIDERATIONS •
Be sensitive to the client's pain threshold, yet apply appropriate pressure to allow the tissue to respond cor rectly
•
Unresolved posterior neck pain may result from acti vated trigger points in these muscles
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Longus Capitis and Longus Colli: Military Neck
Longus capitis and longus colli, along with the anterior suboc cipitals, are the deepest muscles of the anterior neck. They are responsible for giving a person what is called a military neck or a straight neck when they are chronically contracted. This is a painful situation in which the curve is no longer in the neck, causing the neck to be straight and usually forward,
Most believe they can refer to the laryngeal region, anterior neck, and mouth. A client with trigger points in this region may complain of having difficulty in swallowing, with possible pain in the vicinity of the cricoid cartilage and a sore throat.
ORIGIN
Mostly these trigger points will be caused by flexion/exten sion injuries, such as those sustained in automobile injuries or sports injuries, along with a forward head posture. Anyone with a military neck will most likely have several trigger points activated here.
•
Longus capitis: anterior transverse processes of C3-C6
•
Longus colli, vertical fibers: anterior bodies of CI-C3 and C5-C7
•
Longus colli, inferior oblique fibers: anterior bodies of TI-T3
•
Longus col li, superior oblique fibers: anterior tubercles of transverse processes of C3-C5
TRIGGER POINT ACTIVATION
STRESSORS AND PERPETUATING FACTORS •
Whiplash
•
Forward head posture
INSERTION •
Longus capit is: occipital bone anterior to foramen magnum
•
Longus colli, vertical fibers: anterior bodies of C2-C4
•
Longus colli, inferior oblique fibers: anterior tubercles of transverse processes of C5-C6
•
Longus colli, superior oblique fibers: anterior tubercles of atlas (C l )
ACTION •
Longus capitis: flexes head and neck
•
Longus colli: flexes head and neck and assists rotation of the head
PRECAUTIONS •
Be sure to explain to the client how and where you will be working
•
Palpation should be gentle; avoid poking or j abbing movements. This is a very sensitive area for most people
MASSAGE THERAPY CONSIDERATIONS •
Be sensitive to the client's pain threshold, yet apply appropriate pressure to allow the tissue to respond cor rectly
•
Be sure not to move pressure laterally off the transverse processes, as this could cause intrusion onto the carotid artery
•
Unresolved posterior neck pain may result from acti vated trigger points in these muscles
TRIGGER POINTS AND REFERRAL ZONES
Specific trigger points and referral areas for most of the deep est anterior neck muscles have not yet been established.
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Suprahyoid Muscles The suprahyoid muscles attach to the hyoid bone from above and continue upward to attach to the mand ible, temporal bone, etc. These muscles include the mylohyoid, geniohyoid, and digas tric. Related muscles, the infrahyoid muscles, act to stabilize the hyoid bone, so these suprahyoid muscles can move the j aw (Fig. 5 -8).
Mylohyoid This muscle is active in most mouth functions, such as swal lowing, chewing, sucking, and blowing. ORIGIN •
Entire length of the mylohyoid line of the inside sur face of the mandible
INSERTION •
Hyoid bone
ACTION •
Opens mouth (lowers mandible )
•
Elevates hyoid bone
Stylohyoid
• Raises floor of mouth and tongue
Hyoid bon e
TRIGGER POINTS AND REFERRAL ZONES
Trigger points have not been officially recorded for this muscle as of yet; however, trigger points most l ikely set up in the muscle belly. Referrals are likely to occur on the lateral side of the tongue. A client w i th trigger points in this muscle would l i kely complain of difficulty when swal low ing, along with a painful and restrictive fee l ing. TRIGGER POINT ACTIVATION
Trigger points in this muscle can be activated by chronic mouth breathing. Any whiplash-type injury will also acti vate trigger points here.
• FIGURE 5-8 A ttachmen t s i tes for the suprahyoids. Mylohyoid: supe
rior aspec t of the hyoid bone, e n tire len g th of the mylohyoid line of the inside su rface of the mandible. Geniohyoid: superior aspec t of the hyoid bone, infe r ior inner surface of the mid -mandible a t the symph ysis men ti. (Reprin ted w i th permission from Oa tis CA. Kinesiology. Ba l timore, MD: Lippincott Williams & Wilkins, 2 004 .)
PRECAUTIONS
This is inner oral work under the tongue; be sure there are no tissue abnormalities such as a tumor and open sore. MASSAGE THERAPY CONSIDERATIONS •
Trigger points in any of the anterior throat muscles could refer viscerally into the thyroid gland
•
With any whiplash-like accident, always include an examination of this muscle
STRESSORS AND PERPETUATING FACTORS •
Forward head posture
•
Mouth breathing
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Geniohyoid This muscle mainly works synergistically with the digastric muscle. ORIGIN •
Inferior inner surface of the mid-mandible at the sym physis menti
INSERTION •
TRIGGER POINT ACTIVATION
Trigger points will be activated here because of flexion and extension injuries such as whiplash. STRESSORS AND PERPETUATING FACTORS •
Forward head posture
•
Mouth breathing
Hyoid bone PRECAU TIONS
ACTION •
Retraction and depression of mandible
•
Elevates hyoid bone . . . . .. . . .
. . . . . .
. . . . .
. .
. .
. , . .
. ..... . . .... .. . .
. .
. .
.
.
This is inner oral work under the tongue; be sure there are no t issue abnormalities such as a tumor and open sore. . . .
. . .
. . . . . . . . .
TRIGGER POINTS AND REFERRAL ZONES
Nothing has been written regard ing trigger points and refer rals of this muscle as of yet. As with any muscle, it is most likely that a trigger point will setup within the muscle belly. Referrals will most likely be into the mouth area.
MASSAGE THERAPY CONSIDERATIONS •
Trigger points in any of the anterior throat muscles could refer viscerally into the thyroid gland
•
With any whiplash-like accident, always include an examination of this muscle
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Digastric: Pseudo-sternocleidomastoid Pain This is a fascinating muscle in regard to its anatomical attachments. The posterior bellies are united end-to-end by a common tendon that attaches to the hyoid bone through a fibrous loop or sling-like structure.
If there is a trigger point in the anterior section, the cli ent will likely experience pain in the lower front teeth. This source of tooth pain is often overlooked.
ORIGIN
Activation of trigger points in this muscle may be secondary to dysfunction ofother anterior neck and throat mu cles. However, to activate trigger points here, one must only do things sllch as clenching and/or grinding and mOllth breathing. Mechanical irritation may occur in this muscle if a person has an elongated styloid process. This is known as "Eagle syn drome"; the styloid process presses into the muscle belly and causes some tearing and inflammation. There is typically pain present at the angle of the j aw, with symptoms of dizziness and visual blurring. There may be a decrease in vision, as well.
•
Anterior belly: inferior border of mandible
•
Posterior belly: mastoid notch of temporal bone
INSERTION •
Intermediate tendon attached indirectly to hyoid bone by a fibrous loop of fascia
ACTION •
Lowers mandible (opens mouth)
•
Moves hyoid bone upward, forward, and backward
TRIGGER POINTS AND REFERRAL ZONES
Trigger points may be found within the belly area of both the anterior and posterior portions of this muscle. Referral from the posterior trigger points is often felt strongly into the side of the j aw and the throat area near the j aw angle, with spillover up into the occiput. From the anterior sec tion, referral is often into the lower front teeth (Fig. 5 -9). Often, a person with trigger points in the posterior por tion may not feel pain but instead have problems with swal lowing, such as having a lump in the throat or a feeling of something stuck there.
TRIGGER POINT ACTIVATION
STRESSORS AND PERPETUATING FACTORS •
Overload from bruxism and/or mouth breathing
• Eagle syndrome • Whiplash-type injuries
PRECAUTIONS •
Be sure to locate the styloid process before working on the posterior portion of this muscle and not to press on it as it is small and easily broken
MASSAGE THERAPY CONSIDERATIONS •
Use trigger point pressure to each trigger point found
• FIGURE 5-9 Trigger points and referral zones for the digastric. The actual trigger points will usually occur in the belly with strong referral into the
side of the neck up onto the mastoid and into the lower middle teeth.There may be spil lover across the posterior head and into the anterior neck just below the jaw. (Reprinted with permission from Medi Clip, Lippincott Williams & Wil kins.)
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HEAD AND FACE MUSCLES With the final group of muscles, those of the head and face, we consider face pain, such as that from TMJ dysfunction. Occipitalis:The Scalp Tensor Travell and Simons state that tenderness in the occipitalis muscle is found in 42% of patients with ipsilateral face and head pain associated with myofascial pain/dysfunction syn drome. Ipsilateral means affecting or related to the same side of the body. This muscle is usually grouped with the frontalis muscle and is called the "occipitofrontalis" or "the epicranius." For the purposes of splitting the muscles into anterior and pos terior categories, this text presents them separately. ORIGIN •
Occi�ital bone at the superior nuchal line
INSERTION •
Galea aponeurotica
and through the cranium. There may be intense pain deep in the orbit of the eye and the eyeball itself (Fig. 5- 1 0) . Clients with trigger points i n thi region often cannot bear the weight of the back of the head on the pillow when trying to sleep because of pain from a trigger point in the muscle belly. They may report that they must lie on their side to get some sleep. Pain from trigger points in this area is a deep aching pain. If the client reports super ficial scalp tingling and/or hot prickling, this is most likely due to the greater occipital nerve being entrapped by pos terior cervical muscles. If it is trigger point referral the client i experiencing, then moist heat wil l usually pro vide relief; if the pain is due to nerve entrapment, most likely the client will not be able to tolerate heat but will enjoy cold applied there.
ACTION •
Draws back scalp
•
Assists in raising eyebrows and wrinkling forehead
TRIGGER POINTS AND REFERRAL ZONES
From trigger points in the muscle belly, sensation is referred laterally and anteriorly, diffusely over the back of the head
TRIGGER POINT ACTIVATION
Trigger points are most likely to occur in this muscle when a person has decreased visual acuity and/or glaucoma. G laucoma is a disease of the eye characterized by increase in intraocular pressure, which atrophies the optic nerve, caus ing blindness. In both of these cases, there is persistent
• FIGURE 5-10 Trigger points and referral zones for the occipitalis. The trigger point will occur within the muscle belly and refer strongly to the supe
rolateral head and behind the eye with spillover around both. (Repri nted with permission from Simons DG, Travel l JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore: Lippincott Williams & Wilkins, 1 999. Trove" & Simons'Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1 . p. 428, Fig. 1 4.1 B.)
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strong contraction of the forehead and scalp muscles. These trigger points may also be activated as satellites of posterior cervical trigger points that refer sensation to the occipital area.
PRECAUTIONS • This area may be quite sensitive
MASSAGE THERAPY CONSIDERATIONS • Teach clients to use trigger point pressure to release
STRESSORS AND PERPETUATING FACTORS • Decreased vision • Trigger points in posterior cervical muscles causing
satellites in occipitalis
trigger points here for themselves • Be sure to inactivate all key trigger points in the cla
vicular division of the sternocleidomastoid and all pos terior cervical muscles
C H A PT E R 5
,��
ORIGIN
Galea aponeurotica
INSERTION •
Fascia of fac ial muscles and skin above the nose and eyes
ACTION •
Draws scalp back
•
Raises eyebrows
•
Wrinkles forehead
H E AD A N D N E C K
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Frontalis:The Scalp Tensor
This muscle is usually grouped with the occipitalis muscle and is called the "occipitofrontalis" or "the epicranius," For the purposes of splitting the muscles into anterior and posterior categories, this text presents them separately. Travell and Simons label these two muscles as the "scalp tensors."
•
/
The main complaint of clients with trigger points in this muscle is pain in the forehead. TRIGGER POINT ACTIVATION
Trigger points here are most likely to be satellites from those set up in the clavicular portion of the sternocleidomastoid. Also, activation could be from work overload; in this case, constant facial expressions showing anxiety, tension, sur prise, and distrust. The forehead stays wrinkled with these expressions. STRESSORS AND PERPETUATING FACTORS • Longstanding trigger points in the clavicular head of
sternocleidomastoid may be forming satellites here •
Chronic frowning or other expressions that include wrinkling the forehead
PRECAUTIONS • Chronic tension in the belly of frontalis could entrap
TRIGGER POINTS AND REFERRAL ZONES
the supraorbital n erve, producing a unilateral frontal
Trigger points occur within the muscle belly and usually refer strongly around the trigger point itself. There may be some feather-like extensions upward on the forehead of spillover referral (Fig. 5 - 1 1 ) .
headache MASSAGE THERAPY CONSIDERATIONS • Work carefully to avoid nerve entrapment
• FIGURE 5-1 1 Trigger points and referral zones for the frontalis.The trigger point is within the muscle belly close to the eyebrow with strong referral
around itself. There may also be spillover in a feather-like arrangement up higher on the forehead. (Reprinted with permission from Simons DG, Travel l JG, Simons LS. Upper HalfofBody. 2nd ed, Baltimore: Lippincott Williams & Wilkins, 1 999, Trovell & Simons'Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1 . p, 428, Fig. 1 4. 1 A.)
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Corrugator Supercilii This tiny muscle of the face can be key in ridding a person of eye headaches (Fig. 5 - 1 2 ) . ORIGIN •
Medial end of superciliary arch of frontal bone above the nasal bone
INSERTION •
Skin above the middle of the supraorbital margin and above the nasal bone
ACTION •
Draws eyebrows medially and inferiorly
TRIGGER POINTS AND REFERRAL ZONES
No specific trigger points or referral zones have been studied here yet. Trigger points are most likely to set up in the more medial portion of the muscle belly while referring sensation to behind the eyes. A client with trigger points in this muscle will probably complain of headaches behind the eyes. TRIGGER POINT ACTIVATION
As with frontalis, trigger points in this muscle will most likely be activated by intense, sustained facial expressions. It will most likely be that intense looking person that has trigger points here. This is a person who mostly wears an expression of concern or anger on their face, pulling their eyebrows together creating a furrow between them. Probably the per son who looks surprised will also activate trigger points here. STRESSORS AND PERPETUATING FACTORS •
Frowning
•
Wearing an expression of attention, concern, anger, or surprise, with eyebrows raised and forehead wrinkled
•
May be satellites from trigger points in frontalis and the posterior cervical muscles
• FIGURE 5-12 Attachment sites for the corrugator supercilii. Medial
end of the superciliary arch of the frontal bone above the nasal bone, the skin above the middle of the supraorbital margin and above the nasal bone. Note that one end of this muscle does not attach to bone.
PRECAUTIONS
There are no precautions for this muscle. MASSAGE THERAPY CONSIDERATIONS •
Using a pincer grasp is the only way to effectively work on this muscle
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Temporalis: Temporal Headache and Maxillary Toothache This muscle can be a key player in TMJ dysfunction and is often overlooked by massage therapists as a source of trigger points. It can be so tender that a client cries out when a trig ger point is palpated. ORIGIN •
Temporal bone at its lateral surface
INSERTION •
Coronoid process and ramus of the mandible
ACTION •
Elevates the mandible (closes jaw)
•
Retracts the jaw
TRIGGER POINTS AND REFERRAL ZONES
There could be multiple trigger points that set up in the belly of this muscle. Referral areas include all of the upper teeth, with spillover across the maxilla, over the eyebrow, and into the temporal area (Fig. 5 - 1 3 ) . A person with trigger points i n this muscle typically com plains of head pain and headaches, as well as toothaches or gum pain. Rarely will this person complain of jaw restric tion, yet there will be a reduction in its ability to open. There may be complaints of the teeth not meeting correctly, however. The hypersen itivity in the teeth may present as a reac tion to thermal conditions when eating either hot or cold foods.
• FIGURE 5-1 3 Trigger Points and Referral Zones for the temporalis.
Mostly the trigger points occur near or within the large tendinous area above the zygoma and refer strongly into the upper teeth, the eyebrow, and parietal bone with spillover in between all of those points. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
•
Chronic infection or inflammation of the TMJ
•
Cold drafts over the muscle
•
Any overuse of masticatory structures
PRECAUTIONS •
Avoid putting oily fingers in your cl ient's hair when working on this muscle
•
The tendon above the zygomatic arch is often fibrotic and quite tender
TRIGGER POINT ACTIVATION
See section "Stressors and Perpetuating Factors." STRESSORS AND PERPETUATING FACTORS •
Clenching and grinding of the teeth (bruxism)
•
Direct trauma to the muscle, such as getting hit in the side of the head
•
Temporalis is a key player in the function of the TMJ as well as in its dysfunction
•
Prolonged jaw immobilization, as when at the dentist
•
The TMJ is the most often u ed joint in the body
•
Cervical traction without using an occlusal splint to
•
When doing cross-fiber friction work here, be aware of the fan-shaped muscle fiber direction
•
Work slowly and gently while being very deliberate to alleviate trigger points here
MASSAGE THERAPY CONSIDERATIONS
immobilize the mandible in the fully closed position •
Forward head posture
•
Excessive use of the jaw, as when chewing gum
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Masseter: The Trismus Muscle This muscle is usually responsible for a severely restricted jaw opening (Fig. 5 - 1 4 ) . Trismus is a tonic contraction of the muscles of mastication. ORIGIN •
Zygomatic arch and process of the maxilla
INSERTION •
Ramu , angle and neck of the mandible
ACTION •
Elevates mandible (close jaw)
•
Retrudes mandible
TRIGGER POINTS AND REFERRAL ZONES
Trigger points typically occur anywhere within the belly of both the superficial and deeper layers of this muscle. Referrals often occur into the upper and lower molar teeth, the max illa and mandible, the inner ear area, and the eyebrow. These are very strong referrals (Fig. 5 - 1 5 ) . The main complaint of a client with trigger points i n this muscle is typically pain in the teeth and the j aw area. Often, the cl ient is actually feeling referral sensation into the TMJ it elf along with hypertension of this muscle, rather than actual TMJ derangement. Active trigger points often mimic symptoms of dysfunction of the joint. The client also fre quently reports significant restriction of the jaw opening.
Deep portion of masseter
Superficial portion of masseter • FIGURE 5-1 4 Attachment sites for the masseter. Zygomatic arch and the process of the maxilla; ramus, angle and neck of the mandible. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
• FIGURE 5-15 Trigger points and referral zones for the masseter. There will be trigger points all along the length of the superficial layer with s� rong referral to the upper and lower molar teeth, into the maxilla and mandible, and the eyebrow. There may be spillover across the maxilla and mandi ble and into the forehead i n front of the ear. In the deeper layer, the trigger points will usually occur up near the zygoma with strong referrals into the ear and spillover surrounding that. (Reprinted with permission from Medi Clip, Lippincott Williams & Wil kins.)
CHAPTER 5
There may be a unilateral tinnitus associated with trigger points in the upper posterior part of the deep layer. If there is bilateral tinnitus present, it is most likely to be a systemic cause rather than trigger point activity.
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H E A D A N D N EC K
•
Crushing ice or nuts with the teeth
•
An uneven bite ( occlusal imbalance)
81
PRECAUTIONS •
TRIGGER POINT ACTIVATION
When muscle stripping here, avoid pu lling the skin of the face downward
See section "Stressors and Perpetuating Factors," below. MASSAGE THERAPY CONSIDERATIONS STRESSORS AND PERPETUATING FACTORS •
Excessive forward head posture
•
Tension and unresolved anger (clenching teeth)
•
Bruxism (grinding teeth when at sleep)
•
Pipe smoking, chewing gum, nail biting, thumb sucking
•
Improperly fitting dentures
•
For its size, the masseter is the strongest muscle in the body. This means that it can hold quite a bit of tension
•
Hypertonicity of the masseter is a major factor in the function of the TMJ and its dysfunction, along with craniomandibular pain
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The Pterygoid M u scles This group is made up of the medial and lateral pterygoid muscles. As they are difficult to palpate and work with, many massage therapists choose to skip treatment of them. This is a mistake when a person is reporting head and mouth/iaw pain.
Medial Pterygoid: Ache Inside the Mouth There is a very small portion of this muscle that may be palpated and worked with, but this work can be essential in alleviating pain in this area for a person (Fig. 5 - 1 6) . ORIGIN •
Angle of the mandible
INSERTION •
Lateral pterygoid plate
ACTION •
Elevates the mandible (used bilaterally)
•
Laterally deviates mandible to opposite side (used uni laterally)
•
Assists protrusion of the mandible
TRIGGER POINTS AND REFERRAL ZONES
Trigger points usually set into the belly of this muscle, with referral sensation sent mainly into the TMJ area and with spillover down the neck of the mandible into the ear and the throat area, as well as inside of the cheek area (Fig. 5- 1 7 ) . A client with trigger points in this muscle will likely complain of pain that increases when opening the mouth wide, chewing food, or clenching teeth. There may also be a sore throat that makes it hurt to swallow and restriction when opening the jaw.
• FIGURE 5-1 6 Attachment sites for the medial pterygoid. Angle of the mandible and lateral pterygoid plate. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
TRIGGER POINT ACTIVATION
Because a forward head posture places persistent strain on the medial pterygoid, it will also activate trigger points. Trigger points here can be secondary to muscular dysfunc tion due to trigger points in the lateral pterygoid muscle. STRESSORS AND PERPETUATING FACTORS
• FIGURE 5-1 7 Trigger points and referral zones for the medial pterygoid.
•
Thumb sucking beyond infancy
•
Excessive gum chewing
with strong referral to the temporomandibular joint and to the inside of
•
Bruxism
the face with spillover into the mandible and lateral neck. (Reprinted with
•
J aw clenching
•
Anxiety and other emotional tension
•
Occlusal imbalance
PRECAUTIONS •
This muscle is usually extremely tender; be gentle
The trigger points here can be anywhere within the belly of the muscle
permission from Medi Clip, Lippincott Williams & Wilkins.)
MASSAGE THERAPY CONSIDERATIONS •
Trigger points should be inactivated before initiating any prosthodontic treatment
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Lateral Pterygoid:TMJ Dysfunction This muscle is often the key to managing TMJ dysfunction ( Fig. 5 - 1 8 ) . ORIGIN •
Superior division: sphenoid bone
•
Inferior division: lateral pterygoid plate
INSERTION •
Superior division: neck of the mandible j ust below the articular disc
•
Inferior division: neck of the mandible adjacent to the superior division
ACTION •
Both divisions as a unit: actively controls the return of the condylar head when closing jaw
•
Superior division: opens and protrudes jaw
•
Inferior division: opens and protrudes j aw, lateral devi ation to other side
• FIGURE 5-1 8 Attachment sites for the lateral pterygoid. Superior division: sphenoid bone, medial su rface of the neck of the mandible just below the articular disk. Inferior division: lateral pterygoid plate, neck of the mandible adjacent to the superior division. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
TRIGGER POINTS AND REFERRAL ZONES
Mostly the trigger points form in the belly of each of the two division of this muscle. Referral sensation is felt strongly into the TMJ and the max illa j ust below the zygomatic arch ( Fig. 5 - 1 9 ) . TRIGGER POINT ACTIVATION
Trigger points could develop as satellites in response to trig ger points in neck muscles, especially the sternocleidomas toid. Mechanical overload from various activities can cause trigger points ( see section "Stressors and Perpetuating Factors" ) . Bruxism can be either the cause o r the result o f trigger points here due to overuse. It is unclear if a degenerative arthritic change in the TMJ is the result or cause of trigger points here. • FIGURE 5-1 9 Trigger points and referral zones for the lateral ptery
STRESSORS AND PERPETUATING FACTORS
goid.Trigger points will set into the muscle bellies and give strong referral into the temporomandibular joint itself along with strong
•
Occlusal imbalance
•
Bruxi m
•
Gum chewing, nail biting, thumb sucking
Simons LS. Upper Half of Body. 2nd ed. Baltimore: Lippi ncott Williams &
•
Playing a wind instrument with the mandible fixed in protrusion
Wilkins, 1 999. Trovell & Simons' Myofascial Pain and Dysfunction: The
•
Playing the violin holding the mandible against the in trument
PRECAUTIONS •
This muscle is usually extremely tender; be gentle
referral into the maxilla. There may be some spillover around the strong referrals. (Reprinted with permission from Simons DG, Travell JG,
Trigger Point Manual; vol 1 . p. 38 0, Fig. 1 1 . 1 .)
MASSAGE THERAPY CONSIDERATIONS •
Trigger points should be inactivated before init iating any prosthodontic treatment
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Head a nd Neck Neuro m u scu lar Thera py Routine For learning pu rposes this routine w i l l b e com plete for a l l mus
been provided for the therapist to consider.As with all neuromus
cles in this region and consist of both prone and supine posi
cular therapy routines, we work from s u perficial to deep and as
tions. You may pick portions of the routine or use it in its entirety
specifically as possible. Note that the video icon indicates rou
depending u pon the specific conditions and injuries the client
tines that are featured in online video clips, on the book's com
has. Earlier in the cha pter, a l ist of conditions and inj u ries has
panion Web site.
PRONE ROU TINES Routines in this section should be performed with the client in prone position, preferably using the face cradle. In these routines, use general loosening and warming techniq ues of the shou lders and neck, such as petrissage and compression.
Upper Trapezius
e
Begin with no lubrication. Stand at the side of the ta ble facing the cl ient's head. 1 . Perform pincer palpation of trapezius, working from lateral to
medial and holding with direct sustained compression.Ta ke a moment to wait for the tissue to relax a bit (Routine 5-1 ). • ROUTINE 5-' 2. Using fingertips opposing the th u m bs, unroll the upper tra
pezius using the pincer grasp into the inner fibers just su pe rior to the clavicle. Work from medial to lateral with the client's hand a bove h i s or her head on the face cradle for best results.
Note: Apply a small amount of lubrication.
3. Use you r inferior hand to traction the client's shou lder inferi
orly while effleuraging with you r superior hand. This effleur age is to be a gliding squeeze of the b u l k of the u pper trape zius, applying pressure with the thumbs into the fingertips during the glide (Routine 5-2).
• ROUTI N E 5-2
Note: Move to the head of the table and work from a seated position. 4. Perform lengthening strokes using both thumbs together
from the base of the neck toward the acromion process uni latera lly (Routine 5-3).
• ROUTIN E 5-3
CHAPTER 5
Levator Scapula
�
Sit in a chair at the head of the table. 1. At the crook of the neck, isolate the muscle belly with thumb
transverse friction and hold with steady pressure (Routine 5-4).
2. Work the insertion on the vertebral border and su perior angle
of the scapulae. Also, work the anterior surface of the superior angle. Friction and hold with trigger point pressure. You may place the client's hand on his or her back to locate the supe rior angle (Routine 5-5). • ROUTI N E S-4 3. Work the m uscle using g l iding thumb strokes and gentle
transverse friction from (1 to the scapulae staying a long the posterior aspect of the transverse processes (Routine 5-6).
• ROUTI NE 5-5
• ROUTI NE 5-6
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4. Work the attachments o n the posterior transverse processes
of (1 to (4 using trigger point pressure. Be gentle, yet specific to the posterolateral aspect here (Routine 5-7).
Note: Stand at the head of the table. 5. Use forearm compression i nto the muscle belly at the angle of
the neck. Then, with the forearm a n d olecranon, do some lengthening effl eu rage from u pper trapezius through the levator scapula insertion (Routine 5-8).
Posterior Cervical Muscles: Suboccipitals, Occipitalis,
• ROUTINE 5-7
Splenius Capitis/Cervicis, Semispinalis Capitis, Multifidi/Rotatores
e
Sit or stand at the head of the table. 1 . Use thumb strokes inferiorly from the occiput to the base of
the neck, working the m uscles i n the lamina g roove of the neck thorough ly. Be sure to incl ude a l l portions of the poste rior cervical muscles. You may sweep as far lateral as the acromioclavicular joint.
2 . Isolate any tight fibers i n the lamina groove with transverse
friction and trigger point pressure. Note: Be aware of pressure into this area when the client is using the face cradle. Use the pads of thumbs for comfort to the client.
• ROUTINE 5-8
3. Apply fi ngertip transverse friction to the occipital ridge at the
m uscle attachments; isolate the su boccipital m uscles with a more specific tra n sverse friction working from latera l to medial. Then, using longitudinal friction, work from medial to lateral . Be gentle, yet thorough. Hold trigger points with trig ger point pressure as necessary (Routine 5-9). -------
4. Move to between (1 a n d (2 a n d do the same work a s described a bove.
• ROUTI N E 5-9
CHAPTER 5
5. Work occipitalis with friction thoroughly (Routine 5-1 0).
6. Isolate the nuchal ligament and its muscular attachments
using sustained compression and oppositional friction by having the wrists level with the client's neck, using thumbs from both sides at once pushing them toward each other. Hold for release after frictioning the thumbs opposition a l ly against each other. Begin at the neck/shoulder junction. Once this a rea has released, move incrementally up the neck until just below the occiput (Routine 5-1 1 ). Note: Step #6 is typically done after working on both sides of the neck.
• ROUTI N E 5-1 0
Middle Trapezius/Rhomboid Area Stand at the side of the table. Begin with no lubrication. 1. Perform general massage and loosening of middle trapezius,
rhomboids, and u pper erectors. Use compression, palmer and circular friction, and petrissage.
2. Using pincer compression, isolate tight bands in the middle
trapezius. Hold for release.
Note: Lubricate.
3. Perform effleurage to the rhomboids, working deeply a n d
• ROUTINE 5-1 1
specifically t o t h e fiber depth and direction, from insertion to orig in. Stabilize at the inferior angle of the scapulae with the superior hand while thumb stripping superiorly and medially with the inferior hand (Routine 5-1 2).
• ROUTI N E 5-1 2
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Note: Stand at the head of the table.
4. Using both thumbs together, muscle strip the rhomboids
again, this time from origin to insertion (Routine 5-1 3).
5. Friction the rhomboid attach ments on the vertebra l border of the scapula (Routine 5-1 4).
Note: Stand at the side ofthe table.
6. Work the m uscle attachments on the spinous processes by
placing the tip of the T-bar at a 45-deg ree angle into the lat eral aspect of the spinous processes. Work from (7 to T5 using
• ROUTIN E 5-1 3
both cross fi ber and longitudinal friction (Routine 5-1 5).
• ROUTI N E 5-1 4
• ROUTI NE 5-1 5
C H A PT E R 5
7. Work the attach ments of trapezius along the spine of the
sc.a pu lae using transverse friction. Use the tip of the T-bar at a n oblique angle into the superior edge of the spine of the scapulae, then into the inferior edge (Routine 5- 1 6) . Note: You may have to move to the head o f the table to work on the superior edge and the side of the table to work on the inferior border.
8. Forearm lengthening to the a rea. Using the forearm, effleur
age slowly down the erectors, and then downward along the medial border of the scapulae. • ROUTI N E 5-1 6
SUPINE ROUTINES The routines in this section should be performed with the client in the su pine position. Sit at the head of the table. Actively check range of motion of the neck before beginning. Lightly lu bricate the u pper shoulders and the neck. For a l l routines, perform general warm ing of the posterior neck m usculature with emphasis on assessment and preliminary contact and release of major m u scle groups such as trapezius, posterior cervical g roup, and suboccipital gro u p. Include m i l d stretches, mobilization, and good, thorough isolation a n d loosen ing of all musculature.
Posterior Cervical Muscles:Trapezius, Semispinalis Capitis, Multifidi/Rotatores, Splenius Capitis/Cervicis
e
1 . Thumb stroke from the occiput to base of the neck, releasing
the muscles in the lamina groove area. Begin on one side while stabilizing the client's head with the other hand. Place you r thumb adjacent to the spinous process o f (1 with fingers cra dling the neck. Point the thumb downward toward the base of the neck and proceed with gliding thumb strokes. Begin medi ally against the spinous processes and move incrementally lat erally. Allow a minimum of 1 0 complete strokes to this area between the spinous and transverse processes. Work superfi cial to deep incrementally, as well. Allow the thumb to linger on areas of restriction or tenderness as necessary (Routine 5-1 7). Note: Allow extension and flexion of the head and the neck to occur, noting the protraction and retraction of the clien t's chin. It is best to rest the working hand on the table during this move ment and remember to keep the thumb straight.
2. Apply transverse friction to tight bands along with ischemic
pressure. Use the weight of the client's head and attempt to keep your thumb straight to be able to avoid thumb or wrist strain. The muscles that you are impacting from superficial to deep include the trapezius, splenius capitis/cervicis, semispi nalis, multifidi, and rotatores (Routine 5-1 7).
• ROUTI N E 5-1 7
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3 . Tight a reas can a lso be isolated with direct thumb pressure
and using a positional release method. While engaging tight muscles here, bend the head and the neck into the thumb pressu re; hold for release. Proceed into a gentle stretch . Note: You may also use fingers when your thumb gets tired.
4. To work with the dense tendinous area of splenius capitis and
cervicis, place your fingers under the upper trapezius inferior to the neck. Use a thumb anterior to the trapezius and parallel to the transverse processes. Be sure not to press on the posterior scalene. With no pressure a pplied, rotate the client's head toward the side where the thumb is working, actually placing
• ROUTINE 5-1 8
the head on your working arm, which is lying on the table.This will place the thumb just lateral to the spinous processes and in the pocket that forms on the anterior surface of the trapezius. The thumb is to be pointed at a 45-degree angle across the body, toward the nipple of the opposite breast (Routine 5-1 8).
5. Apply friction by sweeping i n a head to toe d i rection; then,
use trigger point pressure as necessary.
6. When the tissue seems clear, pin the tendons with the thumb
while rotating the head in the opposite di rection to give a gentle stretch there (Routine 5- 1 9) . • ROUTI N E 5-1 9 Note: Stand a t the side o f the table.
7. Stretch the posterior cervical area by having the client clasp
hands behind the head. Flex the client's neck and head by pulling the head up holding the client's hands and then push ing down on both forearms equ a l ly (Routine 5-20).
• ROUTI NE 5-20
CHAPTER 5
Suboccipitals
e
Sit at the head of the table.This is a very common a rea for trigger points. Be sure to warm the m uscles thoroughly and be careful with you r pressure. Pay attention to tight bands of tissue and referral patterns. 1 . Rotate the head away from the side being worked on. Warm
the suboccipital area including muscles up to the superior nuchal line. Use circular/transverse friction. Also, release the occipitalis m uscle with friction and trigger point pressure.
2. With the head still rotated, position yourself at the corner of
the table. Let the client's head rest on the table, stabilizing it
• ROUTINE $-21
with you r nonworking hand. Palpate the transverse process of C1 , just inferior to the mastoid process (Routine 5-2 1 ).
3. Use transverse friction beginning between the occipital ridge
and C 1 transverse process and moving from lateral to midline. Repeat this same line from medial to lateral using longitudi nal friction. Be sure to angle under the occipital ridge to effec tively engage the suboccipitals.
4. Repeat this same technique between C1 and C2, working
from lateral to midline, and then medial to lateral using both types of frictions. • ROUTINE $-22 5. Feel for tight fibers and try to identify the individual suboc
cipital muscles, using trigger point pressure as necessary.
6. Isolate these muscles with a stretch, placing fi ngertips on the
anterior shoulder in a n "X" pattern and a llowing the head to rest on your forearms. Lift the head toward the chest while pinning the shoulders to the table (Routine 5-22).
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Levator Scapula
M U S C L E S A ND N E U R O M U S C U L A R T H E R A P Y R O U T I N E S B Y B OD Y R E G I O N
�
1 . Isolate the levator scapula using thumb stripping while stay
ing lateral and under the transverse processes. Always work on the posterior aspect of the transverse processes for this, never on the lateral a spect, toward the insertion at the supe rior angle of the scapu lae. Levator l ies between the trapeziu s a n d scalenes on t h e posterolateral aspect of t h e neck. Its insertion is best worked i n the prone position.
2. Use transverse friction and trigger point pressu re at the ori
gins from (1 to (4 posterior transverse processes. • ROUTINE 5-23
3. Use fi ngertips to engage inward u nder the occipital ridge and
provide traction to the skull, both sides at the same time (Routine 5-23). Note: This is usually done after working both sides of the posterior cervicals. Be sure notto engage the atlas with the points offingertips. This may project the atlas forward: not a good thing for the client!
Sternocleidomastoid
�
Lubricate lightly. 1 . Warm the m u scle by pulling with thumb and finger pressure
from the distal attachments toward the mastoid process. Warm both sides at the same time, pulling a lternately on each while
• ROUTINE 5-24
a llowing the head to rock from side to side. This is to be done lightly and should feel very nice to the client. Rotate the head slightly toward the side being worked on to create slack in the m uscle bel ly. Some believe this will a l so rotate the carotid artery away from pressure applied here (Routine 5-24).
2. Isolate using pincer pal pation and hold for myofascial release,
working incrementa l ly from the mastoid to the sternu m/clav icle.You may have more difficulty grasping the clavicular head, as it is usually tighter. Grasp it between fi ngers and thumbs just superior to its clavicular attach ment and work i ncremen tally up toward the j u nction of the two heads (Routine 5-25).
3 . Rotate the head away from the side being worked. Use trans
verse and longitudinal friction to the entire mastoid process insertion.This incl udes the attachments of longissimus capitis and splenius capitis. This is a large area; be sure to be thor ough. Bring the head back to a straight position.
4. Friction the clavicular and sternal origin attach ments.
• ROUTI NE 5-25
CHAPTER 5
5calenes
e
1 . Warm and loosen with downward gliding strokes, fi ngertip
friction, and direct pressure. Isolate all three: anterior, midd le, and posterior. The a nterior sca lene is located beneath the sternal portion of the sternocleidomastoid. The middle sca lene is lateral to it, whereas the posterior scalene is u nder the lateral aspect of the clavicle (Routine 5-26).
2. Finger strokes downward can easily access attachments behind
the clavicle by rotating the head toward the same side while Simultaneously applying the finger stroke (Routine 5-27). Stretch into lateral flexion with rotation of the head toward the
• ROUTINE 5-26
opposite side while pinning down the attachments on the ribs (Routine 5-28).
• ROUTINE 5-27
• ROUTIN E 5-28
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3 . Use deeper t h u m b strokes and friction to the bellies and
along the vertebra l attachments. Use any trigger point pres s u re necessary a long the way. Stretch by using lateral flexion combined with rotation to the opposite side (Routine 5-29).
4. Repeat the technique on the other side. Recheck the range of
motion.
Suprahyoids, Anterior Suboccipitals, longus Capitis, longus ColIi
e
Stand at the side of the table facing the head.
• ROUTIN E 5-29
1 . Using you r inferior hand, stabilize the hyoid bone. You will
be working on the side closest to you. Stabil ize the hyoid bone by placing the index finger of you r inferior hand on the lateral side of the bone on the opposite side from where you are working (Routine 5-30).
2. Using medial-to-Iateral friction with the other index finger,
work along the superior aspect of the hyoid bone to affect the supra hyoids at their attachment (Routine 5-30).
3. Using your inferior hand, displace the hyoid bone, esopha
g us, and trachea away from the side being worked on. You will be working on the side closest to you. This is done easily
• ROUTIN E 5-30
by using the flat of the length of you r thumb, bringing extra skin over fi rst so not to stretch the superficial tissue through which you will be working. Slightly lift the hyoid bone and thyroid cartilage with the thumb first before displacing lat erally. This is a flexible tube and will move easily. If you hear a noise, you did not lift enough prior to d i s p lacement (Routine 5-3 1 ) .
• ROUTINE 5-31
CHAPTER 5
4. Place the superior index finger midway between the chin
and the a n g l e of the jaw, pointing at a 45-degree a n g l e toward t h e client's nose. P u s h in as close t o t h e occiput as comfortably possible.
You r pressure should be a ng led
toward the client's nose and down toward the table at the same time to affect rectus capitis anterior and the origi n of longus capitis (Routine 5-32).
5. Using medial-to-Iateral sweeps ON LY, a pproximately 1 inch
in width, work the rectus capitis anterior and longus capitis with friction. Now apply trigger point pressure. • ROUTIN E 5-32 6. Instruct the client to turn her head slightly toward you while
you feel the rectus capitis lateralis contract on the side of your finger. Move your finger to that point (Routine 5-33).
7. Apply friction and trigger point pressure.
8. Now begin to friction, again from medial to lateral and back,
while working in an i nferior d i rection down the a nterior neck. Friction to longus colli and longus capitis is to be done from the midline of the neck out to over the transverse proc esses (Routine 5-34). • ROUTI N E 5-33
9. Apply trigger point pressure to any trigger points found
along the way (Routine 5-34). Note: Be careful not to stimulate the cough reflex near the man ubrium; also, avoid pressing on any bone spurs or sharp aspects of the transverse processes. Ifyou feel a definite pulse under your finger. move over so you are not pressing on it.
1 0. After working on the other side of the neck, sit at the head of
the table and apply a n occipital vault and then gentle trac tion to complete.
Masseter
e
Stand at the side of the table, facing the head. Place a surgical g love on your inferior hand. 1. Check your client's range of motion by seeing how many
knuckles she can place between her teeth.
• ROUTIN E 5-34
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2 . Support the outside portion of the masseter with the flat of
you r s u perior hand. With the i ndex fi nger of you r i nferior hand, m uscle strip the medial, or inner aspect, of the masseter, moving from su perior by the zygomatic arch to the inferior attachment at the mandible (Routine 5-35). ------ ---- -
3. Isolate the deep portion of the masseter by having the client
clench her teeth. This should pinch your finger and possibly move it out of the a rea. Have the client relax her jaw, and then reidentify the m uscle fi bers and a pply a pincer compression using the index fi nger and thumb of you r inferior hand. The t h u m b will be on the outside of her cheek. Work the entire length of the muscle thorough ly.
• ROUTIN E 5-35
4. Now m u scle strip along the inferior aspect of the zygomatic
a rch from anterior to posterior, working the attachment of the masseter there. Use trigger point pressure to any tender areas or trigger points (Routine 5-36).
Medial Pterygoid
e
Stand at the side of the table, facing the head. Place a s u rgical g love on you r inferior hand. 1 . Ask the client to open her mouth as far as possible. Place your
inferior index finger on the medial surface of the upper molars and glide you r finger posteriorly until it contacts the medial pterygoid between the upper and lower molars (Routine 5-37).
• ROUTI N E 5-36
2. Now glide you r fi nger su periorly on the medial pterygoid
u ntil it contacts the medial surface of the lateral pterygoid plate and palatine bone. Press into the origi n there for a few seconds and a llow for a myofascial release to take place.
3. Now g l ide you r fi nger down the m uscle toward the lower
molars (inferiorly and posteriorly) u ntil the medial surface of the mandible and its angle is reached. Repeat this several times, or as m uch a s can be tolerated by you r client.
lateral Pterygoid
e
Sta nd at the side of the table, facing the head. Place a surgical g love on you r inferior hand. 1 . Ask the client to shift her mandible laterally toward you, creat
ing space to pal pate the lateral pterygoid.
• ROUTI N E 5-37
C H A PTER 5
2. Glide your inferior index finger a long the lateral su rface of the
upper molars as far su periorly and posteriorly as possi ble. Give some very gentle friction there; it should feel as if there is a tiny pocket at the tip of your fi nger. After applying friction, press into the muscle to allow for a myofascial release.
Suprahyoid and Infrahyoid Muscles
e
Stand at the side of the table, facing the head. Place a s u rgical glove on your inferior hand. 1 . Using your inferior index finger, g lide on the upper surface of the opposite half of the tongue using a hooking action. Begin as far back on the tongue as you can and glide forward. Attempt to reach the rough ridges on the back of the tongue, and then flex your finger pressing into the superior surface as you pull toward the tip of the tongue. Apply this five to eight times,as tolerated.
2. Now use your same index fi nger in the same way, but this time
to the lateral surface of the opposite side of the tongue. Again, five to eight times, as tolerated. --- - --
-
3. Now use your same index finger again this way, but this time
to the inferior surface of the opposite side of the tongue. As above, five to eight times.
4. To treat the mandibular origins of the suprahyoids, support the
tissues externally by placing the tips of your fingers (superior hand-the one without the glove) on the midline of the inferior aspect of the mandible from the outside of the mouth (under the chin). Insert your inferior index finger at the midline of the mandible inside the mouth, at the frenulum of the tongue. Use 1 -inch wide friction movements, side to side, while compressing the suprahyoid muscles against the tips of your external fingers. Begin at the midline under the tongue and move laterally and posteriorly on the side you are standing. Work incrementally back toward the angle of the mandible, staying on those tissues until they soften. This treats the mandibular attachments of the suprahyoids and both bellies ofthe digastric (Routine 5-38).
5. Repeat this work on the other side of your client.
6. Have the client recheck the range of motion using knuckles. Can
she get more knuckles between her upper and lower teeth?
• ROUTIN E 5-38
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Case Study 5- 1 . Gary: A Cl ient with Posterior Neck Pain, Vertigo, a n d Ti n n itus Background
worked specifically with the deeper muscles by displacing the
Gary had been a client for many years, receiving weekly main
hyoid bone and trachea laterally.
tenance sports massage to maintain a high level of health.
U pon palpation of the more medial fibers at C3 to (5 bilat
Gary worked out heavily 6 d/wk with ' free weig hts and
erally, the therapist found trigger points that Gary described
machines. One day, he showed up for his regularly scheduled
as feeling l i ke an ice pick was being jabbed into his ear. The
massage therapy appointment looking a bit pale and wal king
therapist worked to release these trigger points fairly success
slowly and deliberately. When his massage therapist a s ked
fully d u ring this initial session.
about this, Gary stated that 2 days earlier he had woken up
Gary felt better, but there was still a bit of ringing in his
very dizzy and felt quite nauseous whenever he moved. He
ears for the next 2 weeks.The anterior neck work was incorpo
had gone to see his doctor a nd had been prescribed medica
rated into his regular maintenance massage for the next two
tion to keep him feeling less d izzy and q ueasy.
sessions to complete the relief of the tinnitus. Gary had not been working out for 3 weeks, but went back
Treatment
to it upon complete relief of the tinnitus. Per the therapist's suggestion, he employed a personal trainer for a few weeks to
The massage therapist explained how there could be trigger
help him use proper body mechanics for his workouts with a
points set u p in his anterior cervical m uscles causing dizziness
focus to how he was holding/using his neck.
a nd that the dizziness could be causing the nausea. He agreed to have neck and upper shoulder work that day, rather than
Critical Thinking Questions
his usual maintenance work.
1 . Why would the massage therapist think there could be
After loosening his upper and mid trapezius, the therapist spent a few minutes loosening the muscul ature in the lamina groove of his cervical a rea with a focus to his posterior suboc cipitals. This a rea was quite tight, giving the impression that he was straining with his neck when he was working out with the machines a nd weights. Upon q uestioning him regarding his workout form, he agreed that was probably what he had been doing. G a ry assumed the s u pi n e position, and the therapist focused on his anterior cervical muscles. She found referrals of
trigger points causing nausea and tinnitus? 2. Which muscles would you have checked when looking for trigger points into the ear? 3. How could poor body mechanics when working out cause trigger points to set into the anterior cervical muscles? 4. Had there been excessive posterior neck pain a s well,
would working on the a nterior cervical m uscles help this, and why? 5. Without the help of a personal trainer, do you think that
d izziness in the more superficial m uscles and was able to clear
Gary would have been able to continue his workouts with
the trigger points. The tinnitus continued, however. She then
out setting the trigger points back into his neck?
CHAPTER 5
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HEAD AND NECK
Case Study 5-2 •
Mark: A Hockey Player with Head and Neck Pa i n
Background
anterior cervical muscles in the same manner. As the superfi
Mark is a hockey player. He has played hockey since age 6. He
cial tissues softened, the therapist began to work layer by
has suffered five concussions: the fi rst at age 1 5 playing
layer into the deeper tissues. At each session, Mark's fascia
hockey in high school and the fifth d u ring his fourth and final
and m u scles were regaining integrity regarding pliability and
year of playing professionally. He now coaches and plays reg
flexibility, and trigger points were fad ing.
ularly with a professional alumni team.
By the third session, Mark was able to report that he was
During his sophomore year in high school, Mark was diag
beginning to sleep again, but was sti l l waking u p often during
nosed as having several subl uxed vertebrae. He was given
the night and still felt pain in his head and neck, but less. By
strengthening exercises to help change that condition. His
the fifth session, he was no longer waking up d uring the night
neck hurt everywhere at that point. He was very consistent
and no longer had headaches. By the sixth session Mark
about doing the exercises and was able to change his condi
reported he no longer felt pain in his neck.
tion in a few months during the s u m mer, so he could continue playing hockey. He then began to regu l a rly work out using machines and free weights f? r strengthening in genera l . A t a y e 49, Mark real ized that his posterior neck and head hurt all of the time. He was doing a lot of traveling for business and having to carry a bag ful l of files a long with his carry-on baggage through airports, often running to catch his flight. He felt this was the cause of the neck pain and headaches.
Treatment Mark began receiving neuromuscular therapy whenever he was at home. Mark's therapist worked with h i m from his iliac crests u p to and on to his occiput and mastoid processes beginning superficially. The therapist a lso worked with Mark's
Critical Thinking Questions 1 . Why wou l d the therapist work with M a rk's lower back m uscles when his pain was in his head and neck? 2. Which lower back m u scle specifically would be i m portant to work with? 3. Why was it i m portant to work with the more superficial m uscles before getting deeper? 4. Which muscles were i m portant to work with on the occiput a nd mastoid process? 5. Which muscles a re usually responsible for headaches? 6. Would it be i m portant to work both the anterior and pos terior cervical muscles; why?
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REVIEW QUESTIONS
Short Answer Questions
1 . How is soft tissue compromised in a whiplash inj ury?
1 0. Which muscle makes up the majority of the bulk run ning parallel to the cervical spine ? A. Semispinalis capitis
2. Describe the condition named torticollis.
B. Levator scapula
3. Which muscle may be entrapping the supraorbital nerve ?
C. Splenius capitis D. None of the above
4. What causes TMJ syndrome/dysfunction ?
True/False
5 . If one has Eagle syndrome, what symptoms might he experience ?
1 1 . The sternal division of sternocleidomastoid is usually tighter than the other.
Multiple Choice Questions
6. Which cervical muscles attach to the occipital ridge and/or mastoid process ? A. Upper trapezius, rectus capitis posterior major and minor, semispinalis capitis, splenius cervicis B. Sternocleidomastoid, rectus capitis anterior, obliq uus capitis superior, upper trapezius C. Obliquus capitis superior and inferior, sternocleido mastoid, splenius capitis D. All of the above 7. At which joint does most of cervical rotation occur?
1 2. Travell and Simons labeled the splenii muscles "the stiff neck" muscles. 1 3 . Splenius capitis trigger points can produce a "dome headache." 1 4. The galea aponeurotica is an attachment site for both the occipitalis and frontalis muscles. 1 5 . Holding a phone to the ear using the shoulder can acti vate trigger points in the levator scapula muscle. Matching
a. Bilateral
d. Tinnitus
g. Eagle syndrome h. G laucoma
A. C2-C3
b. Ipsilateral
e. Hypoesthesia
B. C5-C6
c. Unilateral
f. Dysesthesia
C. C6-T l
1 6. A dulled sensitivity to touch.
D. None of the above 8. The brachial plexus emerges from between which two muscles ? A. Anterior and middle scalenes
i. Lamina groove
1 7. A condition that includes having an elongated styloid process causing mechanical irritation to certain muscles. 1 8. Related to the same side of the body.
C. Pectoralis major and pectoralis minor
1 9. The area that lies between the spinous and transverse processes.
D. M iddle and posterior scalene
20. A ringing sound in the ears.
B. Posterior scalene and pectoralis minor
9. Which neck muscles refer sensation to the eye or the forehead ? A. Splenius capitis, lower trapezius, levator scapula B. Levator scapula, scalenes, middle trapezius C. Upper trapezius, sternocleidomastoid, suboccipitals D. All of the above
C H A PTER 5
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HEAD AND NECK
1 01
REFERENCES 1.
Menachem A, Kaplan 0, Dekel S. Levator scapulae syndrome: an anatomic-clinical study. Bull Hasp Joint Dis .
2.
1993;530 ):2 1-24.
Sola AE, Rodenberger ML, Gettys BB. Inc idence of hypersen sitive areas in posterior shoulder muscles. Am J Phys Med
Rehabil.
1 95 5 ;34: 585-590.
3.
Sola AE, Ku itert J H . Myofascial trigger point pain in the neck
4.
Jaeger B. Are "cervicogenic" headaches due to Illyofascial pain
and shoulder girdle. Northwest Med.
1 95 5 ; 54:980-984.
and cervical spine dysfunction! CeJ)halalgia.
1 989;9: 1 5 7- 1 64.
THIS PAGE INTENTIONALLY LEFT BLANK
UPPER TORSO �
KEY TERMS
Note that common conditions encountered in this region
Neuralgia: severe pain occurring along a nerve
are included among the key terms.
Rotator cuff tendinitis: inflammation of the supraspinatus
Adhesive capsulitis or frozen shoulder: inflammation of the
tendon and, in some cases, of the infraspinatus, teres minor,
anterior and inferior glenohumeral joint capsule, which
and subscapularis tendons
shortens and thickens
Scoliosis: abnormal lateral and rotational curvature of the
Bicipital tendinitis: inflammation of the tendon of the long
spinal column
head of biceps brachii
Small hemipelvl5. a condition in which one side of the pelvis is
Hypercontraction. a condition in which the contractile
smaller than the other
elements in muscle fiber contract beyond normal
Subdeltoid bursitls� inflammation of the subdeltoid bursa
Hyperkyphosis. an increase in the normal posterior curve of
Subluxation. a partial dislocation of a joint
the spinal column
Thoracic outlet syndrome: a condition in which a lack of space
Impmgement yndrome' a condition in which a lack of space
between the clavicle and the first rib, along with a chroni
between the coracoacromial arch and the proximal humerus
cally sh�:>rtened pectoralis minor, leads to the compressing of
leads to soft tissue being compressed (pinched) there
the brachial plexus
Kyphosis: the normal, posterior curvature of the spine; if
Torticollis: stiff neck associated with tight muscles on one
excessive, it can represent a pathological condition
side of the neck that usually cause chronic lateral flexion and
Lateral pelvic tilt: a muscular imbalance in the pelvic girdle
twisting of the head
resulting in one hip being high and the other low
Upper and/or midtrapezius strain: caused by a forward head
Myotatic unit: a group of agonist and antagonist muscles that
posture with rounded shoulders and possibly a collapsed
function together as one unit due to sharing spinal reflex
chest
responses
OVERVIEW OF THE UPPER TORSO REGION
remember that when working with any section of anatomy,
In this chapter, we are concerned with the muscles of the
also work on the muscles/areas to which the trigger points
upper torso, both anterior and posterior, including the
refer. The goal here is to find all active, latent, and associ
shoulder and rotator cuff, upper back, and chest areas. Please
ated trigger points and then deactivate them.
if you discover referral areas outside of that section you must
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POSTERIOR SHOULDER/UPPER BACK AREA The first portion of the upper torso presented will consist of the muscles of the posterior shoulder and upper back area. Trapezius:The Coat Hanger When viewed as a whole, the trapezius forms a diamond shape on the posterior shoulder area of the upper back, whereas the upper trapezius is shaped like a coat hanger, hence its nickname from Travell and S imons ( Fig. 6-1).
ORIGIN •
Medial superior nuchal line of the occiput
•
Ligamentum nuchae/spinous processes Cl-T I l
INSERTION •
Lateral one-third of the clavicle
•
Acromion
•
Spine of the scapula
ACTION •
Scapular elevation ( upper and middle)
•
Scapular retraction/adduction (entire muscle)
•
Scapular depression ( lower)
•
Upward scapular rotation ( entire muscle)
•
Head, cervical, and thoracic extension (entire muscle)
TRIGGER POINTS AND REFERRAL ZONES According t o Travel! and S imons, there are seven areas where trigger points ( TPs) may be commonly found in the trapezius m uscle. T P I and TPl are located in the upper trapezius. In the lower trapezius, we have TP3 and TP4, and in the middle trapezius, we have TP5 , TP6, and TP7. Activation of TPI is often associated with constant pos terolateral neck pain along with temporal headaches on the same side. Occasionally, sensation is also experienced along the angle of the jaw. This may be misdiagnosed as cervical radiculopathy or atypical fac ial neuralgia-severe pain along a nerve. TPl causes similar neck pain but no head ache. Sensation upon motion in this upper section alone will occur when the head and the neck are almost fully rotated actively to the opposite side. When the trigger points in this section are active and there is also involve ment of the levator scapulae and/or splenius cervicis, an acute stiff neck may develop. This will limit the ability to rotate the head toward the same side, stretching the upper trapezius. With activation of both TP I and TPl, there is likely to be an intolerance of the weight of wearing heavy clothing like an overcoat that rests on the trapezius at the
•
FIGURE 6-1
Attachment sites for the trapezius. (Repri nted with per
mission from Life Art, Lippincott Williams & Wilkins.)
angle and back of the neck rather than resting on the acromion processes. TP3 and TP4 cause sensation in the suprascapular, inter scapular, acromial, and, possibly, neck areas. There will be very little restriction of neck motion, however. TP3 is often responsible for persistent upper back and neck pain once other trigger points have been eliminated. This trigger point may be the key to satellite trigger points in upper back and neck muscles as well. TP5 is often associated with a burning interscapular sen sation, whereas TP6 often proj ects referred sensation across the acromion, rendering the shoulder intolerant of pressure from a heavy coat or a large purse carried on the shoulder by a strap. TP7 may be associated with goose bumps on the anterolateral upper arm and possibly the thigh. According to Travel! and Simons, it could feel like "shivers running up and down the spine," as though someone has scraped finger nails down a blackboard ( Figs. 6-l through 6 - 5 ) .
C H AP T E R 6
• FIGURE 6-2 Trigger points and referrals zones for the trapezius. ( Reprinted with permission from Simons DG, Travell JG, Simons LS.
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UPP E R T O R S O
105
• FIGURE 6-3 Trigger points and referral zones for the trapezius. ( Reprinted with permission from Simons DG, Travell JG, Simons LS.
Upper Half af Body. 2nd ed. Baltimore, MD: Lippincott Williams &
Upper Half of Body. 2nd ed. Baltimore, M D: Lippincott Williams &
Wilkins, 1 999. Trave" & Simons'Myofascial Pain and Dysfunction: The
Wilkins, 1 999. Trove" & Simons'Myofascial Pain and Dysfunction: The
Trigger Point Manual; vol 1 . p. 279, Fig. 6.1 .)
Trigger Point Manual; vol 1 . p. 280, Fig. 6.2.)
• FIGURE 6-4 Trigger points and referral zones for the trapezius. ( Reprinted with permission from Simons DG, Travell JG, Simons LS.
• FIGURE 6-5 Trigger points and referral zones for the trapezius. ( Reprinted with permission from Simons DG, Travell JG, Simons LS.
Upper Half of Body. 2nd ed. Baltimore, MD: Lippi ncott Williams &
Upper Half of Body. 2nd ed. Balti more, M D: Lippincott Williams &
Wilkins, 1 999. Trove" & Simons'Myofascial Pain and Dysfunction: The
Wilkins, 1999. Trave" & Simons'Myofascial Pain and Dysfunction: The
Trigger Point Manual; vol l . p. 281 , Fig. 6.3.)
Trigger Point Manual; vol 1 . p. 2 8 1 , Fig. 6.4.)
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TRIGGER POINT ACTIVATION Trigger points may be activated by sudden trauma in any area of the trapezius. Examples of this may be receiving whiplash from an auto accident or taking a fall of any type. In the upper trapezius, the function of neck stabilization is often ovedoaded by a titted shoutder girdte because of body asymmetry such as a short leg or small hemipelvis. I n the case of a short leg, there will b e a lateral pelvic tilt, which functionally curves the spine taterally ( scoliosis) and tilts the shoulders, causing one side to sag. Now the upper trapezius must work to keep the head and the neck vertical, and the eyes level ( righting reflex), which, in turn, causes an overload to this portion of the muscle. The muscle may also be strained by other overload situations that seem obscure. These microtraumas can be caused by pressure from cloth ing and accessories, such as too tight and narrow bra straps supporting the weight of large breasts, the shoulder strap of a heavy purse on one side, or a backpack or heavy coat. The middle trapezius may also become overloaded by the arm being held up and forward for long periods of time. Maintaining this posture will also overload pectoralis major, which may, in turn, develop latent trigger points that shorten these fibers, causing them to pull the scapula for ward. The antagonistic m iddle trapezius fibers must also overload to counteract the constant protraction of the scap ula ( rounded shoulders). This severe overload causes the middle trapezius to develop painful trigger points. Fibers in the lower trapezius are strained by prolonged bending while reaching forward when sitting or sitting with an elbow on the desk supporting the chin.
•
•
Hunching because of cold weather
•
Collapsed chest and protracted shoulders
•
Kyphotic and scoliotic conditions
PRECAUTIONS •
The tower portion of this muscle is usually quite thin and you may not be able to detect the part inferior to the scapula
•
When lengthening with a forearm, avoid "flicking" off the lower portion of the muscle just medial to the scap ula, as this may cause discomfort
•
The lower trapezius tends to become bound up with adhesion, again at the level j ust medial to the scapula
•
When working on the upper portion at the insertion site, be careful to avoid the brachial plexus
MASSAGE THERAPY CONSIDERATIONS •
The insertion points are a common site of tenderness and fibrotic build-up
•
This is a common muscle for adhesions. To be effective when treating the lower portion at the level of the scapula, l ift the muscle off the underlying tissues using a pincer grasp
•
Bolstering under the anterior aspect of the humerus shortens the muscle, allowing better engagement
•
Be sure to check the lateral border of the superior fibers of upper trapezius in the cervical area
•
The middle portion of trapezius is usually extremely fibrous and must be examined using compression along with transverse friction
•
Myofascial work may be effective due to the extensive layering of the muscles in this area
emotional d istress
•
This muscle is most indicated in tension headaches
Cradling the telephone between the shoulder and the ear
•
Swimming can help release stress in upper trapezius
•
Using a gliding squeeze and the fingertips to unroll the upper portion is very effective
•
Learn to d istinguish between the upper and the middle fibers
•
The middle fibers become very thick with rounded shoulders and head protraction
•
Friction to the spine of the scapula will be effective
STRESSORS AND PERPETUATING FACTORS •
•
Hab i tual elevation of the shoulders from anxiety/
Rotating the head to one side in a fixed position while sleeping, etc
•
Playing the violin
•
Driving with hands at the top of the steering wheel
•
Protracted head postures
•
Wri ting at a desk that is too high
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Splenius Capitis and Splenius Cervicis: Ache Inside the Skull Bilaterally, the paired splenius cervicis and splenius capitis muscles each form a "V" shape (Figs. 6-6 and 6-7)
ORIGIN Splenius Capitis •
ligamentum nuchae
•
Spinous processes C3-T3
Splenius Cervicis •
Ligamentum nuchae
•
Spinous processes T3-T6
INSERTION Splenius Capitis •
Mastoid process
•
Occipital bone
Splenius Cervicis •
Transverse processes C I-C3
ACTION (BOTH) • •
•
Extension of the neck when used bilaterally Rotation of the head erally
to
same s ide when used unilat
FIGURE 6-6 Attachment sites for the splenius capitis. (Reprinted with permission from Life Art, Lippi ncott Williams & Wilkins.)
TRIGGER POINTS AND REFERRAL ZONES Referral sensation from a trigger point in splenius capitis usually refers pain to the top of the head on the same side. There will usually be a headache. Referrals from trigger points in splenius cervicis will usually present as diffuse pain through the inside of the head and behind the eye on the same side, and occasionally into the occiput. From a lower trigger point here will come referral into the angle of the neck, or the "crook of the neck" area ( Fig. 6-8). The client will most l ikely complain of pain in the neck, the head, and the eyes. This person may also c laim a st iff neck with limited ability to rotate the head and the neck. A long w ith the eye pain may be blurred vision. This symp tom has been known to resolve i mmed iately and com pletely w i th the inact ivat ion of the responsible trigger po�:-,t.
TRIGGER POINT ACTIVATION Postural stress causing overload of extension or rotation of the head and the neck are most likely to begin as well as perpetuate trigger points in both splenii muscles. Examples here are sitting in a position that extends the neck to compensate for a strong thoracic kyphosis or assuming a
• FIGURE 6-7 Attachment sites for the splenius cervicis. ( Reprinted with permission from Life Art, Lippincott Williams & Wilkins.)
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Splenius capitis
\) \1 v
v
A
B • FIGURE 6-8 Attachment sites and trigger points with referrals zones for the splenius cervicis and splenius capitis. (Repri nted with permission from Simons DG, Traveli JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins, 1999. Trovell & Simons'Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1 . p. 433, Fig. 1 5. 1 .)
head-back position while playing certain musical instru ments. Also, working at a desk with the head turned to one side and proj ected forward can activate trigger points.
STRESSORS AND PERPETUATING FACTORS •
Use of the dominant eye for reading
•
Cold air blowing on the neck
•
Behaviors associated with "protracted head syndrome"
•
Bird watching with binoculars
•
There may be restriction of forward head f.exion, so again be careful with passive stretching
MASSAGE THERAPY CONSIDERATIONS •
Splenius capitis is frequently overlooked when trying to understand dome headaches
•
Splenius capitis shares a common attachment on the mastoid process with sternocleidomastoid and longis simus capitis
•
Effective work on the attachment of splenius capitis at the mastoid process requires precise frictioning to make sure the engagement is strong enough to affect all three muscle attachments there
•
Sleeping with the head and the neck bent in an awkward position
•
Any whiplash injury
•
Excessive hyperextension of the head/neck
•
Painting a ceiling
•
Be sure to friction each origin site on the spinous processes
Pulling a heavy rope or hose with a forward head posture ( Fig. 6-8B)
•
Those who suffer with problems in the splenius cervi cis often complain of a stiff neck, and rotation is frequently restricted
•
Muscle lengthening of spleniu cervicis may be h�lpful in alleviating symptoms of protracted head syndrome
•
With the client in a prone position, splenius cervicis may be engaged using a firm pincer grip in the posterior cervical area
•
PRECAUTIONS •
B e careful when applying passive stretching t o these muscles, as there may be painful restriction of rota tion of the head to the opposite side if there is an issue
CHAPTER 6
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1 09
'Supraspinatus: Subdeltoid Bursitis
Thi muscle is a major player in conditions related to the rotator cuff ( Fig. 6-9)
ORIGIN •
Supraspinous fossa of the scapula
INSERTION •
Greater tubercle of the humerus at the superior facet
ACTION •
•
Rotator cuff function: to stabilize the head of the humerus in the glenoid fossa Abduction of the humerus at the shoulder
TRIGGER POINTS AND REFERRAL ZONES There are typically trigger points in both the belly of this muscle and at the tendinous insertion site. Referral sensa tion from trigger points is usually felt as a deep ache in the mid-deltoid area of the shoulder and may extend down the lateral arm and forearm. There may also be a concentration of pain at the lateral epicondyle of the humerus and occa sionally into the lateral wrist. The main complaint from a person with trigger points here will be referred sensation that may be felt strongly dur ing abduction of the arm at the shoulder. It will usually be experienced as a dull ache when at rest. Trigger points here will rarely cause severe, sleep-disturbing pain unless there are active trigger points present in other shoulder muscles. In general, it is rare that trigger points here will cause severe pain; however, there may be snapping or clicking noises from the shoulder joint, which go away when the trigger point is deactivated. A person with trigger points may also experience difficulty reaching his or her head to comb hair, brush teeth, or shave. There will also be complaints of restriction at the shoulder during sports activities that require the elevation of the arm from the shoulder as when serving in tennis ( Fig. 6-10).
• FIGURE 6-9 Attachment sites for the supraspinatus. ( Reprinted with permission from Life Art, Lippincott Williams & Wilkins.)
TRIGGER POINT ACTIVATION Trigger points can be activated by carrying heavy objects, such as a briefcase, with the arm hanging down at the side or by regularly walking a large dog that pulls hard on the leash. Activation can also happen when lifting an object to or above shoulder height with the arm outstretched or having to repeatedly do prolonged elevation of the arms.
•
FIGURE 6-10 Trigger points and referral zones for the supraspinatus. ( Reprinted with permission from Simons DG, Travell JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore, MD: Lippi ncott Williams &
Wilkins, 1 999. Travell & Simons'Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1 . p. 539, Fig. 2 1 . 1 .)
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STRESSORS AND PERPETUATI NG FACTORS •
Carrying heavy objects, such as a suitcase, at the side trying to keep it from h itting the knees
•
Reaching back to lift a heavy object from the back seat of your car when sitting in the front . . . .
. . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PRECAUTIONS •
Apply n o more pressure than necessary t o elicit a mild state of discomfort as this muscle may be extremely tender to pressure
•
Never twist w ith the pressure bar; use a back-and-forth movement only
MASSAGE THERAPY CONSIDERATIONS •
Rotator cuff problems in supraspinatus may be misdiag nosed as deltoid ischemic pain or trigger points: it mimics subdeltoid bursitis
•
This is a very common area for tendonitis
•
Remember that this muscle helps maintain balance among the scapulohumeral muscles in cooperation with the other rotator cuff muscles
CHAPTER 6
I U P P E R TO R S O
1 1 1
Infraspinatus: Shoulder Joint Pain When one sees the referral sen ation illustration, it is easy to see why Travell and Simons called this the "shoulder joint pain" muscle ( Fig. 6- 1 1 ) . Infraspinatus and teres minor have identical actions for the most part.
ORIGIN •
Medial two-thirds of the infraspinous fossa of the scapula
INSERTION •
Greater tubercle of the humerus at the middle facet
ACTION •
Rotator cuff function: to stab ilize the head of the humerus in the glenoid fossa of the scapula
•
Lateral rotation and extension of the humerus at the shoulder
•
Horiz')ntal abduction of the humerus
TRIGGER POI NTS AND REFERRAL ZONES Trigger points usually set up within the belly of the muscle. Most people with trigger points here will report intense pain in the front of the shoulder and usually deep within the joint. It may also be described as projecting down the anterolateral aspect of the arm to the lateral forearm, the radial aspect of the hand, and occasionally to the fingers. Also, there may be times when referral sensation is also experienced in the upper posterior cervical region. If trigger points are also present in teres minor, then there may be referral sensation present in the back of the shoulder as well ( Fig. 6- 1 2 ). Any pain sensa tion felt at or around the shoulder joint will mainly come from this muscle with representation from the supraspinatus and sometimes the levator scapulae as well. People with trigger points in this muscle will often have difficulty reaching into their back pants pockets, fastening their bras behind their backs, zipping the back of a dress, or getting their arms into their coat sleeves. They may have difficulty brushing their hair or teeth or, for tennis players, feel pain that limits the strength of their stroke. Often, a person with active trigger points here will experience a weakness or feeling of fatigue in the shoulder. This person may not be able to lie on the painful side at night. Also, when lying on the pain-free side, there may be pain due to the uppermost arm falling forward placing the muscle into a stretch position during sleep.
• FIGU RE 6-1 1 Attachment sites for the infraspinatus. ( Reprinted with permission from LifeArt, Lippi ncott Williams & Wilki ns.)
TRIGGER POINT ACTIVATION Trigger points here will usually be activated by an acute stress or by multiple overload stresses, such as when fre quently reaching out and back to lift heavy objects. This muscle is very likely to be strongly active during most move ments of the arm and the shoulder and so develop trigger points as the result of acute overload. The onset of shoulder pain is usually within a few hours of the initial trauma.
STRESSORS AND PERPETUATING FACTORS •
Reaching into the back seat of the car to bring an object forward between the front seats
•
Sleeping on the affected side will compress and stimu late trigger points
•
Sleeping on the unaffected side will also activate trig ger points because the arm falls forward, overstretching the muscle at the musculotendinous junction
•
Grabbing backward for support on the stairs to regain balance
•
M ishitting a ball during racquet sports
•
Overuse of ski poles
11 2
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B
• FIGURE 6-12 Trigger points a n d referral zones for the infraspinatus. (Reprinted with permission from Simons DG, Travell JG, Simons LS. Upper Half of Body. 2nd ed. Balti more, MD: Lippincott Williams & Wilkins, 1 999. Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1 . p. S53, Fig. 22.1 .)
•
This area may be extremely tender. Work gently, get ting deeper into the layers of this muscle gradually
People with problems in this muscle find it d ifficult to fully use their shoulder
•
This is a thin, flat muscle with several overlapping sec tions. It does an extreme amount of work and is quite prone to forming trigger points
The insertion to this muscle must be examined in any rotator cuff inj ury
•
This muscle should be examined in all shoulder, arm, forearm, and hand pain syndromes
PRECAUTIONS •
•
MASSAGE THERAPY CONSIDERATIONS •
Trigger point sensation in the form o f pain is com monly felt deep within the shoulder joint
C H A PT E R 6
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1 13
This muscle is one of the rotator cuff team and has nearly identical actions as the infraspinatus. Travell and Simons consider the teres minor the "little brother" to the infrasp inatus. The main referral area is the size of a silver dollar ( Fig . 6- 1 3) .
ORIGIN •
Upper two-thirds of the dorsal surface of the scapula at the axillary border
INSERTION •
Greater tubercle of the humerus at the lower facet
ACTION •
Rotator cuff funct ion: to stabil ize the head of the humerus in the glenoid fossa of the scapula
•
Later�l rotation and extension of the humerus
•
Horizontal abduction of the humerus
TRIGGER POINTS AND REFERRAL ZONES
• FIGURE 6-13 Attachment sites for the teres mi nor. ( Reprinted with permission from Life Art, Lippincott Williams & Wil kins.)
A trigger point is usually found in the muscle belly near the musculotendinous j unction. The referral will mainly be into the posterior deltoid region and will feel like a painful bursa about the size of a silver dol lar. The actual trigger point will be well below the subacromial bursa but will feel like bursitis because of the sharp, deep quality of the pain ( Fig. 6-14 ). Clients with trigger points in this muscle typically com plain more of posterior shoulder pain than of restriction of movement. When the complaint is of severe, deep pain into the anterior shoulder, it will probably not be from teres minor but from the infraspinatus. A trigger point in teres minor may also result in a feeling of numbing and t ingling into the forth and fifth fingers that is aggravated by reaching above shoulder height or behind.
TRIGGER POINT ACTIVATION Teres minor's involvement is usually not a single-muscle syndrome. Trigger points here are activated along with those in the infraspinatus. Causes are overloading the muscle when reaching up and back.
STRESSORS AND PERPETUATING FACTORS •
Holding the steering wheel tightly during an automo bile accident
•
Losing balance when lifting a heavy object overhead
•
Working in cramped quarters with the arm reaching overhead
•
Playing volleyball
• FIGURE 6-14 Trigger points and referral zones for the teres mi nor. ( Reprinted with permission from Simons DG, Travell JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore, M D: Lippincott Williams &
Wi lkins, 1999. Travell & Simons'Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1 . p. 565, Fig. 23.1.)
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• FIGURE 6-1 5 Anatomical region of the shou lder. (Reprinted with permission from Simons DG, Travell JG, Si mons LS. Upper Half of Body. 2nd ed. Baltimore, M D: Lippi ncott Williams & Wilkins, 1 999. Trave" & Simons'Myofascial Pain and Dysfunction: The Trigger Point Manual; vol l . p. 568, Fig. 23.3.)
PRECAUTIONS •
infraspinatus. After alleviating this anterior pain, the person then becomes aware of teres minor referring to the back of the shoulder
Be gentle with pressure along the lateral border of the scapula, as teres minor may be extremely tender •
The therapist may want to consider this muscle as syn ergistic to the infraspinatus and work the two together as a pair
•
These tendons must be examined in any type of rotator cuff injury ( Fig. 6- 1 5 )
MASSAGE THERAPY CONSIDERATIONS •
When a person experiences pain i n the front of the shoulder, the cause is l ikely to be trigger points of the
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115
Active trigger points in latissimus dorsi are often confused as pain from intrathoracic disease ( Fig. 6- 1 6 ).
ORIGIN •
•
Spinous processes of the lower six thoracic and all lumbar vertebrae by way of the thoracolumbar aponeuroses The l ast three or four ribs
•
Posterior il iac crest
•
Inferior angle of scapula
INSERTION •
Bicipital groove of the humerus
ACTION •
•
Adduction, extension, and medial rotation of the arm at the shoulder joint Forceful depression of the shoulder girdle
TRIGGER POINTS AND REFERRAL ZONES Trigger points here are usually in the upper muscle belly, where the fibers are twisting around the fibers of teres major, and in the lower muscle belly at the attachment at the lower ribs. Referral phenomena are often experienced as mid tho racic back pain or a constant aching at the inferior angle of the scapula. There may also be referral sensation to the back of the shoulder and down the medial aspect of the arm, fore arm, and hand, including the ring and little fingers. The person will have difficulty reaching behind to the lower scapular region. A key trigger point here might be responsible for setting up a satellite trigger point in muscles located within the referred zone, such as the triceps brachii and flexor carpi ulnaris, along with the lower trapezius and iliocostalis thora cis. The inferior trigger point in the long fibers over the lower ribs will refer sensation to the front of the shoulder and sometimes to the posterior iliac crest area. There have been some reports of trigger point sensation at the lum bosacral area attributed to trigger points i n the fasc ial attachments to the thoracolumbar aponeurosis ( Fig. 6- 1 7 ). Often this pernicious infrascapular, m idthoracic back ache that is referred from trigger points in latissimus dorsi are extremely unresponsive to stretching or changing posi tion to achieve relief of the sensation. As this is a very long, slack muscle, movement other than depression will rarely cause pain, and acute trauma or overload are unlikely to activate trigger points. Pain will occur from reaching up and way out from the body to handle something large and
•
FIGURE 6-1 6
Attachment sites for the latissimus dorsi. (Repri nted
with permission from Life Art, Lippincott Wi l l ia ms & Wil kins.)
awkward. Most sensation from trigger points here will not be experienced upon movement, only at rest. Often a per son w ith this type of pain has been through many medical tests and treatment to the area of referral rather than to the trigger point as the source of pain.
TRIGGER POINT ACTIVATION Trigger points are most likely t o b e activated when this mus cle is stretched by reaching forward and up rather than by overloading it during depression and arm extension. It is possible for a tight bra around the chest to also activate trig ger points in this muscle.
STRESSORS AND PERPETUATING FACTORS •
Reaching repeatedly forward and upward, e ither to manipulate an awkwardly large object or to pull some thing down
•
Exercising by pulling heavy weights overhead
•
Throwing a baseball
•
Hanging from a swing or rope
•
Working for several hours with a heavy chain saw at shoulder level
1 16
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M U S C L E S A N D N E U RO M U S C U LAR THERAPY ROUTI N E S BY BODY REGION
I!
�
\----,/'
t
\ '
ri
1\
• FIGURE 6-1 7 Trigger points and referra l zones for the latissimus dorsi. (Reprinted with permission from Simons DG, Travell JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore, M D: Lippincott Wi l l iams & Wilkins, 1 999. Travel! & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual; va l l .
p. 573, Fig. 24.1 .)
•
Pressing down to twist weeds out of the soil repeatedly while gardening
•
Doing the butterfly stroke when swimming
MASSAGE THERAPY CONSIDERATIONS •
Determination of trigger points in this muscle requires careful analysis of activities that require the forceful depression of the shoulder girdle or repetitive exten s ion combined with adduction
•
Latissimus dorsi and teres major make up the lateral border of the armpit
•
Pincer compression is a very effective technique. Take care not to hyperextend your wrist
•
A s ide- lying position of the client may allow for bet ter therapist b iomechanics when working with this muscle
PRECAUTIONS •
•
When performing a pincer compression on the bulk of this along with teres major, be sure to firmly grasp the entire bundle j ust lateral to the armpit. I t will be extremely uncomfortable to the client if you press into the edge of the bundle only The muscle belly that crosses the ribs is often glued down at the lateral border
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1 17
Major:Twin to Latissimus Dorsi Teres major, latissimus dorsi, and the long head of triceps brachii work as a myotatic unit during extension and medial rotation of the arm. A myotatic unit is a group of agonist and antagonist muscles that function together as one unit due to sharing spinal reflex responses. These muscles com monly develop trigger points together ( Fig. 6- 1 8 ).
ORIGIN •
Inferior angle of the scapula: dorsal surface
INSERTION •
BiCipital groove of the humerus (partly joined with the insertion of latissimus dorsi)
ACTION •
Adduction, medial rotation, and extension of the arm
TRIGGER POINTS AND REFERRAL ZONES There is often no tendemess of trigger points here. Referrals include sensation to the posterior deltoid area and over the long head of triceps brachii. Occasionally, there will also be sensation to the dorsal forearm. The usual pattem of trigger points will be to the mid-muscle belly and to the area of origin. A final trigger point may be located at the musculotendinous junction. Experience of symptoms from trigger points will likely occur upon motion, not upon rest ( Fig. 6-19 ) . A person may experience pain when reaching overhead and then com pensate for slight restrictions without being aware of it.
• FIGURE 6-1 8 Attachment sites for the teres major. (Repri nted with permission from Life Art, Lippincott Williams & Wilkins.)
TRIGGER POI NT ACTIVATION •
Driv ing a car or tractor that does not have power steering
•
Excessive reaching overhead and forward as when serving in tennis
STRESSORS AND PERPETUATING FACTORS •
Using the butterfly stroke to swim
PRECAUTIONS •
To address this muscle, a pincer compression must be used. This will include pincering the latissimus dorsi. When compressing the two together, i t may be extremely tender; be gentle
MASSAGE THERAPY CONSIDERATIONS •
•
Teres major will feel like it i s within latissimus dorsi when using the pincer compression To isolate this muscle, begin at the inferior angle of the scapula, and then sweep proximal to d istal off the lat eral border of the scapula
• FIGURE 6-1 9 Trigger points and referral zones for the teres major. (Repri nted with permission from Simons DG, Travell JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore, M D: Lippi ncott Williams &
Wilkins, 1 999. Trovell & Simons'Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1 . p. 588, Fig. 25. 1 .) Reprinted with permission
from Simons DG, Travell JG, Simons LS.Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 1: Upper Half of Body. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins, 1 999; p. 588, Fig. 25. 1 .
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Serratus Anterior: Stitch in the Side Muscle This muscle is known as the "stitch in the side muscle" because its trigger points, when activated, cause symptoms of being short of breath or not being able to take deep breaths without hurting.
ORIGIN •
Ribs one through eight or nine
TRIGGER POINT ACTIVATION The trigger points may be activated by muscle strain result ing from excessive exercise or severe coughing.
STRESSORS AND PERPETUATING FACTORS •
Excessive running, push-ups, or other exercise
•
Lifting heavy weights overhead
•
INSERTION •
Posterior surface of the superior angle of the scapula
•
Posterior surface of the vertebral border of the scapula
•
Posterior surface of the inferior angle of the scapula
ACTION •
Upward rotation and protraction of the scapula
•
Stabilizes the scapula against the ribs, preventing it from "winging out"
•
Assists elevation of the scapula
TRIGGER POI NTS AND REFERRAL ZONES There may be chest pain present from trigger points in ser ratus anterior. This sensation may be at rest if severe enough. When the trigger points are mild, there may be a "stitch in the side" sensation while running. The external oblique muscle interdigitates with the lower area of serratus anterior fibers on the ribs and may also have a trigger point that refers similarly but lower down in the side. A person with this condition may have to stop running occasionally to take in a few deep breaths. Also, this person may not be able to lie on the affected side at n ight comfortably. This trigger point may also contribute to the pain felt from a heart attack on the left side. Test ing range of motion at the shoulder will rarely aggravate this trigger point ( Fig. 6-20).
Severe coughing and irritation of the lungs caused by smoking, asthma, bronchitis, and pollution
PRECAUTIONS •
Be gentle with this muscle, as a burning sensation usu ally occurs when it is worked on
•
If a client's scapula seems glued down, it will be impor tant to work toward loosening it to be able to work more thoroughly on serratus anterior
MASSAGE THERAPY CONSIDERATIONS •
Weakness in this muscle will allow a winging out of the scapula
•
Travell and Simons also refer smoker's muscle"
•
Only a small portion of the superior aspect of this mus cle can be palpated ( at attachments to ribs one through three) because of obstruction by pectoralis major
•
Prolonged pressure on this muscle, such as occurs when one sleeps on one's side each night, may cause acute pain upon awakening
•
A client with a breathing problem resulting from trig ger points, hypercontraction, and/or ischemia may present with a stitch in the side or not be able to finish an ordinary sentence without stopping for a breath
to
this muscle as "the
• FIGURE 6-20 Attachment sites and trigger points with referral zones for the serratus anterior. (Reprinted with perm ission from Simons DG, Travell JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore, MD: Lippincott William s & Wilkins, 1 999. Trovell & Simons'Myofascial Pain and Dysfunction: The Trigger Point Manual; vol
1. p. 888, Fig. 46.1 .)
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119
�...2.!n.22 idsl Major and Minor: Superficial Backache and Round Shoulder Muscles The rhomboid muscles are often tender because of having to remain in a stretched-out position for long periods of time as a result of an imbalance with their antagonist muscles, pectora lis major and minor. The pectoralis muscles are much stronger than the rhomboids and will cause a chronic round-shouldered posture, overstretching the rhomboids ( Fig. 6-2 1 ) .
ORIGI N (MAJOR AND MI NOR) •
Spinous processes of C7-T5
INSERTION (MAJOR AND MINOR) •
Vertebral border of the scapula from the root of the spine to the inferior angle
ACTION •
Retraction ( adduction) of the scapula
•
Downward rotation of the scapula
•
Elevation of the scapula
•
Assist forceful adduction and extension of the arm by stabilizing the scapula in a retracted position
• FIGURE 6-21 Attachment sites for the rhomboid major and mi nor. ( Reprinted with permission from Life Art, lippi ncott Williams & Wil kins.)
TRIGGER POINTS AND REFERRAL ZONES Compared with other shoulder girdle muscles, the rhom boids rarely develop trigger points. There is usually referred sensation concentrating along the vertebral border of the scapula and between the shoulders in the paraspinal mus cles. This may spread over the supraspinous area as well. This is similar to the pattern of levator scapula minus the neck portion of involvement. The complaint is usually of superficial aching that occurs at rest but that is not influ enced by ordinary movement. Trigger points in these mus cles may be responsible for snapping and crunching noises during movement of the scapula ( Fig. 6-2 2 ) .
TRIGGER POINT ACTIVATION The powerful pectoralis major pulls the shoulder forward, overstretching the weaker rhomboids. Activation is made easy with prolonged holding of the arm in abduction or flexion above 90 degrees, or leaning forward while working w ith a round-shouldered position, then shortening the fibers by sleeping on one's side.
STRESSORS AND PERPETUATING FACTORS •
•
Lying on one's side during sleep, placing the muscle on that side into a shortened position Painting a ceiling
•
Leaning forward to work, as when sewing or writing in longhand
•
Having scoliosis in the upper thoracic area: a prolonged stretch of the concave side
• FIGURE 6-22 Trigger points and referral zones for the rhomboid major and minor. (Reprinted with permission from Simons DG, Travell JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore, M D: Lippincott Williams & Wilkins, 1 999. Travell & Simons'Myofoscial Pain and Dysfunction: The Trigger Point Manual; vol 1 . p. 6 1 4, Fig. 27. 1 .)
1 20
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PRECAUTIONS •
These are re latively thin m uscles and are located in the second layer of muscles, being deep only to the trapezius. Be sure not to use so much pressure that you press right through them i n to the deeper layers
MASSAGE THERAPY CONSIDERATIONS •
Rhomboid m i nor is often t ighter and more painful than rhomboid major
•
Rhomboids, lower trapezius, and levator scapula create a common biomechanically stressed area at the root of the spine of the scapula
•
The rhomboids and lower trapezius often adhere to each other in those who have overuse syndrome or chronically rounded shoulders
•
Rhomboids should be examined when there is a diag nosis of fibromyalgia
•
Referral sensation may be misdiagnosed as scapulocos tal syndrome
CHAPTER 6
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UPPER TORSO
1 21
Deltoid: A Dull Actor There is a complexity of interwoven fibers in the middle portion of the deltoid, whereas only a simple fusiform type of fibers is in the anterior and posterior parts ( Fig. 6-23 ) .
ORIGIN •
Anterior: lateral one-third of the clavicle
•
M iddle: acromion process
•
Posterior: inferior aspect of the lateral two-thirds of the spine of the scapula
INSERTION •
Deltoid tuberosity of the humerus
ACTION •
Anterior: forward flexion of the arm, horizontal adduc tion of the arm, and assists medial rotation of the humerus
•
Middle: abduction of the humerus
•
Posterior: extension of the arm and assists lateral rota tion of the humerus
• FIGURE 6-23 Attachment sites for the deltoid. ( Reprinted with per mission from Life Art, Lippincott Williams & Wil kins.)
TRIGGER POI NTS AND REFERRAL ZONES There are many trigger points in all three parts of the del toid; it can be riddled with them. Referrals mostly encircle the actual trigger point but can also refer a short d istance away. Sensation will be felt mostly in the posterior and mid dle parts, with spillover sensation to the anterior, middle, and posterior parts, along with the lateral humerus to j ust above the elbow ( Fig. 6-24 ) .
There will be pain upon movement and, occasional ly, at rest as well. The sensation will be directed into the deltoid area itself. If there are multiple trigger points in this muscle, there will be extreme impairment of strength with the pos sibility of not being able to reach a 90-degree abductio[\ from the shoulder. This person may experience a "catch" that hurts during abduction of the arm, as well.
• FIGURE 6-24 Trigger points and referral zones for the deltoid. (Reprinted with permission from Simons DG,Travell JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins, 1 999. Travel! & Simons'Myofascial Pain and Dysfunction: The Trigger Point Manual; vol l . p. 624, Fig. 28.1 .)
1 22
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· ·..····· ··.. ·· ···· .. ·······....· · TRIGGER POINT ACTi VATION · · .... . ..... . . . . ...... . .. . . .. . .. . ... .
.
.
.
. .
This muscle is very likely to receive forceful impacts d irectly against the underlying humerus. The anterior part can be traumatized by a repeated recoil of a rifle when shooting or reaching out to a railing to catch oneself from falling. This part may be overloaded by using heavy power tools at shoul der height or sorting mail into shoulder-height boxes for long periods of t ime. The posterior part is easily overloaded by over exercise using weights, or using ski poles for long periods of time. This is also a site for intramuscular injections of medica t ions. If the needle is placed into a latent trigger point, it is likely to activate it. The anterior portion does not usually develop trigger points alone as a result of activity, but usu ally in association with trigger points in other muscles. The middle part is less v ulnerable to overload than are the other two parts. Trigger points will set in, however, if there is repetitive, jerky abduction of the arm. Also, satellite trigger points are likely to set in here because of key trigger points in the infraspinatus. A person may feel symptoms after impact trauma to this muscle during sports or an injury of some sort. The com plaint will be of pain upon movement of the shoulder and possibly upon rest as well. There will be d ifficulty in raising the arm into the horizontal position as well as in bringing the hand to the mouth. . . . .. .. . . . . . · · · ·
•
Typing on a keyboard that is too high
•
Driving a car with hands at the top of the steering wheel
•
Swimming w i th the freestyle stroke
PRECAUTIONS •
Areas of hardness may be felt under the deltoid. This may be attachments of other muscle groups. If tender, treat these attachments using moderate pressure through the deltoid
•
The subdeltoid bursa near the greater tubercle of the humerus may be inflamed and can cause true bursitis
MASS'AGE'THERA'Py 'co�is'I'DERATi6Ns" " " " " " " " " " •
Trigger points in any or all of the three parts of the deltoid may refer pain sensation to the subacromial area and, therefore, be overlooked. According to Travell and Simons, often this will mistakenly be diag nosed as subdeltoid bursitis. If treated as though it were subdeltoid bursitis, it will be injected at the bursa and will have a poor therapeutic result consequently
•
The tendon attaching to the deltoid tuberosity may be ischemic
•
Pain upon flex ion of the arm may indicate trigger points in the anterior fibers
•
If there is limited but pain-free range of motion, the deltoid may be treated w ith the person seated, leaning forward onto the massage table with the arm resting overhead
•
Many other muscles are likely to refer sensation into the deltoid muscle
STRESSORS AND PERPETUATiNG· ·FACTORS · · · · · · · · · · .
. . . .
. . .
. . . . .
.
.
. . . . . .
•
I ntramuscular injections such as B vitamins, penicil lin, and influenza vaccine
•
Overhead repetitive strain during prolonged lifting
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123
Serratus Posterior Superior: Cryptic, Deep, U pper Back Pain This muscle is labeled the "cryptic, deep, upper back pain" because of having very annoying trigger points with very painful referrals, such as a very deep ache under the upper portion of the scapula.
ORIGIN •
Spinous processes of C 7 through T 2 o r T3
INSERTION •
Superior borders of ribs 2 through
5
ACTION •
Raises ribs 2 through 5 to assist inspiration
TRIGGER POI NTS AND REFERRAL ZONES Sensation from trigger points in this muscle refers strongly directly around the trigger points as well as to the posterior part of the deltoid, the elbow, both po terior and anterior sides of the wrist, and the radial side of the hand. There may be spillover sensation into the chest and between all of the strong referrals, as well. The person will report a steady, deep ache at rest, with it increasing by lifting an object with outstretched hands or lying on the same side as the aching ( Fig. 6-2 5 ) . Clients will likely identify the painful area a s being under the upper portion of the scapula. They will also likely expe-
•
FIGURE 6-25
rience painful sensation intensely over the posterior border of the deltoid and the long head of the triceps brachii, with numbness into the hand.
TRIGGER POINT ACTIVATION Trigger points here are activated by overloading the tho racic respiratory effort because of coughing (pneumonia, asthma, chronic emphysema ) , or paradoxical breathing ( using the diaphragm and abdominal muscles out of phase ) .
STRESSORS AND PERPETUATING FACTORS •
Chronic or long-standing coughing
•
Paradoxical breathing
•
Smoking cigarettes
•
Writing at a desk or table that is too high
•
Scoliosis
PRECAUTIONS •
Rhomboids, which are superficial to serratus posterior superior, must be cleared before working on this muscle
MASSAGE THERAPY CONSIDERATIONS • •
To palpate its insertion, the scapula must be abducted Remember to work d irectly on the ribs, not between them
Attachment sites and trigger points with referral zones for the serratus posterior superior. (Reprinted with permission from Simons
DG, Travel! JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore, M D: Lippincott Williams & Wilkins, 1 999. Travell & Simons'Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1 . p. 901 , Fig.47. 1 .)
1 24
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Thoraco l u m ba r Pa raspinals: Lumbago
Generally referred to as the throacolumbar paraspinals, these muscles may be categorized as superficial and deep. They all appear within the lamina groove. Superficial Muscles: Erector Spinae The uperficial paraspinal musculature consists of a superfi c ial group of longitudinal, long-fibered muscles. They are
spinalis, longissimus, and iliocostalis. Of the three muscles making up this superficial group, it is the longissimus thora cis and iliocostalis thoracis that are most likely to develop trigger points. Hypercontracted erector spinae muscles cause a sway-backed condition called hyperkyphosis in the tho racic area, whereas hypercontraction of one side only causes scoliosis.
Spinalis Thi is the most medially placed of the erector spinae mus cles ( Fig. 6-26 ) .
ORIGIN •
Ligamentum nuchae
•
Spinous processes of C7 and T I l through L2
INSERTION •
Spinous processes of T4 through 8 and C2
ACTION •
Extension of the spine (bi lateral)
•
Lateral flex ion of the spine (unilateral)
•
Rotation of the spine ( unilateral)
TRIGGER POI NTS AND REFERRAL ZONES
IttrM�"<;J"'-- Spinalis
Although Travell and Simons do not mention this muscle as specifically having trigger points, other authors have noted them and claim that these may occur at any point along the length of the muscle. A person experiencing sensation from trigger points here will most likely complain of the inability to move his or her back w ithout pain occurring.
TRIGGER POINT ACTIVATION In a long back muscle, such as spinalis, sudden overload or a traumatic event such as a quick awkward movement com bining bending and twisting of the back when l ifting some thing heavy will certainly activate trigger points. Also, acti vation may occur by repetitive microtrauma, as in repetitive strain inj uries.
STRESSORS AND PERPETUATING FACTORS •
Protracted head syndrome and/or excessive neck hyperextension
•
Dowager's hump and protruding vertebrae at C7 and T I
•
Scoliosis
• FIGURE 6-26 Attachment sites for the spinalis. ( Reprinted with per mission from Moore KL, Ag u r A. Essential Clinical A natomy. 2nd ed. Philadelphia, PA: Lippi ncott Williams & Wilkins; 2002.)
CHAPTER 6
PRECAUTIONS •
•
•
•
•
A person may need special bolstering and support sys tems if he or she has scoliosis and/or "roto-scoliosis" With the above conditions, a person may be uncom fortable lying prone for prolonged periods of time When performing deep effleurage with an elbow, do not rotate while exerting deep pressure, as this may torque the superficial fascia and cause bruising Be sure the elbow does not intrude on the spinous processes, as they are sharp. Avoid traumatizing the supraspinous ligament and interspinalis muscles attach ing to them
/
UPPER TORSO
1 25
When using the elbow to perform deep effleurage, be sure to stop at the sacrum when moving in an inferior direction, as this may cause trauma to the tissues over lying the sharp, bony protrusions there
MASSAGE THERAPY CONSIDERATIONS •
•
•
The erector spinae muscles act as flexors of the trunk/ spine when standing. This involves eccentric contrac t ion It is not uncommon to find the erector spinae muscles weak and fatigued once released Good cl ient follow - up practices should include strengthening techniques
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Lo ngissimus Of the three superficial paraspinal muscles, the medial-lying longissimus is one of the two most l ikely to develop trigger points. Sensation will be referred both above and below the trigger po int. This portion of longissimus has the longest fibers of the paraspinal muscles. This muscle can be quite thin in some areas but as thick as 2 inches in other areas ( Fig. 6-2 7 ) .
Longissi mus
--.----7-4-';� l rJI l
ORIGIN •
Sacrum and il iac crest via the thoracolumbar apone urosis
•
Transverse processes of T I through 5 and L 1 through 5
•
Articular processes of C5 through 7
I NSERTION •
Transverse processes of C2 through C6 and TI through TI2
•
Ribs 4 through 1 2
•
Mastoid process
ACTION •
Extension of the spine (bilateral)
•
Lateral flexion of the spine (unilateral)
•
Rotation of the spine ( un ilateral)
TRIGGER POI NTS AND REFERRAL ZONES A trigger point is usually found in the lower thoracic area at T I 0 or T I L This trigger point may cause nagging pain in the lower back and buttock area. Often, these symptoms will be diagnosed as lumbago. It is common that the sensa tion will begin unilaterally and then, left untreated, become bilateral as muscles on both s ides become involved ( Fig. 6-28 ) . A person with trigger points in this region will most likely complain of restriction upon spinal movement, such as arising from a chair or climbing the stairs.
TRIGGER POINT ACTIVATION Any sudden overload of this muscle may activate trigger points. This could be a specific activity or a traumatic event. A lso repetitive movement over a period of time may acti vate trigger po ints here. Any quick awkward movement, such as a combination of bending and twisting of the back, especially when the muscle is fatigued or chilled, will likely activate trigger points.
•
FIGURE 6-27
Attachment sites for the longissimlls. ( Reprinted with
permission from Moore KL, Agur A. Essential Clinical A natomy. 2nd ed. Philadelphia, PA: Lippi ncott Williams & Wilkins; 2002.
STRESSORS AND PERPETUATING FACTORS •
Hyperlordosis and hyperkyphosis, which cre�te fat igue and ischemia
•
Twisting and lifting at the same t ime. Often occupa tional injuries occur because of the employee lifting an object on the floor off to the side without turning first to face the object
CHAPTER 6
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UPPER TORSO
1 27
PRECAUTIONS •
Avoid flicking across the muscle when applying deep transverse friction
•
When performing deep effleurage with an elbow, do not rotate while exerting deep pressure, as this may torque the superficial fascia and cause bruising
•
Be ure the elbow does not intrude on the spinous processes, as they are sharp. Avoid traumatizing the supraspinous ligament and interspinalis muscles attach ing to them
•
When using the elbow to perform deep effleurage, be sure to stop at the sacrum when moving in an inferior direction, as this may cause trauma to the t issues over lying the sharp, bony protrusions there
MASSAGE THERAPY CONSIDERATIONS •
Longissimus, along with the other erector muscles, will respond well to longitudinal friction, which helps lengthen muscle fibers
•
FIGURE 6-28
Trigger points and referral zones for the longissimus.
(Reprinted with permission from Simons DG, Travell JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore, M D: Lippincott Williams &
Wilkins, 1 999. Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1 . p. 91 5, Fig. 4B. 1 D.)
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Iliocostalis This is the most lateral of the superficial paraspinal muscles. This muscle can be as thick as 2 inches in some areas, whereas being quite thin in other areas ( Fig. 6-29).
ORIGIN •
Sacrum and iliac crest via the thoracolumbar aponeu rosis
•
Posterior ribs 3 to 1 2 at their angles
INSERTION •
Superior aspect of ribs 1 to 1 2 at their angles
•
Transverse process of C4 to C7
ACTION •
Extension of the spine (bilateral)
•
Lateral flexion of the spine ( unilateral)
•
Rotation of the spine ( unilateral)
TRIGGER POINTS AND REFERRAL ZONES A trigger point may be found at the midscapular area along with longissimus thoracis in the upper thoracis, whereas another is usually located in the lower thoracic area at about T I l . They both refer strongly to a spot a bit lower and more lateral to the trigger point. The upper trigger point will also include spillover sensation above and below it from the medial border of the scapula to the spinous processes and through the body into the chest. The lower trigger point will include spillover sensation above and across the scapula and below all the way to the posterior iliac crest ( Fig. 6-3 0 ) . Again, a s it i s with longissimus, the chief complaint will be of restricted spinal movement.
TRIGGER POINT ACTIVATION A n y sudden overload of this muscle may activate trigger points. This could be a specific activity or a traumatic event. Also, repetitive movement over a period of t ime may acti vate trigger points here. Any quick, awkward movement, such as a combination of bending and twisting of the back, especially when the muscle is fatigued or chilled, will likely activate trigger points.
STRESSORS AND PERPETUATING FACTORS •
Leaning into a side bend, then quickly twisting into a forward bend without straightening first
•
Prolonged sitting in car seats or chairs without support
•
Whiplash injuries, which can strain this muscle
•
FIGURE 6-29
Attachment sites for the il iocostalis. (Reprinted with
permission from Hendrickson T. Massage for Orthopedic Conditions. Baltimore, MD: Lippi ncott Williams & Wilkins; 2003; Fig. 4-46.)
PRECAUTIONS •
Chronic pain that does not respond to treatment may indicate other structural involvement
•
If there is a chronic condition, the person may feel discomfort upon initial compression of this muscle. Be careful here of using any twisting movements
CHAPTER 6
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UPPER TORSO
1 29
L,
-.- T' 1 ......
•
FIGURE 6-30 Trigger points and referral zones for the i liocosta lis. (Reprinted with permission from Simons DG, Travell JG, Simons LS.
Upper Half
of Body. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins, 1 999. Trovell & Simons ' Myofascial Pain and Dysfunction: The Trigger Point Manual; vol l .
p. 91 5, Fig. 48.1 .)
•
•
Be wre the elbow does not intrude on the spinous processes, as they are sharp. Avoid traumatizing the supraspinous ligament and interspinalis muscles attach ing to them When using the elbow to perform deep effleurage, be sure to stop at the sacrum when moving in an inferior direction, as this may cause trauma to the tissues over lying the sharp, bony protrusions there
•
When perfor m i ng deep effle urage w i th an elbow, do not rotate while exerting deep pressure, as this m a y torque t h e superfi c i a l fasc i a and cause bru ising
MASSAGE THERAPY CONSIDERATIONS •
The lower r i b attachments are often sites of pain, espe cially when a person has an exaggerated lordotic curve
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Deep Paraspinal Muscles: Lumbago The deep paraspinal muscles consist of semispinalis, multi fidus, and rotatores. The entire group of these deep paraspi nal muscles i s also called "the transversospinalis group." A s
the fibers o f these three deep paraspinal muscles become deeper, they also become progressively shorter and more horizontal and also become more of a rotator of the spine rather than an extender of it.
Semispinalis Semispinalis is classified anatomically as the outermost or most superficial of the deep paraspinal muscles. Its referral sensation patterns seem to correspond to those of the longis simus fibers ( Fig. 6-3 1 ) .
ORIGIN •
Transverse processes of C7 to T 1 0
•
Articular processes C4 to C6
INSERTION •
Spinous processes of C2 to T4, spanning three to six vertebrae
•
Occiput
ACTION •
Extension of the spine (bilateral)
•
Rotation of the spine toward the opposite side (unilateral)
•
Primarily, fine adjustments between vertebrae rather than any gross spinal movements
TRIGGER POI NTS AND REFERRAL ZONES According to Travell and S imons, a trigger point may occur in any muscle along its length and refer elsewhere. Trigger points here may bring about the common complaint of pain in the back . These trigger points are the most common causes of enigmatic back pain.
TRIGGER POINT ACTIVATION As with the more superficial muscles in the thoracic region, trigger points in this muscle may be activated by sudden overload, as in a traumatic event or sustained or repeated movements over a period of t ime. Also, any quick, awkward movement that combines bending, lifting, and twisting of the back when the muscles are fat igued will most likely acti vate a trigger point.
STRESSORS AND PERPETUATING FACTORS •
Scoliosis
•
Chronic holding or twisting patterns, such as when a person sits on one leg w ith his trunk twisted
•
Anterior pelvic tilt ( too much pelvic flexion)
•
Subluxation of vertebrae
PRECAUTIONS •
Avoid gouging the t issue when applying friction
•
FIGURE 6-31
Attachment sites for the semispinalis. (Repri nted with
permission from Hendrickson T. Massage for Orthopedic Conditions . Baltimore, MD: Lippincott Williams & Wilkins; 2003; Fig. 4-40A.
MASSAGE THERAPY CONSI DERATIONS •
Work the lateral aspect of the spinous processes using deep transverse friction
•
This muscle responds well to longitudinal forearm lengthening, getting deeper incrementally
•
You may lengthen this muscle using the forearm "from distal to proximal and/or the reverse
•
Chronically tight or painful fibers may feel like wire strings or small cables
CHAPTER 6
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UPPER TORSO
1 31
Multifidus This is the m iddle layer of the deep paraspinal muscles ( Fig. 6-32).
ORIGIN •
Transverse processes of C4 through L5
INSERTION •
Spanning two to four vertebrae, into the spinous proc ess of each vertebrae above each site of origin
ACTION •
Extension of the spine (bilateral)
•
Rotation of the spine toward the opposite side (unilat eral)
TRIGGER POINTS AND REFERRAL ZONES There is usually a trigger point found medial to the scapula along side the spinous process of approximately T4 and T5 . Generally, this will refer strongly around itself without spreading sensation out d istally ( Fig. 6-33). People w ith a trigger point in this muscle will likely experience a sensation of steady aching deep in the spine. One or both sides of this muscle may visibly bulge in the low back area. The sensa tion, according to Travell and Simons, may seem to originate in the spine rather than in the muscles for this person, and there will be little relief from changing positions.
TRIGGER POINT ACTIVATION As with the more superficial muscles in the thoracic region, trigger points in this muscle may be activated by sudden overload, as in a traumatic event or sustained or repeated movements over a period of time. Also, any quick, awkward movement that combines bending, lifting, and twisting of the back when the muscles are fatigued will most likely acti vate a trigger point.
STRESSORS AND PERPETUATING FACTORS •
Scoliosis
•
Chronic holding or twisting patterns, such as when a person sits on one leg with h is trunk twisted
•
Anterior pelvic tilt ( too much pelvic flexion)
•
Subluxation of vertebrae
•
FIGURE 6-32
Attachment sites for the multifidus. (Reprinted with
permission from Hendrickson T. Massage for Orthopedic Conditions. Baltimore, M D: Lippi ncott Williams & Wilkins; 2003; Fig. 4-40B.
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B Multifidi and rotatores
Mu ltifidi
• FlGU RE 6-33 Trigger points and referral zones for the mu ltifidus. ( Reprinted with permission from Simons DG, Travell JG, Si mons LS. Upper Half of Body. 2nd ed. Baltimore, MD: lippincott Williams & Wilkins, 1 999. Trovell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1 . p.
917, Fig. 48.2.)
PRECAUTIONS •
Avoid gouging the tissue when applying friction
MASSAGE THERAPY CONSIDERATIONS •
Work the lateral aspect of the spinous processes using deep transverse friction
•
Unilateral contraction of the tissues of the lamina groove can contribute to scoliosis. Bilateral contrac tions can contribute to a hyperlordotic curve. Small localized areas of contraction can be responsible for isolated subluxations-partial dislocations of a joint-of the spinal vertebrae
C H A PT E R 6
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UPPER TORSO
133
This is the deepest layer of the deep paraspinal muscles ( Fig. 6-34) . . . . . .
. . . . . . . . . . . . . . . . . . . . .
ORIGIN •
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Transverse processes of the vertebrae, except Cl
Semispinalis capitis
INSERTION •
Spinous processes of the vertebrae above each point of origin spanning only one vertebrae
ACTION •
Extension of the spine (bilateral)
•
Rotation of the spine ( unilateral)
TRIGGER POINTS AND REFERRAL ZONES There is usually a trigger point found medial to the scapula against the spinous processes around the area of T4 to T5. This will refer strongly around itself without much spillover sensation at a distance. This will usually be experienced as midline pain and tenderness ( Fig. 6-3 5 ) . People with a trigger point in this muscle will likely experience a sensation of steady aching deep in the spine. One or both sides of this muscle may visibly bulge in the low back area. The sensation may seem to originate in the spine rather than in the muscles for this person, and there will be little relief from changing positions.
Multifidus --+-"':"-b-�--1.-fIj��,.::.J
TRIGGER POINT ACTIVATION As with the more superficial muscles in the thoracic region, trigger points in this muscle may be activated by sudden overload, as in a traumatic event or sustained or repeated movements over a period of t ime. A lso, any quick, awkward movement that combines bending, lifting, and twisting of the back when the muscles are fatigued will most likely acti vate a trigger point.
•
FIGURE
6-34 Attachment sites for the rotatores. (Re p rinted with p er mission from Oatis CA. Kinesiology. Baltimore, MD: li p p i ncott Williams & Wilkins; 2004; Fig. 30-8.)
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STRESSORS AND PERPETUATING FACTORS •
Scoliosis
•
Chronic holding or twisting patterns, such as when a person sits on one leg with h is trunk twisted
•
Anterior pelvic tilt ( too much pelvic flex ion)
•
Subluxation of vertebrae
PRECAUTIONS •
Avoid gouging the tissue when applying friction
MASSAGE TH ERAPY CONSIDERATIONS •
Work the lateral aspect of the spinous processes using deep transverse friction
•
Uni lateral contraction of the t issues of the lamina groove can contribute to scoliosis. Bilateral contrac tions can contribute to a hyperlordotic curve. Small localized areas of contraction can be responsible for isolated subluxations of the spinal vertebrae
· �· · " ·,: J ft� .
-.
:--
•.J - :: • • v
v
• FIGURE 6-35 Trigger points and referral zones for the rotatores. (Reprinted with permission from Simons DG, Travell JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore, MD: Lippincott Williams &
Wilkins, 1 999. Travell & Simons'Myofascial Pain and Dysfunction: The Trigger Point Manual; vol l . p. 91 7, Fig. 4B.2A.)
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135
ANTERIOR SHOULDER/CHEST AREA This section of the upper torso consists of the muscles of the anterior shoulder and chest area. Sternalis: Anomalous Substernal Ache Sternalis is highly variable in presence, symmetry, length, bulk, attachments, and innervation. It may occur bilaterally, but more often unilaterally: either side could be missing. I t i s reported t o b e present in 1 o f 20 individuals. If bilateral, it may fuse across the sternum. Of 13 studies involving 1 0, 200 bodies, the sternalis was found 1 . 7% ro 1 4.3% of the time. l Find ings from these studies also showed that this muscle may be as thick as X inches over the sternum. This text cites the usual attachments.
ORIGIN •
Sternum
•
Fascia over either pectoralis major or sternocleido mastoid, possibly forming a continuation of those muscles
INSERTION
ACTION •
No skeletal movement is attributed
•
The reason for contraction of this muscle remains a mystery
TRIGGER POINTS AND REFERRAL ZONES Trigger points are most often found t o the left o f the midline at the midsternal level, with a possibility of another located close to the lower attachment in the muscle belly. Referral sensation is strongly felt covering the majority of the ster num, with a possibility of spillover across the chest j ust under the clavicle and down the anteromedial aspect of the forearm to the elbow ( Fig. 6-3 6 ) . The sensation felt from trigger point activity in this muscle will most likely be intense, deep substernal pain. Occasionally, a person will also complain of soreness over the sternum.
•
3rd through 7th costal cartilages
TRIGGER POINT ACTIVATION
•
Fascia covering pectoralis major
•
Possibly the sheath of rectus abdominis
Activation is likely to occur upon acute heart attack or angina pectoris and will probably persist long after the
• FIGURE 6-36 Attachment sites and trigger points with referral zones for the sternalis. ( Reprinted with permission from Simons DG, Travell JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins, 1 999. Travell & Simons'Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1 . p. 858, Fig. 44.1 .)
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event that set i t in. Trigger points are also l ikely to occur as satellites from referral zones of trigger points in sterno cleidomastoid. In add i t ion, trigger points may be acti vated as a resu lt of direct trau m a to the costosternal area.
STRESSORS AND PERPETUATING FACTORS •
Forward head posture
•
Rounded shoulders
•
Maintaining high levels of anxiety
PRECAUTIONS •
Be sure this client has been released from the doctor's care and has this release in writing for you
•
Be sure to inform the client that he may experience similar pain as his previous heart attack or angina when you press on the trigger points
MASSAGE THERAPY CONSIDERATIONS •
As this muscle has no real movement, often sternalis is overlooked as a source of trigger points
CHAPTER 6
•
•
ORIGIN Clavicular head: medial half of the clavicle
•
Sternal head: sternum
•
Costal head: cartilage of ribs 2 through 6 or 7
•
Abdominal: aponeuroses of the external oblique and, occasionally, rectus abdominis
INSERTION •
UPPER TORSO
1 37
Major:The Poor Posture and Heart Attack Muscle
The anatomy of pectoralis major is quite complex as it has multiple overlapping layers of muscle fiber, looking simi lar to a playing card arrangement held in one's hand. Pectoralis major influences three joints, namely, the sternoclavicular, acromioclavicu lar, and glenohumeral. This muscle is d ivided into four sections: clavicular, sternal, costal, and abdominal. There i a very thick musculotendinous j unction due to the overlapping fibers wrapping around each other as they work their way toward the insertion. Often, anatomists will omit the abdominal portion of the muscle, possibly because of it not seeming to develop in certain individuals. There seems to be quite a bit of disagreement among anatomists as to the attachments of this muscle, but most agree on the following (Figs. 6-37 and 6-3 8 ) .
•
/
The crest of the greater tubercle of the humerus at the lateral lip of the bicipital groove ( there are two d istinct layers here, ventral and dorsal)
ACTION •
Adduction, horizontal adduction, and medial rotation of the humerus
•
Assists in protraction of the shoulder
•
Flexion of the humerus ( upper fibers, especially the clavicular head)
•
Depression of the shoulder girdle ( lower fibers)
•
Extension of the humerus from an elevated po ition ( sternal, costal, and abdominal heads)
TRIGGER POINTS AND REFERRAL ZONES Trigger points may form in pectoralis major within any o f the muscle bellies and are likely to develop in fi ve specific areas, each with a distinct referral pattern. The sensation from these trigger points is usually referred unilaterally and might localize substernally in the area of the chest and breast, extending down the ulnar aspect of the arm into the fourth and fifth fingers. There might be a trigger point in the costal section that is somatovisceral in nature. The exact location is the medial right side at the level of the sixth rib. According to Travell and S imons, deactivation of this particular trigger point may terminate episodes of cardiac arrhythmia. Any or all trigger points on the left side may refer sensation in the form of pain patterns that are easily mistaken for the pain of ischemic heart d isease ( Figs. 6-39 and 6-40 ) .
Sternal lamina, ventral layer
-Ar\rtn,mm,,,' lamina, dorsal layer (cut)
•
FIGURE 6-37
The thickly layered insertion of pectora lis major. (Reprinted with permission from Simons DG, Travell JG, Simons LS. Upper Half of Body.
2nd ed. Baltimore, MD: Lippincott Williams & Wilkins, 1 999. Travel! & Simons'Myofascial Pain and Dysfunction: The Trigger Point Manual; vol l . p. 825,
Fig. 42.5C.)
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there may be intense chest pain upon activity or at rest. This may even disturb this person's sleep. There is a possibility of hypersensitivity of the nipples with diffuse soreness of the breast area, making it difficult to wear a bra or shirt.
TRIGGER POINT ACTIVATION Any posture or activity that activates a trigger point, if not corrected, will also perpetuate it. Usually, activation is caused by a rounded shoulder posture, as it causes sustained shortening of the muscle fibers. Interestingly, chronic short ening of the fibers in pectoralis major can induce this pos ture. The trigger points will be self-perpetuating unless cleared. One can see why this has the label of "poor posture and heart attack muscle."
STRESSORS AND PERPETUATING FACTORS •
Prolonged periods of sitting while reading, writing, or working at the computer
•
Standing in a slouched, posture with collapsed chest, protracted head syndrome, protracted/rounded shoul ders
•
Lifting a heavy object with arms outstretched in front
•
Sustained lifting of a heavy object in a flexed position ( using a chain saw )
•
I mmobi l ization of the arm in an adducted position ( having the arm in a sling)
•
Overuse of arm adduction (using manual hedge clippers)
•
Sustaining high levels of anxiety or the exposure of fatigued muscle fibers to cold air (sitting in the shade to dry off after a swim)
•
Sustaining an acute myocardial infarction
• FIGURE 6-38 Attachment sites for the pectoralis major. (Reprinted with permission from Life Art, Lippincott Williams & Wilkins.)
When there is muscle fiber shortening going on to the extent of protraction of the shoulder girdle, the person is likely to be equally aware of their secondary interscapular back pain within the middle trapezius and rhomboids as they are of the referral sensation from trigger points in the pecto ralis major. There will be complaints of pain in the front of the shoulder and subclavicular area along with restricted abduction, particularly horizontal abduction. There may be a sense of chest constriction along with sensation down the ulnar aspect of the arm into the hand. If on the left side,
• FIGURE 6-39 Trigger points and referral zones for the pectoralis
• FIGURE 6-40 Trigger points and referral zones for the pectora lis
major. (Reprinted with permission from Simons DG, Travell JG, Simons
major. (Reprinted with permission from Simons DG,Travell JG, Simons
LS. Upper Half of Body. 2nd ed. Balti more, MD: Lippincott Williams &
LS. Upper Half of Body. 2nd ed. Baltimore, MD: Lippincott Williams &
Wilkins, 1 999. Travell & Simons'Myofascial Pain and Dysfunction: The
Wilkins, 1 999. Travell & Simons'Myofascial Pain and Dysfunction: The
Trigger Point Manual; vol 1 . pp. 820, 822; Figs. 42.1 B and 42.2.)
Trigger Point Manual; vol
1. p. 820, Fig. 42. 1 A and B.)
C HAPTER 6
•
Excessive exercise such as push-ups or using weight machines to strengthen the pectoralis muscles
PRECAUTIONS •
Pectoralis major can have a somatovisceral effect: a trigger point on the right side only at the medial, costal section
•
Elimination of the above mentioned trigger point may terminate episodes of cardiac arrhythmia, according to Travell and Simons
•
Due to the above two precautions, be sure to practice within your proper scope and refer the client to a doc tor (or emergency room if necessary) if they have not done so on their own
•
Care must be taken not to compress or invade in any way the breast tissue when examining or working on this muscle
/
U P P E R TO R S O
1 39
MASSAGE THERAPY CONSIDERATIONS •
A person may report intermittent chest pain, chest con striction, sleep d isorders, and/or breast tissue sensitivity
•
It may be wise to refer this person to a medical doctor to be sure there is no sign of heart disease
•
Trigger points in the sternal and costal sections have been noted to cause pain, swelling, and disruption of lymphatic drainage of the breast tissue. Treating these trigger points will usually bring rapid relief of swell ing and tenderness according to Travell and Simons
•
Pincer compression at the musculotendinous j unction is best used when the therapist kneels at the side to allow for good wrist and hand mechanics ( the wrist and hand will be on the same level plane as the muscle tissue this way)
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Pectoralis Minor: Neurovascular Entrapper When the pectoralis minor has trigger points, the taut fibers are likely to entrap the axi llary artery along with the bra chial plexus, which may mimic cervical radiculopathy.
TRIGGER POINT ACTIVATION
ORIGIN •
Anterior ribs 3 through 5 near the costal cartilage
I NSERTION •
Coracoid process
ACTION •
Protraction o f the scapula
•
Depression of the scapula
•
Downward rotation of the scapula
•
Assists forced inspiration
TRIGGER POINTS AND REFERRAL ZONES There are usually a couple o f trigger points found in the belly of the musc le. The strongest referral is to the anterior deltoid area. There may be spil lover to the entire chest (on the same side as the trigger point) and down the med ial aspect of the ent ire arm into the third through fifth fingers anteriorly. Accord ing to Travell and Simons, a trigger point on the left side may refer a sensation that mimics cardiac ischemia or angina, j ust as it can in the pectoralis major ( Fig. 6-4 1 ) . The maj or complaints will be similar to
•
FIGURE 6-41
those of pectoralis major. There may be difficulty in reach ing forward and up or in reaching backward at shoulder level.
As with the pectoralis major muscle, any posture that acti vates a trigger point and is not corrected may also perpetu ate it. These trigger points here may be activated as satellite trigger points because of their placement within the area of pain caused by myocardial ischemia, or as satellites of trigger points in the scalene or pectoralis major muscles.
STRESSORS AND PERPETUATING FACTORS •
A trauma such as broken ribs in the upper chest
•
A whiplash accident
•
Severe coughing
•
Use of crutches to walk
•
Prolonged compression with a tight strap by carrying a heavy knapsack
•
Collapsed chest, respiratory problems, or prolonged vigorous inspiration
•
Hyperkyphosis, poor sitting habits, poor chair design, muscle imbalances, poor posture in general
•
Prolonged position of an arm overhead when sleeping or painting a ceiling
Attachment sites and trigger points with referral zones for the pectora lis minor. (Reprinted with permission from Simons DG, Travell
JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore, MD: Lippi ncott Williams & Wilkins, 1 999. Travell & Simons'Myofas cial Pain and Dysfunction: The Trigger Point Manual; vol l . p. 845, Fig. 43.1 .)
CHAPTER 6
•
FIGURE 6·42
I
UPPER TORSO
1 41
Structures that may be entrapped by the pectora lis minor. (Reprinted with permission from Simons DG, Travel l JG, Simons LS. Upper
Half of 8ody. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins, 1 999. Travel! & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual; vol
1 . p. 850, Fig. 43.48.)
PRECAUTIONS •
The brachial plexus, axillary artery, and subc lavian vein all pass deep beneath this muscle
•
Pectoralis minor is a major player when it comes to distortion of posture of the upper body as it pulls the shoulder forward ( Fig. 6-42 )
•
This person may complain of numbing and tingling or other neurovascular symptoms due to entrapment of the neurovascular bundle
•
Symptoms will be similar to those of thoracic outlet syndrome
•
Another way to access this muscle is with the person in a side-lying position. This position allows the breast tissue and pectoralis major to shift medially, allowing pectoralis minor more superficial exposure
•
A thorough examinat ion of the upper 2 inches of the three tendons attaching to the coracoid process ( pectoralis m inor, coracobrachialis, and short head of b iceps brac h i i ) is necessary for all shoulder problems
MASSAGE THERAPY CONSIDERATIONS •
•
For comfort when working with a client in a supine position, slacken the muscle and be sure the direction of the friction stroke is perpendicular to the axis of the body This muscle is usually tender due to the slumping pos ture patterns existing in our society
1 42
PART I I
/
M U S C LE S A N D N E U R O M U S C U LA R THERAPY ROUTI N E S BY BODY REGION
Subclavius: Poor Posture and Heart Attack This muscle lies beneath the clavicle and over the first rib ( Fig. 6-43 ) .
ORIGIN •
J unction of the first rib with its costal cartilage
INSERTION •
Groove on the inferior surface of the clavicle
ACTION •
Assists protraction of the shoulder indirectly
•
Stabilization of the clavicle at the 1 st rib during move ments of the shoulder
•
Depresses the clavicle
TRIGGER POINTS AND REFERRAL ZONES A trigger p o i n t is likely to occur i n t h e m uscle belly a t t h e sternal e n d referring across t h e chest under t h e clavi cle, down the anterior upper arm and the lateral forearm, with spi llover going into the thumb and first two fingers on both the anterior and posterior sides ( Fig. 6-44 ) . A client with trigger points in this m uscle may complain of sensations similar to thoracic outlet or carpal tunnel syn dromes.
TRIGGER POINT ACTIVATION •
A c u t e or chron i c overload due asymmetry
to shoulder
STRESSORS AND PERPETUATING FACTORS •
Falling and catching oneself with outstretched arms
PRECAUTIONS •
•
Be sure there is no fracture to the clavicle before work ing on this muscle Chronic shortening of this muscle may cause or con tribute to the entrapment and symptoms of thoracic outlet syndrome
MASSAGE TH ERAPY CONSIDERATIONS •
B e sure t o stabilize the superior aspect o f the clavicle when pushing up into the inferior surface into the sub clavius muscle
•
FIGURE 6-43
Attachment sites for the subclavius, also shows
pectoralis minor. (Reprinted with permission from Life Art, Lippincott Williams & Wilkins.)
C H A PT E R 6
/
UPPER TORSO
A
• FIGURE 6-44 Trigger points and referral zones for the subclavius. (Reprinted with permission from Simons DG, Travell JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins, 1999. Trovell & Simons'Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1 . p. 823, Fig. 42.3.)
1 43
1 44
PA R T I I
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M U SC L E S A N D N E U R O M U S C U L A R TH ERAPY ROUTI N E S BY BODY REGION
Subscapularis:The Frozen Shoulder Muscle Trigger points in subscapularis are often the key to a frozen shoulder syndrome.
ORIGIN •
Subscapular fossa of the scapula ( anterior surface of the scapula)
INSERTION
•
Repeated forceful lifting overhead while using strong adduction (swinging a child overhead and then down again between the "swinger's" legs)
•
Sudden overload from the trauma of falling backward and catching oneself by reaching back
•
Dislocation of the shoulder joint
•
Fracture to the proximal humerus
•
Lesser tubercle of the humerus
•
Tearing of the shoulder joint capsule
•
Blends into the lower aspect of the joint capsule
•
Prolonged immobilization of the shoulder joint in the adducted and medially rotated position ( writing long hand in a slumped forward posture)
ACTION •
Rotator cuff function: stabilizes the head of the humerus into the glenoid fossa
•
Medial rotation of the humerus
•
Assists adduction of the humerus
TRIGGER POI NTS AND REFERRAL ZONES There will be trigger points in the muscle belly as well as the musculotendinous j unction. The strongest referral areas are the posterior glenohumeral joint region and the posterior wrist. There may be spillover referral sensation wrapping the entire wrist, across the scapula, to the middle deltoid, and down the medial aspect of the upper arm ( Fig. 6-4 5 ) . A person with trigger points i n this muscle may complain of progressively painful restriction of abduction and lateral rotation of his or her arm. This person will be unable to reach backward at shoulder height and, therefore, will not be able to throw a ball. There may be pain both at rest and upon motion, with inability to reach across to the opposite armpit.
TRIGGER POINT ACTIVATION •
•
Unusual repetitive exertion of forcefu l medial rotation (pitching a baseball or swimming the crawl stroke)
FIGURE 6-45
STRESSORS AND PERPETUATING FACTORS •
Repeated or chronic tendonitis
•
Reaching into the back seat of a car to lift a heavy object
•
Having to use the arm overhead for prolonged periods of time (sleeping wrong or painting a ceiling)
•
Forceful med ial rotation with the arm horizontally abducted (playing tennis or weight lifting)
PRECAUTIONS •
Compression techniques applied to the scapula poste riorly will affect thi muscle
MASSAGE THERAPY CONSIDERATIONS •
Chronic contraction of subscapularis may mimic fro zen shoulder syndrome ( adhesive capsulitis). Th is should always be checked in an individual diagnosed with "frozen shoulder"
•
Use the lesser tubercle as a bony landmark for locating the subscapularis tendon
•
Use a broad sweep to friction this tendon
•
The belly of subscapularis may be accessed directly through the axilla
Attachment sites and trigger points with referral zones for the subscapularis. (Reprinted with permission from Simons DG, Travell JG,
Simons LS. Upper Half of Body. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins, 1 999. Travel! & Simons'Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1 . p. 598, Fig. 26. 1 .)
C HAPTER 6
/
UPPER TORSO
1 45
U pper Torso N e u ro m u sc u l a r Thera py Routi ne You may use the fol lowing information in its enti rety o r choose
teres major a n d latiss i m u s dorsi to be s u re there is no com pen
portions of it when working with specific conditions and inju
satory issue there.
ries, such as those listed earlier in this chapter for the thera p i st
Note: U n less otherwise ind icated, the client should be in the
to consider. For i nstance, when worki n g with a rotator cuff
prone position, prefera bly u s i n g the face cradle, for this routine.
i nju ry, you would l i kely want to work with the trapezi u s fi rst
Wa rm and loosen the shoulder g i rd l e with com pression a n d
because it is su perficial to su praspinatus. Then, you can move
petrissage through t h e sheet. Note that t h e video icon i n dicates
on to work with the four rotator cuff m u scles and tendons. It
routines that a re featured in o n l i ne video cli ps, on the book's
would a lso be i m portant to work with the deltoid a nd, possibly,
compa nion Web site.
UPPER AND MIDDLE TRAPEZIUS
�
No l u brication is needed. Stand at the side of the table. 1. Perform skin rolling i n eight d i rections. Using a pi ncer palpa
tion of the skin over the trapezius muscle and infraspinatus, begin rolling the skin between the thumb and the fingers, as if examining it. The eight d i rections are s u perior, inferior, lat eral, medial, oblique from lateral to medial in a s u perior d irec tion, then inferior direction, and oblique from medial to lateral in both superior and inferior d i rections.
2. Perform pincer pal pation, holding the b u l k of the u pper tra
pezius, and then the middle trapezius, using d irect sustained compression. Be thorough with this, and then address the tight bands in the middle trapezius with friction.
3. Use fingertip and thumb "unro l l ing" of the u pper trapezius.
Work from medial to lateral (Routi ne 6- 1 ).
Note: It may help to place the client's arm overhead on the face cradle to inactivate the upper trapezius fibers.
Note: Apply a small amount of lubrication to the entire shoulder girdle. 4. Perform a gliding squeeze of the u pper trapezius from lateral
to medial. Use quite a bit of pressure and an equal squeeze between the thumb and the fingers.
Note: Move to the head of the table.
• ROUTINE 6-1
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5. Use lengthening, deep effleurage strokes with thumbs i n the
lamina groove toward the insertion at the acromion from the "crook of the neck area." Also, isolate insertions of the trapezius with friction at the spine of the scapula, acromion, and lateral clavicle. A pressure bar may also be used on these attachments.
Note: Within this sequence, address any trigger points as they become apparent, using direct trigger point work and appropri ate pressure.
SU PRASPINATUS
e
Stand at the head of the table. 1. Perform lengthening, deep effleurage t h u m b strokes from
the origin toward the insertion, or from medial to lateral, iso lating the tissue in the supraspinous fossa.
2. Isolate the muscle belly using transverse friction applied with
t h u mbs. Th is m ust be a very deep stroke, a s it m ust get through the upper trapeziu s to affect the supraspinatus.
3. Apply direct trigger point pressure to any tight fibers or trig
ger points found (Routine 6-2).
4. Use a pressure bar to work into supraspinatus as far laterally
as pOSSible, staying between the clavicle and the spine of the sca pula (Routine 6-3). The pressure bar's bevel should be horizontal.
• ROUTINE 6-2
• ROUTINE 6-3
CHAPTER 6
LEVATOR SCAPULA
�
Stand 'at the side of the table. 1 . Work the muscle belly from the crook of the neck area into the
neck just below the attach ment at C4 using lengtheni ng, deep effleurage t h u m b strokes, and transverse friction. Be thorough with this (Routine 6-4).
Note: Move to the head of the table. 2. Work the insertion on the vertebral border of the scapula,
beg i n n i ng at the root of the spine of the sca p u la moving superiorly, and then laterally around the superior ang le. Use a pressure bar if necessary.
• ROUTIN E 6-4
3. Work the anterior surface of the su perior angle of the scapula
by positioning the client's arm behind on the low back for access. L'sing thumbs, go in deeply enough to push through the trapezius, and then move anteriorly to get to the su perior angle. Return the arm to the table when done (Routine 6-5).
4. Using gentle friction and trigger point pressure, work the ori gins at the posterior transverse processes of C1 through C4. Be sure to friction the posterior aspect of the transverse proc esses, not the lateral aspect (Routine 6-6). • ROUTINE 6-5 5. Complete with forearm compression into the muscle belly of
levator scapula at the crook of the neck. Lean in with body weight to create a stretch, and then complete with a slow, deep effleurage along the vertebral border of the scapula.
• ROUTINE 6-6
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UPPER TORSO
1 47
1 48
PART I I
I
M U S C L E S A N D N E U R O M U S C U LA R T H E R A P Y R O UT I N E S BY B O DY R E G I O N
M I DDLE A N D LOWER TRAPEZI U S, RHOMBOIDS, SERRATUS POSTERIOR S U PERIOR, SPLEN I U S CAPITIS AND CERVIClS, AND UPPER PARASPI NALS
e
Stand at the side of the table. 1 . Warm the vertebral border of the scapula and the lower tra pezius, specifically from the a rea ofT1 2 to the su perior scapu lar angle of the scapula using lengthening, deep effleurage thumb strokes (Routine 6-7). This effectively warms several lay ers of the musculature by way of making the area hyperemic.
Note: Begin at the head of the table, changing positions as neces
• ROUTINE 6-7
sary. 2. Using the appropriate pressure to be effective with each layer
of muscle here, use muscle stripping with thumbs between the spinous processes and the scapula, following the direction of fibers of the above m uscles. Work from T1 to T1 2 going from s u perficial to deep in regard to each muscle's fiber direction.
3. Use the pressure bar on the lateral surface ofthe spinous proc
esses at a 45-deg ree angle from C7 to T1 2. Sweep from side to side and then scoop down toward the table (Routine 6-8).
4. Use tra nsverse and longitudinal friction thoroug hly on a l l portions, including origins and insertions, o f trapezius, rhom boids, and then the u pper erectors.
5 . Isolate serratus posterior superior at the spinous processes of
C7 to 13, using transverse friction and trigger point pressure where needed.
Note: Move to the head of the table. The client's hand should be on the low back with a small bolster under the head ofthe humerus. 6. Thumb strip from the spinous processes to as far u nder the
medial border of the scapula as possible, being specific to ser ratus posterior superior on the ribs.
7. Friction the attach ments u nder the medial border ofthe scap ula, on ribs 2 through 5.
Note: Move to the side of the table. The client's hand is on the low back, with the small bolster removed.
• ROUTI NE 6-8
CHAPTER 6
8. Isolate the lateral border of the lower trapezius at the midlevel
of the scapula using fi ngertip transverse friction (Routine 6-9). The lateral border of the muscle will be at an oblique angle running from the spine of the scapula downward and medi ally toward the spinous process of Tl 2. Grasp and compress (pincer compression), using both hands, and wait for the tis sue to change. Again, this will be at the midlevel of the scap ula. lf too slippery due to l ubrication, then use a tissue or the sheet to facilitate a better contact.
Note: Move to the side of the head of the table. The client's arm should be replaced on the table.
• ROUTINE 6-9
9. Perform a deep lengthening using the forearm to a pply slow
effleurage to the m iddle and lower trapezius, rhomboids, u pper paraspinals, serratus posterior su perior, and the splenii muscles from the crook of the neck area to Tl 2. Use one stroke straight down the erectors and a second stroke just med ial to the scapula (Routine 6- 1 0).
INFRASPINATUS
�
Use compression to warm the entire rotator cuff area. Stand at the side of the table. The client's arm should be hanging off the table. Lubricate. 1 . Begin by warming this m uscle with t h u m b stripping from
origin to insertion. Be sure to work on each bundle of this muscle in the appropriate direction.
• ROUTIN E 6-1 0
2. Perform deeper thumb strokes to the belly of infraspinatus to
begin to lengthen the fibers. Isolate any tight fibers using fric tion and then direct trigger point pressure.
Note: Move to the head of the table. 3. Apply transverse friction and muscle stripping using thumbs
over the surface of the scapula from insertion to origin this time (Routine 6-1 1 ). Work any trigger points found with direct trigger point pressu re. Trigger points are often found in the horizontal fibers of this m uscle.
Note: Move to the side of the table.
• ROUTIN E 6-1 1
UPPER TORSO
1 49
15 0
PA R T I I
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M U S C L E S A N D N E U RO M U S C U LA R THERAPY ROUTI N E S BY BODY R E G I O N
4. Use a pressure bar to isolate tight bands under the spine of the scapula. Go in at a 4S-degree angle for better access here (Routine 6-1 2).
TERES MINOR
e
Stand at the side of the table. The client's arm should be hanging off the side of the table. 1 . Warm this m uscle using thumbs g liding from the origin to the
insertion (toward the shoulder joint).
2. Isolate teres minor along the scapular axillary border using
- ROUTI N E 6-1 2
transverse and longitudinal friction. Friction here is best done with both thumbs pointed toward each other, so the thumb pads are against the lateral border ofthe scapula (Routine 6-1 3). This muscle will feel like a tight cord originating just a bit lower than the halfway point on the axillary border of the scapula, leading to its insertion at the posterior aspect of the greater tubercle of the humerus.
Note: Be very gentle here as this muscle may be very tight and sensitive.
3. Isolate any tight a reas or trigger points using d i rect trigger
point pressure.
- ROUTIN E 6-1 3
LATISSIMUS DORSI
e
Begin at the head of the table, changing positions as necessa ry. The client's arm should be hanging off the table. Lubricate. 1 . Warm the m uscle belly using an open palm for strokes in an
inferior direction working between the breast and the scapula (Routine 6- 1 4). Next, petrissage the muscle belly located over the latera I ri bs.
- ROUTIN E 6-14
CHAPTER 6
2. Isolate any tight bands fou n d in this m uscle with a pi ncer
gr.asp. Hold with steady pressure u ntil the tissue changes (Routine 6- 1 5).
3. Use palmar deep lengthening toward the origin at the crest.
Try passively stretching the muscle by pulling the client's arm toward the head while doing this palmar effleurage toward the iliac crest. Use you r outside hand to do the effle u rage (Routine 6- 1 6).
4. Using your outside forearm, perform broad forearm lengthen
ing from insertion to origin. Be gentle here as this is a su perfi cial m uscle directly over the ribs (Routine 6-1 7).
• ROUTINE 6-1 5
• ROUTINE 6-1 6
• ROUTIN E 6-1 7
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UPPER TORSO
1 51
1 52
PART I I
I
TERES MAJOR
M U SC L E S A N D N E U RO M U S C U LA R T H E RAPY ROUTI N E S BY BODY R E G I O N
e
Stand at the side of the table.The client's arm should be hanging off the side of the table. 1 . Identify the fibers of teres major originating on the scapula at the inferior angle at the posterior su rface. Once identified, use transverse friction to the m u scle belly (Routine 6-1 8).
2. Continue to friction, following the muscle off the axillary bor
der of the scapula, moving toward the insertion. Depending u pon its tone, it may become more difficult to palpate nearing the insertion.
- ROUTI N E 6-1 8
3. I solate now with a t h u m b/fi nger p i n cer compression by
reaching with both hands under and around the marg i n of latiss i m u s dorsi (Routine 6-1 9). Hold with steady pressure u ntil the tissue changes. You may also mobil ize using this pincer compression as the client mimics an active swimming motion with the arm. This last sentence is u nclear; please revise and cla rify your meaning.
SERRATUS ANTERIOR
e
Stand at the side of the table.The client's arm should be hanging off the table. 1 . Warm using palmar or fi ngertip friction between the axillary
- ROUTI N E 6-1 9
scapular border and the breast.
2. Isolate each individual slip of this m uscle against the ribs with
fi ngertip tra nsverse friction using the pads of the fi ngers (Routine 6-20). Work anterior to latissimus dorsi directly onto the ribs. Be gentle here; this may be extremely sensitive.
3. Elevate the inferior angle ofthe scapula by placing the client's
hand on the low back, and, with your inside hand, grasp the bundle of serratus anterior tendons between your thumb and fi ngers. This bundle of tendons will be under or "deep to" the inferior angle of the scapula. Hold with steady pressure, com pressing the tissue between thu mbs and fi ngers until the tis sue changes and becomes softer (Routine 6-2 1 ).
- ROUTI NE 6-20
C H A PT E R 6
4. From the axillary border, use fingers to work under the scap
ula,.accessing the superior portion of this muscle. Use friction and then steady pressure until the tissue changes.
DELTOIDS
e
Stand at the side of the table, changing position as necessary. Lubricate. 1. Position' the client's arm over the head on the face cradle to
access the entire deltoid. Warm the entire muscle using petris sage. Be thorough here, warming each of the three m uscle bund les well.
2. Use gliding thumb effleurage along the posterior deltoid
from the spine of the scapula toward the insertion. The poste rior deltoid passes across the shoulder joint to the deltoid tuberosity. Use gliding thumb effleurage on the middle and anterior bundles, from the origins to the insertion, as well.
• ROUTI N E 6-21
3. Using a pressure bar, work the origin of the posterior deltoid
along the inferior aspect of the spine of the scapula. Use the beveled head of the pressure bar perpendicularly and friction with it (Routine 6-22).
4. Still using a pressure bar, work the origi n of the middle and
anterior deltoid at the acromion and clavicle. Again, hold the bevel perpendicularly to friction these attachments against the bone.
5. Isolate all three deltoid bundles individually using petrissage.
Work any tight bands and trigger points found in the muscle using a pincer compression, transverse friction, and trigger point pressure. Take the time to do this work thorough ly.
Note: Stand at the client's elbow facing the shoulder; change posi tion as necessary. 6. Apply muscle stripping again, this time from the insertion to the origins of the entire muscle. Now friction the insertion at the deltoid tuberosity.
• ROUTI N E 6-22
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UPPER TORSO
15 3
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SIT TENDONS
M U S C L E S A N D N E U RO M U SC U LA R T H E R A P Y R O U T I N E S BY B O DY R E G I O N
�
Stand at the side of the table. The client's arm should be on the table at his or her side. 1 . Palpate and friction the tendons of the SIT muscles. First, locate the acromioclavicular joint, and then cross over to the head of the h umerus. You should be at the superior facet of the g reater t u bercle. This is the insertion for su praspinatus. Staying on the same axis as the body, move inferiorly approxi mately 1 inch to locate the insertion of infraspinatus. This will be directly beneath the spine of the scapula, but out on the g reater tu bercle. Friction th is. Again, move a pproximately
1 inch inferiorly, staying on the greater tubercle to find the teres minor insertion. Now friction (Routines 6-23 to 6-25).
• ROUTINE 6-23
Note: Have the client turn to a supine position on the table.
• ROUTIN E 6-24
• ROUTIN E 6-25
C H A PT E R 6
STERNALIS
e
Stand at the head of the table. The client should now be supine. 1 . Using the pads of you r fingertips, create a myofascial melting of sternalis; this may be done through the sheet if necessary (Routine 6-26). Beg in s u periorly and move slowly in a n inferior direction, a l l owing t h e tissue t o melt. This is done as a myofascial release.
Note: Stand at the side of the table, changing sides when necessary. 2. Still using the pads of the fingertips, perform deep transverse
friction to the entire sternum a rea. Again, this may be done through the sheet if necessary.
• ROUTI N E 6-26
PECTORALIS MAJOR AND THE INSERTIONS OF TERES MAJOR AND LATISSIMUS DORSI
C
Stand at the side of the table facing the client's head. The client should be supine. 1 . Warm and loosen using compression to the muscle belly,
along with passive movement of the upper arm at the shoul der joint.
Note: Lubricate.
2. Using the inside hand, thumb glide through the muscle belly
from origins on the clavicle and upper sternum toward the
• ROUTI NE 6-27
insertion on the bicipital groove (Routine 6-27).
3. Provide circu lar friction with fingertips to the origins a long
the clavicle, sternum, and ribs, as well as to the muscle belly. Isolate any tight fibers with transverse friction, and then use direct trigger point pressure. This may be done through the sheet when necessary.
4. With the arm externally rotated and at a 4S-degree angle, con tinue thumb g liding into the insertion along the tendon at the bicipital groove. Apply thumb transverse friction to the tendon. To do this, the deltoid must be pushed up and out of the way (Routine 6-28).
S. Move distally along the bicipital g roove approximately one
thumb width and friction the insertions of teres m,!jor and latissimus dorsi.
• ROUTI N E 6-28
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UPPER TORSO
1 SS
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M U S C L E S A N D N E U RO M U SC U LA R T H E R A P Y R O U T I N E S B Y B O DY R E G I O N
6. Isolate the pectoralis major muscle belly and musculotendi
nous ju nction by g rasping it between t h u m b and fi ngers. Hold with steady pressure to loosen tight fi bers. Using active movement of the a rm at the shoulder while holding the mus cle belly can be extremely effective to loosen or release tight ness. The client will make movements from the shoulder as if conducting an orchestra overhead (Routine 6-29).
7. End with more compression into the muscle below the clavi cle along with passive movement of the upper a rm at the shoulder joint.
PECTORALIS MINOR
e
Stand at the head of the table. The client's a rm should be at his or her side and supinated. 1 . Identify the fi bers of pectoralis minor by sinking throug h pec toralis major using fi ngertips. It can be isolated most easily at
• ROUTIN E 6-29
its tendon, approxi m ately 2 i nches d i rectly inferior to the coracoid process.
2. Begi n to gently apply transverse friction to the muscle bellies
a long with longitudi n a l friction (Routine 6-30). Take the time to be thorough, working from the i nsertion to the origins that are located d i rectly on ribs 3 throug h 5.
Note: Be sure to feel for the pectoralis minor fibers running in a line almost parallel to the vertical axis of the body. Fibers going in any other direction, horizontally as an example, will be pectoralis major fibers.
SUBCLAVIUS
e
• ROUTINE 6-30
Sit at the head of the table. 1. Support the clavicle at the superior aspect using the pad of
one thumb (Routine 6-3 1 ).
2. Apply transverse a n d longitudi n a l friction using the pad of
one fi nger of the other hand along the inferior aspect of the clavicle, working medial to lateral.
3 . Hold with trigger point pressure to inactivate any trigger
points found. • ROUTINE 6-31
C H A PT E R 6
SUBSCAPULARIS:TENDINOUS INSERTION
�
Stand at the side of the table. 1 . Locate the lesser tubercle with a finger of the outside hand.
Confirm the exact location by feeling it move upon medial and lateral rotation of the client's humerus. This can be either active or passive movement (Routine 6-32).
Note: The lesser tubercle is directly on the anterior surface of the head of the humerus when the humerus is in a neutral position (the client's arm is in a position with the lateral edge toward the ceiling for it to be in a neutral position). Another way to locate this tendon is to palpate half way between the long and the short heads of the biceps brachii tendons.
2. Move the thumb just medially Y2 inch to % inch to work the
tendon with transverse friction. This friction will be in a supe rior/inferior d i rection. Use a very broad sweep of approxi mately 1 inch to apply the friction. It will feel like a smooth, flat surface here. Be thorough with this work (Routine 6-33).
• ROUTINE 6-32
• ROUTI N E 6-33
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SU BSCAPULARIS: MUSCLE BELLY
e
Stand at the side of the table. 1. Holding the client's arm out to the side, use the outside hand's
fingertips to gently palpate the axillary border of the scapula. These seeming tight fibers found here are the latissimus dorsi and teres major. Do not apply pressure to the axil lary border of the scapula through these muscles/tendons, as it will be very sensitive (Routine 6-34).
2. Now place fingertips more medially into the a rmpit area and
leave in place, only applying very gentle pressure at this point. Lift the client's a rm up and medially into protraction across the chest (Routine 6-35).
3. Have the client support his or her a rm at the wrist with his or
her other hand. Now, use your other hand to reach under the client's body, grasp the medial border of the scapula, and pull it in a lateral direction. This will abduct the scapula and a llow
• ROUTI NE 6-34
further access into the subscapular fossa (Routine 6-36).
4. Begin to gently press into the subscapularis belly, accessing as much of the muscle belly as possible using steady pressure to apply myofascial melting.
5. Once softened, begin to gently use transverse and longitudi
nal friction to any tight fi bers. Hold with trigger point pressure to deactivate the trigger points found.
6. End with some shoulder and scapular mobilization using pas
• ROUTIN E 6-35
sive movement.
•
ROUTIN E 6-36
CHAPTER 6
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Case Study 6- 1 •
Bill: A Hockey Player With a Shoulder I njury
Background
eral years of this type of treatment, he began seeing a neu
Bill M is a 33-year-old , 6-ft, 21 O-Ib retired professional hockey
romuscular therapist.
player who had numerous shoulder injuries during his career.
Critical Thinking Questions
He suffered an injured left labrum, a tear in the long head of
1 . If you were Bill's neuromuscular therapist, what wou l d be
his biceps brachii, and multiple dislocations and separations, all in his right shoulder. He was left with very l ittle range of motion in this shoulder. He had many s u rgeries to regain
your primary goals for the therapy? 2. Which regions and m uscles would you work on?
range of motion, clean u p scar tissue, and manage pain. He
3. Which strokes would you use i n you r work and why?
also had physical therapy and general therapeutic massage
4. What special precautions would you take in working on
therapy following his surgeries, with mixed results. After sev-
his shoulder, given his history of injuries and s u rgeries?
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REVIEW QUESTIONS
Short Answer Questions 1.
What is the significance of working the lateral aspects of the spinous processes in the thoracic spine ? What is being worked on ?
2. N ame the three muscles that insert at the b ic ipital
groove of the humerus. 3. List the four muscles involved in downward rotation of
the scapula. 4. Which two muscles have attachments on the inferior
angle of the scapula? 5. Which part of the trapezius most commonly refers pain
to the head? Multiple Choice Questions
6. Which two muscles act in both flexion and horizontal
adduction of the shoulder? A. Pectoralis minor and upper trapezius B. Teres major and pectoralis major C. Pectoralis major and anterior deltoid D. Subclavius and pectoralis minor 7. Which muscle does Travell and Simons refer to as "the
1 0. Eliminating trigger points in which muscle may actu
ally terminate episodes of cardiac arrhythmia? A. Pectoralis minor B. Pectoralis major C. Anterior deltoid D. Subclavius True/False
1 1 . Scoliosis is a lateral curve i n the spinal column: either
a "c" - or an "s" -shaped curve. 1 2. Upper trapezius, levator scapulae, and serratus anterior
all contribute to elevating the shoulder. 1 3 . Pain medial to the vertebral border of the scapula could
indicate ischemia and trigger points in rhomboids, mid dle trapezius, and levator scapulae. 14. The lower attachments of serratus anterior interdigi
tate with the attachments of rectus abdominis. 1 5 . To palpate the trigger point in serratus posterior supe rior, the scapula must first be abducted. Matching
a. Spinalis
d. Iliocostalis
g. Teres major
smoker's muscle?"
b. Rotatores
e. Teres minor
h. Pectoralis major
A. Serratus anterior
c. Multifidi
f. Pectoralis minor
i. the SIT muscles
B. Pectoralis major C. Pectoralis minor
1 6. Which is the most medial of the erector spinae?
D. Trapezius
1 7. Which is the deepest of the deep paraspinal muscles?
8. What is the structure called that attaches latissimus dorsi to the spinous processes and sacru m ? A . Iliolumbar ligament B. Oblique fascia C. Palmar aponeurosis D. Thoracolumbar aponeurosis 9.
Which are the four muscles of the rotator cuff? A. Infraspinatus, teres major, supraspinatus, subscapu laris B. Deltoids, teres major, teres m inor, latissimus dorsi C. Supraspinatus, infraspinatus, teres m inor, subscapu laris D. Pectoralis maj or, pectoralis minor, teres m inor, sub scapularis
1 8. Which is a rotator cuff muscle? 1 9. Which muscle inserts at the bicipital groove of the
humerus ? 20. The greater tubercle of the humerus is the common
insertion of which muscles?
CHAPTER 6
REFERENCE 1 . Eisler P. Die Musckeln des Stammes. lena, Germany: Gustav Fischer Verlag; 1 9 1 2 :470-475; Figs. 70, n.
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ARM, WRIST, AND HAND �
KEYTERMS
N ote that common conditions encountered in this region
Epicondylitis: inflammation of either epicondyle of the
are included among the key terms.
humerus or surrounding tissues
Anomalous: exceptional o r abnormal; deviating from the
Fusiform muscle: a muscle that is spindle-shaped, with
normal rule
tapering at both ends
Aponeurotic tissue: tissue from an aponeuroses; a fibrous
Heberden's nodes: often identified with osteoarth ritis. The
sheet of connective tissue that serves to attach muscle to
node is an enlargement of soft tissue, sometimes partly
bone or other tissues
bony, on the dorsal surface of either side of the terminal
Bicipital tendonitis: inflam mation of the long head tendon of
phalanx at t he distal interphalangeal joint.
biceps brachii
Hypothenar eminence: the fleshy mound of muscle tissue that
Carpal tunnel syndrome: a condition that presents with pain
covers t he fifth m etacarpal distal to the medial carpals
in the wrist and hand and numbness of the t humb, index,
Main ray: referring to the middle finger or toe
middle, and ring fingers with atrophy and weakness of the
Musculotendinous junction: w h ere a muscle and tendon join
thenar muscles due to compression of t h e m edian nerve in the wrist
Congenital: existing prior to or at birth Dupuytren contracture: contracture of the pal mer aponeuro ses causing the ring and the little fingers to bend into the palm and not be extended
Electromyographic test (EMG): a test to record graphica l l y the contraction of a muscle using electric stimulation
Enigmatic: puzzling
together
Synergistic muscles: muscles that work together to perform specific movement
Thenar eminence: t he fleshy m ound of muscle tissue that covers the first metacarpal distal to the base of t he thumb
Thoracic outlet syndrome: a complex condition caused by condi tions in which nerves or vessels are compressed in the neck or axilla; also known as thoracic outlet compression syndrome
Trigger finger/trigger thumb: a state in w h ic h flexion or exten
Entrapment of either the ulnar or the median nerve: a press
sion of a digit is arrested temporarily but finally is completed
ing on either nerve within soft tissue causing radicular
with a jerk; usua l l y found when a sheathed tendon is within
symptom s
an inflamed sheath
OVERVIEW OF THE ARM, WRIST, AND HAND REGION In this chapter, we will concern ourselves with the mus cles of the arm and the hand region, beginning with the
upper arm, then moving on to the forearm and, finally, the hand. We will cover both the anterior and posterior por tions of the arm. As always, our goal here is to find all active, latent, and associated trigger points, and then deactivate them.
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Conditions one may encounter when working with this area of the body are usually caused by mechanical overload and repetitive strain injuries. Carefully consider each cli ent's medical history and also be aware of symptoms of potentially undiagnosed conditions. Although it is not the massage therapist's role to diagnose conditions, you should
learn to recognize possible symptoms of key conditions and refer your client to a primary care physician if you suspect a condition that falls outside of your scope of practice. You may also want to request that your client bring in a written diagnosis from his or her doctor if necessary.
UPPER ARM (BRACHIUM) The first portion of the arm presented will be the muscles of the upper arm. This area is also known as the "brachium."
Biceps Brachii: A Three-Joi nted Motor Biceps brachii is the most superficial muscle on the anterior humerus. It rarely has anatomical anomalies, which are exceptional or abnormal presentations. In less than 1 % of the population, there will be a third head attached at the coracoid process (Fig. 7-1). ORIGIN • Short head: coracoid process of the scapulae • Long head: supraglenoid tubercle of the scapulae with
its tendon lying in the intertubercular (bicipital) groove of the humerus INSERTION • Tuberosity of the radius
ACTION • Flexes the arm at the elbow vigorously when forearm is supinated • Assists abduction of the shoulder when arm is laterally
rotated • Strongly supinates forearm when elbow is flexed • Weakly assists flexion of the arm at the shoulder • Long head helps keep the head of the humerus in the
glenoid fossa when a heavy weight is carried in the hand • Short head assists horizontal adduction of the arm
TRIGGER POINTS AND REFERRAL ZONES Trigger points are usually found within each of the two bel lies of this muscle. Referral sensation will be most strongly felt in the long head tendon and at the insertion. There may be some spillover activity between those two points, as well as across the superior border of the scapulae (Fig. 7-2). A person with these trigger points will typically com plain of superficial anterior shoulder pain, not deep pain in the shoulder joint. They will usually experience this when
• FIGURE 7-1 Attachment sites for the biceps brachii. Short head: cora coid process of the scapulae. Long head: supraglenoid tubercle of the scapulae with its tendon lying in the intertubercular (bicipital) groove of the humerus. Both heads: radial tuberosity. (Reprinted with permis sion from LifeArt, Lippincott Williams & Wilkins.)
C H A PT E R 7 I A R M , W R I S T , A N D H A N D
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j�C
1 65
TRIGGER POINT ACTIVATION Overstress of this muscle is what usually leads to setting up trigger points here. Satellites can develop from key trigger points in the infraspinatus. Travell and Simons cited a study 1 of biceps brachii trigger points being activated by position ing the supine person in a way that held the biceps in the stretched position during a prolonged period of time. The trigger points were inactivated by deep massage and passive stretching to relieve the person of this enigmatic, or puz zling, pain. STRESSORS AND PERPETUATING FACTORS • Performing a strong backhand tennis or racquetball stroke, executed with the elbow straight and forearm supinated in the attempt to put a top-spin on the ball • Unaccustomed vigorous repeated supination (using a
screwdriver, turning stiff doorknobs, etc.) • Lifting heavy objects with the hand/arm supinated • FIGURE 7-2 Trigger points and referral zones for the biceps brachii. The trigger points will usually set into the muscle belly closer to its insertion with strong referral to site of i nsertion as well as into the long tendons of the origins.There could be spillover between these two points. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
raising the arm above the shoulder level upon flexion and abduction. They may experience diffuse aching and tender ness and inflammation over the long head bicipital tendon, a condition known as bicipital tendonitis. If this person presents with a sudden painful catch in the shoulder when abducting the arm, refer him or her to a doc tor to have the long head tendon checked to be sure it is not being pinched between the acromion and the glenoid labrum. This condition must be dealt with surgically.
• Sustained elbow flexion overload (playing the violin or
guitar, using electric hedge clippers, etc.) PRECAUTIONS • Begin work on the long head tendon gently, as it can be quite tender. MASSAGE THERAPY CONSI D ERATIONS • A good position for working the long head tendon is with your hand above the client's shoulder, with your thumb positioned to apply long strokes downward from proximal to distal through the intertubercular groove. • The tendon of the long head can become misplaced,
out of the intertubercular groove; if this occurs, it will be quite sore. • Remember to have the entire arm supinated to be able
to work on the entire muscle.
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Coracobrachia l is: H ide a nd Go Seek Locating trigger points in this muscle requires more skill than with most muscles due to their mainly being satellites from the anterior deltoid, the short head of biceps brachii, and the long head of triceps brachii. ORIGIN • The apex of the coracoid process of the scapulae (the tendon blends with the short head tendon of biceps brachii there) INSERTION • Medial surface of the humerus at the midpoint of the shaft ACTION • Flexion and adduction of the arm at the glenohumeral joint • Weak assistance in returning the arm to neutral from
lateral and medial rotation TRIGGER POINTS AND REFE RRAL ZONES Trigger points are usually found in the proximal muscle belly just below the musculotenclonus junction of its origin but can be as far distal as the middle of the muscle belly. A musculoten clonus junction is where a muscle and tendon join together. Sensation is referred over the anterior deltoid region and inferiorly down the posterior aspect of the arm, con centrating over the triceps brachii, the dorsum of the fore arm, and the dorsum of the hand. It usually skips the elbow and wrist regions. When these trigger points are most active, the referral sensation is greater or more intense.
Chances are that this feeling will even persist when at rest, as well (Fig. 7-3). The primary complaint of clients with trigger points in this region is typically upper limb pain, usually in the front of the shoulder and posterior arm. They often describe the pain as occurring when they are reaching behind the body and across the low back. This movement stresses this muscle because it involves strong medial rotation along with extension. TRIGGER POINT ACTIVATION These trigger points usually develop secondarily to active trigger points in related, synergetic muscles: the short head of biceps brachii and pectoralis major. Synergistic muscles are muscles that work together to perform specific movement. STRESSORS AND PERPETUATING FACTORS • Trigger points in its synergistic muscles • Keeping the arm in adduction, as when having to wear
a sling PRECAUTIONS • Positive isolation or identification is important before working here due to nerve and lymphatic tissue in this area MASSAGE THERAPY CONSIDERATIONS • If trigger points are suspected here after relieving those found in synergistic muscles, have the person perform a back rub test to confirm by placing the posterior wrist at the small of the back and rubbing it across to the opposite side
• FIGURE 7-3 Anatomical attachment sites and trigger points with referrals for coracobrachialis. (Reprinted with permission from Simons DG, Travell JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins, 1999. Trave" & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1 . p. 639, Fig. 29.1 .)
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1 67
Brachia l is: Workhorse E l bow Flexor This muscle is interesting as its main referral area is quite distant from the trigger point (Fig. 7-4). ORIGIN • Distal half of the anterior shaft of the humerus INSERTION • Coronoid process at the proximal end of the ulna run ning deep to the biceps brachii insertion on the radius ACTION • Flexion of the elbow TRIGGER POINTS AND REF ERRA L ZONES The trigger points are usually found within the muscle belly, along with tight bands in the mid-muscle area. The main referral area is quite distal to the trigger points, strongly wrapping the base of the thumb. There may be some spillover sensation to the anterior upper arm and ante rior elbow areas as well. TRIGGER POINT ACTIVATION Activating these trigger points is usually from stress overload during heavy lifting. Often these trigger points set in after activation of trigger points in the biceps brachii and supinator, especially if the person has ep i condylitis. Epicondylitis is inflammation of either epi condyle of the humerus and surrounding tissues (Fig. 7 - 5 ) .
STRESSORS AND PERPETUATING FACTORS • Using a power tool for long periods of time • Carrying groceries • Ironing clothing often • Fingering the strings of a guitar or a violin • Radial nerve entrapment at the lateral border of the
muscle • Having arm in a sling or taped to the side of the body
for long periods of time
• FIGURE 7-4 Attachment sites for the brachialis.The distal half of the anterior shaft of the humerus, coronoid process of the ulna. ( Reprinted with permission from Life Art, Lippincott Williams & Wilkins.)
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PRECAUTIONS • Be sure to stay away from the median nerve located deep to the muscle on the medial side of the arm • If there is radial nerve entrapment taking place, the
person will most likely be experiencing numbness to the dorsum of the thumb and its web area. A trigger point can actually cause this entrapment here MASSAGE THERAPY CONS I D ERATIONS • T he lateral border is usually more tender and develops more trigger points than the medial border • Pincer compression is an effective technique for releas
ing tension in the muscle belly • Referral sensation at the base of the thumb is felt at
rest as well as with the use of the thumb • Brachialis is the strongest of the elbow flexors, the
workhorse, so it is usually quite tender
• FIGURE 7-5 Trigger points and referral zones for the brachialis.The trig ger points will set in anywhere within the muscle belly sending strong referral to the base of the thumb, both anterior and posterior, with spill over at the insertion point and into the anterior upper arm. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
C H A PT E R 7
_
A R M , W R I S T, A N D H A N D
1 69
Triceps Brach i i : Three-Headed Monster
Trigger points in this muscle are commonly overlooked. They can cause quite a bit of dysfunction (Fig. 7-6). ORIGIN • Long head: infraglenoid tubercle of scapulae • Medial head: posterior humerus, medial and distal to
the radial nerve lying in the spiral groove • Lateral head: posterior humerus, lateral and proximal
to the radial nerve lying in the spiral groove INSERTION • Common tendon at the olecranon process of the ulna ACTION • All portions extend the forearm at the elbow joint; the medial head is providing the majority of this action, however • The long head adducts and, to a certain degree, extends
the arm at the shoulder joint TRIGGER POINTS AND REF ERRAL ZONES Each head has its own very definite trigger points and refer ral areas. Most trigger points are usually found within the muscle bellies. There is often one in the tendon proximal to the olecranon, as well. The long head trigger points refer strongly to the lateral side of the upper scapular area and posterior deltoid as well as to the lateral elbow region. There may be spillover sensa tion from the angle of the neck and the shoulder running all the way down the posterior arm to the wrist. The medial head usually has two trigger point areas that refer strongly to the lateral and the anteromedial elbow with spillover above and below these two points and possibly into the anterior surface of the mo t medial two fingers. The lateral head's trigger point usually strongly refers right around itself, but could have spillover around the strong referral area, into the posterior forearm and the pos terior surface of the most medial two fingers. The common tendon will also have a trigger point within it that refers very strongly into the posterior elbow (Figs. 7-7 to 7-9 ). A client with trigger points in this muscle will probably complain of vague, hard-to-Iocalize pain in the posterior shoulder and upper arm. The client will likely not demon strate restriction of movement due to compensation by keeping the elbow slightly bent. You may observe the client holding the elbow away from the side, avoiding body con tact due to a very sensitive medial epicondyle.
• FIGURE 7-6 Attachment sites for the triceps brachii. Long head: infra glenoid tubercle of the scapulae. Lateral head: posterior humerus above the spiral groove. Medial head: posterior humerus below the spiral groove. All heads: olecranon process of the ulna. (Reprinted with permission from Life Art, Lippincott Williams & Wilkins.)
The client will likely describe pain more upon forceful extension at the elbow, such as when playing a racquet sport or golf. Chances are that if left without seeking treatment, this client will develop serious epicondylitis either medially or laterally. TRIGGER POINT ACTIVATION Trigger points in this muscle are likely to occur as a result of overload from overuse. STRESSORS AND PER PETUATING FACTO RS • Using crutches or a cane that is too long • Having the anatomical variation of a short humerus • Straining the muscle during sports • Doing too many push-ups
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• FIGURE 7-7 Trigger points and referral zones for the triceps brachii, numbers 1 and 2. N u mber 1 trigger point is in the muscle belly of the long head with strong referral to the posterior deltoid and lateral condyle of the humerus. There could be spillover from the base of the neck, across the shoulder, down the posterior upper arm and forearm as well. N u mber 2 trigger point will set up in the lower belly of the medial head and refer strongly to the lateral condyle of the humerus with a bit of spillover down the lateral posterior forearm. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
\) • �
• FIGURE 7-8 Trigger points and referral zones for the triceps brachii, numbers 3 and 4. Number 3 trigger point sets up within the upper por tion of the muscle belly of the medial head with strong referral around itself. Spillover may surround the strong referral; go down the posterior forearm and into the posterior side of the ring and pinky finger. Number 4 trigger point sets up within the long, dense tendon above the insertion and refers strongly into the olecranon process. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
• Driving a car with manual transmission in heavy traffic
and having to shift constantly • Doing fine needle work without having any elbow support • Muscular strain from sports such as golf and tennis, espe
cially when using poor form to swing the racquet or club • Prolonged elbow extension without the use of elbow
support • Overhead push-ups and bench pres es
PRECAUTIONS • When working on this muscle, be sure you are on the muscle, not on the lateral humerus between the triceps and biceps brachii muscles • This is a relatively large muscle and the only one on the
posterior humerus, so be thorough in your work here MASSAGE THERA PY CONSIDERATIONS • The ideal client position for work on this muscle is prone with the elbow flexed at the side of the table • With chronic rotator cuff problems, the long head of tri
ceps should be checked at its attachment to the scapulae • Trigger points in this muscle are often overlooked • Trigger points here increase muscular tension and
cause dysfunction as well as pain
• FIGURE 7-9 Trigger points and referral zones for the triceps brachii, number 5.This is a tricky trigger point that sets into the musclf� belly on the anterior surface of the medial head. It has strong referral just below the actual trigger point on the anterior surface of the humerus with spillover down the anterior forearm and into the anterior side of the ring and pinky fingers. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
C H A PT E R 7
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171
FOREARM This area includes both the anterior and the posterior sides, with the flexor and extensor muscles along with supinator and pronator muscles.
Brachiora d i a l i s: Painfu l Weak Grip This muscle will most likely develop trigger points in association with the radial hand extensor muscles {Fig. 7 - 1 0 ). ORIGIN • Supracondylar ridge of the humerus INSERTION • Styloid process of the radius ACTION There is often confusion about the function of the brachio radialis. At one point, it was named supinator longus because it was thought that its primary action was supination of the forearm. Travell and Simons discuss a researcher named Duchenne whose stud/ clearly demonstrated that the bra chioradialis is most involved in elbow flexion as its action. He also showed that this muscle brings the forearm to a neu tral position from either supination or pronation. According to most anatomists, brachioradialis acts more as a pronator than a supinator. • Elbow flexion (acts as a strong assistant) • Brings forearm back to neutral from either pronation
or supination (acts as a weak assistant to all other fore arm movements) TRIGGER POINTS AND REF ERRAL ZONES Mostly, trigger points set up within the belly of the muscle, generally distal to the elbow. The referrals are strongly felt at the lateral epicondyle and base of the thumb at the web space. There may be spillover sensation along the length of the muscle, as well (Fig. 7- 1 1 ). Symptoms of these trigger points will always be consist ent with symptoms of the radial extensor muscles. A person with these trigger points will likely complain of dysfunction such as limited movement and/or weakness as well as pain. Pain will most likely be the major complaint. TRIGGER POINT ACTIVATION Mainly, these trigger points are activated by repetitive and forceful hand gripping. The larger the object is to be grasped, the more the likelihood of mechanical overload due to greater ulnar deviation of the hand.
• FIGURE 7-'0 Attachment sites for the brachioradialis. Lateral supra condylar ridge of the humerus, styloid process of the radius. (Reprinted with permission from Life Art, Lippincott Williams & Wilkins.)
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STRESSORS AND PERPETUATING FACTORS • Abuse of combining gripping and twisting motions, as when playing racquet sports • Grasping large objects often
PRECAUTIONS • Be sure when pincer grasping this muscle that your pressure is mainly on this rather than on extensor carpi radialis longus and brevis, both of which are deep to brachioradialis • To work with this muscle thoroughly, be sure your fric
tion begins proximally on the supracondylar ridge of the humerus MASSAGE THE RAPY CONSIDERATIONS • This is one of the several muscles involved in tennis elbow/epicondylitis • Brachioradialis is smaller than the extensor carpi radi
alis longus. It is a thin muscle that lies immediately over extensor carpi radialis longus, and it is usually dif ficult to distinguish which of these muscles is referring sensation from a trigger point
• FIGURE 7-11 Trigger points and referral zones for the brachioradialis. Trigger points will set up within the muscle belly, usually just below the elbow, sending strong referral to the lateral condyle of the humerus and into the web of the thumb with spillover down the lateral radius. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
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173
Supinator:Tennis E l bow Tennis elbow is actually lateral epicondylitis. This condi tion usually begins with trigger points in the supinator along with the extensor group. This muscle used to be called supi nator brevis when anatomists were still calling brachioradi alis the supinator longus (Figs. 7- 1 2 and 7- 1 3 ) . ORIGIN • Dorsal surface of the ulna • Lateral and ventral ligaments of the radioulnar joint • Anterior capsule of the humeroulnar joint
INSERTION • Proximal one-third of the radius, wrapping it from lat eral to medial then attaching ACTION • Supination of the forearm TRIGGER POINTS AND REFERRAL ZONES Always within the belly of the muscle, trigger points usually set in on the anterior surface above the radius. The referral pattern has very little spillover. There is usually very strong sensation at the lateral epicondyle of the humerus on both the anterior and posterior surfaces as well as into the base of the thumb and the index finger at the web space (Fig. 7- 1 4 ).
• FIGURE 7-12 Attachment sites for t h e supinator: anterior view. Proximal one-third of the radius, wrapping it from lateral to medial then attaching. This is the insertion. (Reprinted with permission from Life Art, Lippincott Williams & Wilkins.)
• FIGURE 7-13 Attachment sites for the supinator: posterior view. Dorsal surface of the ulna, lateral and ventral ligaments of the radioul nar joint, anterior capsule of the humeroulnar joint. These are all ori gins. (Reprinted with permission from Life Art, Lippincott Williams & Wilkins.)
• FIGURE 7-14 Trigger points and referral zones for the supinator. Trigger points in the muscle belly usually set in on the posterolateral edge of the radius with very strong referrals to the lateral epicondyle on both the anterior and posterior sides as well as to the posterior web and thumb. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
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A client with active trigger points here will often complain of having aching pain in either, or both, the lateral epicondyle and the dorsal surface of the web of the thumb. This pain will probably be experienced when the elbow is at rest after using it. Travell and Simons state that it is their experience that nearly every person with lateral epicondylar pain and tender ness has an active trigger point in the supinator, and this most often contributes to the pain of tennis elbow.
hand repeatedly throughout the day. Also, trigger points could be activated simply by carrying a heavy briefcase or suitcase with the elbow straight because the supinator must constantly be stabilizing. STRESSORS AND PERPETUATING FACTORS • Stress overload (as discussed above) • Opening tight jars or using a screwdriver by only using
the wrist TRIGGER POINT ACTIVATION Trigger points will set in and become active when a racquet sports player mis-hits the ball off center, twisting the racquet while the elbow is completely extended; usually this occurs with a backhand stroke. The supinator is being strained with this activity because of full elbow extension. When this is the case, the biceps brachii cannot assist to resist the added force. Activation of trigger points here could also be from resisting unexpected pronation or by executing an extremely forceful supination. Travel1 and Simons also use terms such as briefcase elbow, door-handle elbow, and dog walker's elbow. These names refer to any excessive or forceful, repetitive, or sustained supination of the forearm, especially when the elbow is straight. Also, it could be forceful elbow flexion when the forearm is held in pronation. Briefcase elbow occurs by the briefcase being flipped onto the desktop by the carrying
• Turning stiff doorknobs • Wringing wet clothes when doing laundry • Meticulous ironing • Walking a large dog that pulls on the leash • Handshaking long lines of people • Raking leaves or washing walls
PRECAUTIONS • There may be entrapment of the radial nerve which, in turn, may activate trigger points MASSAGE THERAPY CONSIDERATIONS • Access to this muscle works best when the client's elbow is flexed with the forearm held in a neutral position • It will be important to soften brachioradialis and
extensor carpi radialis longus before working with the supinator
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Extensor Group: Painful Weak Grip
This muscle's nickname, "painful weak grip," also applies to the brachioradialis muscle.
Extensor Carpi Radialis Lon g u s This muscle has a very long tendon that makes u p two thirds of its entire length (Fig. 7-15 ) . Travell and Simons mention that this muscle often has anatomical variations. They cite a studyl in which, of 375 upper limbs that were studied, 30% had variations. These were mainly the number and arrangement of tendinous attachments to the metacar pal bones. A few extensor carpi radialis longus and brevis muscles were actually fused together, as well. ORIGIN • Distal third of the lateral supracondylar ridge of the humerus INSERTION • Base of the second metacarpal on the posterior surface ACTION • Wrist and finger extension • Radial flexion of the wrist (also called wrist abduction
or radial deviation) TRIGG ER POINTS AND REFERRAL ZONES The trigger points of this muscle usually set up in the muscle belly very near the elbow. The referral sensation is often strongly felt around the trigger point, with some spillover sensation down the back of the arm, but more so on the posterior surface of the hand, radial side (Fig. 7 - 1 6) . Symptoms reported by clients are nearly identical to those of brachioradialis. It is difficult to delineate which symptoms are caused by which muscle. Mainly, the com plaints are of dysfunction in the form of weakness and pain. Pain is probably the major complaint. TRIGGER POINT ACTIVATION Trigger points are most often activated in this muscle by forceful, repetitive hand gripping. The larger the object being grasped is, the more likely this muscle is to develop trigger points, just as with brachioradialis.
• FIGURE 7-15 Attachment sites for the extensor carpi radialis longus. Base of the 2nd metacarpal on the posterior surface, distal third of the lateral supracondylar ridge of the humerus. (Reprinted with permission from Life Art, Lippincott Williams & Wilkins.)
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STRESSORS AND PERPETUATING FACTO RS • Repetitive forceful hand gripping with extension of the elbow • Grasping large objects for long periods of time • Gardening with a trowel • Throwing a Frisbee • Faulty biomechanics, that is, not maintaining a neutral
position of the wrist
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PRECAUTIONS • Due to confusion between carpal tunnel syndrome and referred pain from trigger points in the hand extensor muscles, you may want to tread gently here, as the cli ent could have both conditions MASSAG E TH ERAPY CONS I D ERATIONS • Tendonitis of the extensor origin is called "tennis elbow" • Trigger points here can produce dysfunction in the
form of limited movement and/or weakness, as well as pain • Trigger points in the scalene and supraspinatus muscles
can induce satellite trigger points in this muscle
• FIGURE 7-16 Trigger points and referral zones for the extensor carpi radialis longus.The trigger point will set up within the muscle belly and strongly refer around itself.There may be quite a bit of spillover in the posterior hand with a bit surrounding the strong referral and then down the posterior forearm. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
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Carpi Rad i a l i s Brevis
Occasionally, this muscle has the anatomical variation of being fused to the extensor carpi radialis longus (Fig. 7-17). ORIGIN • Lateral epicondyle of the humerus via the common extensor tendon deep to extensor carpi radialis longus muscle belly INSERTION • Base of the third metacarpal on the posterior surface ACTION • Wrist and finger extension • Radial flexion of the wrist (also called wrist abduction
or rad ial deviation) TRIGGER POINTS AND REF ERRAL ZONES The trigger points in this muscle are mostly found at the midpoint within the muscle belly. They may be overlooked, as the referral sensation is experienced as strong pain in the back of the wrist with some spillover sensation around the primary zone of referral (Fig. 7-18). Symptoms of these trigger points reported by clients are nearly identical to those of brachioradialis. It is diffi cult to delineate which symptoms are caused by which muscle. Mainly, the complaints are of dysfunction in the form of weakness and pain. Pain is probably the major complaint. TRIGGER POINT ACTIVATION Trigger points in this muscle are primarily activated by forceful, repetitive hand gripping. The larger the object being grasped is, the more likely this muscle is to develop trigger points, just as with brachioradialis.
• FIGURE 7-17 Attachment sites for the extensor carpi radialis brevis.
Base of the 3rd metacarpal on the posterior surface, lateral epi condyle of the humerus via the common extensor tendon deep to extensor carpi radialis longus muscle belly. (Reprinted with permis sion from Life Art, Lippincott Williams & Wilkins.)
STRESSORS AND PERPETUATING FACTORS • Repetitive forceful hand gripping with extension of the elbow •
Grasping large objects for long periods of time
•
Gardening with a trowel
•
Throwing a Frisbee
•
Faulty biomechanics, that is, not maintaining a neutral position of the wrist
PRECAUTIONS • Portions of the radial nerve may be entrapped by this muscle MASSAGE THERAPY CONSIDERATIONS • This is the most common muscle involved in the con dition of tennis elbow
• FIGURE 7-18 Trigger points and referral zones for the extensor carpi
radialis brevis. While the trigger points will usually be found within the muscle belly, there will be strong referral to the posterior surface of the hand with spillover around it. (Reprinted with permiSSion from Medi Clip, Lippincott Williams & Wilkins.)
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I M USCLES A N D N E U ROMUSCULAR T H E RAPY ROUTINES BY BODY REGION
Exten sor Dig itorum T he tendons of this muscle are united at the back of the hand by highly variable oblique bands that limit independ ent movement (Fig. 7- 1 9 ) . ORIGIN • Lateral epicondyle of the humerus via the common extensor tendon INSERTION • Dorsal surface of the distal phalanx of fingers nos. 2-5 ACTION • Extension of all phalanges (especially the proximal phalanges) of fingers nos. 2-5 •
Extension of the hand at the wrist
• Assists abduction of the index, ring, and little fingers
away from the middle finger (the middle finger is also called "the main ray") • During gripping this muscle acts in conjunction with
the lumbricals and interossei of the hand TRIGGER POINTS AND R E F ERRAL ZONES Trigger points for this muscle are usually be found in the upper muscle belly. They can be medial and/or lateral. The referral sensation is typically felt strongly in the upper por tion of the middle and ring fingers as well as in the lateral epicondyle of the humerus. There may be some spillover to the anterolateral wrist area as well as between the actual trigger points and the middle and ring fingers (Figs. 7-20 and 7-21). A client with trigger points in this muscle will most likely complain of either pain like that of tennis elbow or of feel ing arthritis in the fingers. TRIGGER POINT ACTIVATION Overuse of forceful repetitive finger movements by musi cians (mostly pianists), carpenters, or mechanics com monly activates trigger points in this muscle. Travell and Simons report having seen activation by a fracture of the forearm.
• FIGURE 7-1 9 Attachment sites for the extensor digitorum. Dorsal
surface of the distal phalanx of fingers no. 2-5, lateral epicondyle of the humerus via the common extensor tendon. (Reprinted with per mission from Life Art, Lippincott Williams & Wilkins.)
STRESSORS AND PERPETUATING FACTORS • Repetitive forceful hand gripping •
Playing the piano for long periods of time
•
Throwing a Frisbee
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• FIGURE 7-20 Trigger points and referral zones for the extensor digitorum--middle fi nger. The trigger point is usually in the upper muscle belly with very strong referral to the middle finger on the pos terior surface with spillover between the actual trigger point and the strong referral. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
• FIGURE 7-21 Trigger points and referral zones for the extensor digitorum-ring finger. Again the trigger point is in the u pper mus cle belly with strong referral to the ring finger. There may also be strong referral to the posterolateral el bow area with spillover between the two strong referrals. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
PRECAUTIONS • It is possible for a tendon to lose its mooring over the metacarpophalangeal joint. This displacement must be repaired surgically
MASSAG E THERAPY CONS I DERATIONS • Travell and Simons cite a study done by Hong4 that indicates key trigger points in either the scalenes or the serratus posterior superior could induce satellite trigger points in the extensor digitorum
•
If a client sleeps with his hands and fingers fully flexed, this muscle will be overstretched. According to Travell and Simons, this encourages the development of a car pal tunnel syndrome
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Exten sor Carpi U ln a ri s According to Travell and Simons, there are fewer trigger points found here than in the other extensor carpi muscles (Fig. 7-2 2 ). ORIGIN • Lateral epicondyle via the common extensor tendon I N S ERTION • Base of the fifth metacarpal on the medial surface ACTION • Wrist and finger extension •
Ulnar flexion (also called ulnar deviation or wrist adduction )
TRIGGER POI NTS A N D REF ERRAL ZON E S Usually, trigger points i n this muscle are found in the belly of the muscle at about the halfway point. Referral sensation is fclt strongly on the posterior surface of the medial wrist area (Fig. 7- 2 3 ). Symptoms reported by clients are nearly identical to those of brachioradialis. It is difficult to delineate which symptoms arc caused by which muscle. Mainly, the com plaints are of dysfunction in the form of weakness and pain. Pain is probably the major complaint. TRIGGER POINT ACTIVATION Mostly, trigger points in this muscle are activated by force ful, repetitive hand gripping. The larger the object being grasped is, the more likely this muscle is to develop trigger points, just as with brachioradialis.
• FIGURE 7-22 Attachment sites for the extensor carpi ulnaris. Base of
the 5th metacarpal on the medial surface, lateral epicondyle via the common extensor tendon. (Reprinted with permission from Life Art, Lippincott Williams & Wilkins.)
STRESSORS A N D PERPETUATING FACTORS • Repetitive forceful hand gripping with extension of the elbow •
Grasping large objects for long periods of time
•
Gardening with a trowel
•
Throwing a Frisbee
•
Faulty biomechanics, that is, not maintaining a neutral position of the wrist
PRECAUTIO N S • Arthritic wrist pain may b e aggravated b y referred myofascial pain from this and other extensor mus cles MASSAGE THE RA PY CON S I D E RATIONS • This muscle, together with the flexor carpi ulnaris muscle, strongly adducts the wrist
'
• FIGURE 7-23 Trigger points and referral zones for the extensor carpi
ulnaris. This trigger point is usually within the muscle belly and has a strong referral to the posterolateral wrist area with a bit of spillover surrounding. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
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Anconeus: The Little H e l per This muscle has been observed electromyographically to be activated by all index finger movements and to contrib ute to stabilization of the humeroulnar joint. Other elec tromyographic tests of anconeus show that it works together with supinator and the triceps brachii medial head to stabilize the elbow joint during pronation and supination of the forearm. An electromyographic test records graphically the contraction of a muscle using elec tric stimulation. Muscle fibers of anconeus appear to be an extension of the triceps brachii medial head. Travell and Simons refer to this muscle as the "little helper," as it assists the triceps (Fig. 7-24 ) . ORIGIN • Lateral epicondyle of the humerus I NSERTION • Lateral side of the olecranon process •
Dorsal shaft of the ulna
ACTION • Elbow extension (assists triceps brachii) TRIGGER POINTS AND REFERRAL ZON ES Trigger points in this muscle are usually located in the mus cle belly close to the insertion at the ulna. The referral sen sation will usually be to the lateral epicondyle of the humerus (Fig. 7-2 5 ) . A client with trigger points in this muscle will most likely complain of pain in the elbow, especially when playing a racquet sport. TRIGGER POINT ACTIVATION Trigger points may be activated in this muscle because of overload from overuse.
• FIGURE 7-24 Attachment sites for the anconeus. Dorsal shaft of the
ulna, lateral side of the olecranon process, lateral epicondyle of the humerus. (Reprinted with permission from Life Art, Lippincott Williams & Wi lkins.)
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STRESSORS AND PERPETUATING FACTORS • Use of crutches or a cane that is too long •
Having the anatomical variation of a short humerus
•
Straining the muscle during sports
•
Doing too many push-ups
•
Driving a car with manual transmission in heavy traffic and having to shift constantly
•
Doing fine needlework without having any elbow support
• FIGURE 7-25 Trigger points and referral zones for the anconeus. The
trigger point is within the muscle belly usually just inferior to the ole cranon with a strong referral to the lateral epicondyle. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
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Vigorous repetitive extension of the elbow, usually accompanied by a sudden impact or vibration, for example, using a heavy hammer or operating motor ized equipment with the arm extended and held in front of the chest
PRECAUTI ONS • According to Travell and Simons, this anomalous exceptional or abnormal-muscle has been reported to be the cause of ulnar compression neuropathy
MASSAGE THERAPY CONSIDERATIONS • This muscle can be extremely tender and feel gritty upon palpation; be gentle •
Using sustained pressure to this muscle while applying mobilization can be effective in loosening tight bands, for example, flexion to extension or alternating supi nation and pronation
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Fl exor Group: Lightening Pain and Trigger Finger
Next, we consider the muscles in the anterior forearm that primarily provide forearm and finger flexion. Trigger points here may cause entrapment of the ulnar or the median nerve, a pressing on either of these nerves within soft tissue causing radicular symptoms.
Flexor Carpi Radialis With the arm in anatomical position, this is the most lateral of the flexors and quite superficial (Fig. 7-2 6 ) . ORIGIN •
Medial epicondyle via the common flexor tendon
INSERTION • Base of second and third metacarpals ACTION • Flexion of the hand at the wrist •
Assists wrist abduction (also known as radial deviation and radial flexion)
TRIGGER POINTS AND REFE RRAL ZONES The trigger points in this muscle typically set up within the belly of the muscle, usually at the mid point. Referral sensa tion is usually felt on the radial side of the anterior wrist quite strongly, with a bit of spillover up the forearm half way and into the palm (Fig. 7-27 ) . A client with trigger points i n this muscle i s likely to report having difficulty using scissors or shears when cutting heavy cloth, when gardening, or when snipping tin. They also may have problems with doing fine movements with fingers such as placing their hair in rollers. If this person has carpal tunnel syndrome, then only working with the mus cles of the arm will not be helpful. Carpal tunnel syndrome presents with pain in the wrist and the hand and numbness of the thumb, index, middle, and ring fingers, with atrophy and weakness of the thenar muscles due to compression of the median nerve in the wri t. TRIGGER POINT ACTIVATION Usually, trigger points in this muscle become activated because of acute or chronic mechanical overload of the muscle. Satellite trigger points may develop from key trigger points in the pectoralis minor muscle. Tightly gripping an object for long periods of time would be considered mechan ical overload.
• FIGURE 7-26 Attachment sites for the flexor carpi radialis. Base of
second and third metacarpal, medial epicondyle via the common flexor tendon. (Reprinted with permission from Life Art, Lippincott Williams & Wilkins.)
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L
STRESSORS AND PERPETUATING FACTORS • Any prolonged, gross gripping, such as occurs when using hand tools, holding ski poles, or grasping a steer ing wheel for long periods of time • Not correcting an active trigger point will also perpet
uate it PRECAUTI ONS • According to Travell and Simons, there may be an anomalous, or abnormal, flexor carpi radialis brevis originating in the proximal radial aspect of the fore arm, inserting at the base of the second or third meta carpal. This muscle may be involved in anterior inter osseous nerve compression MASSAGE THERAPY CONSIDE RATIONS • Tendonitis at the origin of this muscle is called golfer's elbow • Trigger finger may develop here: a condition in which
flexion or extension of a digit is arrested temporarily but finally is completed with a jerk
•
FIGURE 7-27 Trigger points and referral zones for the flexor carpi radialis. The trigger point will set up within the muscle belly, usually half way down the forearm, and strongly refers into the anterior wrist with a bit of spillover above and below the strong referral. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
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Flexor Carpi U l naris This muscle is located on the extreme medial aspect of the forearm when in anatomical position (Fig. 7-28 ) . ORIGIN • Humeral head: medial epicondyle via the common flexor tendon •
Ulnar head: medial margin of the olecranon and prox imal two-thirds of the dorsal edge of the ulna
INSERTION • Pisiform ACTION • Flexion of the hand at the wrist •
Wrist adduction (also known as ulnar deviation and ulnar flexion)
TRIGG ER POINTS AND REFERRAL ZONES As with the flexor carpi radialis, the trigger points in this muscle are within the muscle belly. The main referral zone is to the ulnar aspect of the anterior wrist (quite strongly), with some spillover into the medial metacarpal area of the hand and up the medial aspect of the forearm (Fig. 7-2 9 ) . Symptoms of trigger points i n this muscle are identical to those of trigger points in flexor carpi radialis. Clients with these trigger points are likely to report having difficulty using scissors or shears when cutting heavy cloth, gardening, or snipping tin. They also may have problems with doing fine movements with fingers, such as placing their hair in rollers. If this person has thoracic outlet syndrome, only working with the muscles in the arm will not be sufficient. Thoracic outlet syndrome, also known as thoracic outlet compression syndrome, is a complex condition caused by conditions in which nerves or vessels are compressed in the neck or axilla. TRIGGER POINT ACTIVATION Again, trigger point activation in this muscle is identical to how trigger points are activated in flexor carpi radialis. Usually, trigger points here become activated as a result of acute or chronic mechanical overload of the muscle. Satellite trigger points may develop from key trigger points in the pectoralis minor muscle. Tightly gripping an object for long periods of time may be considered mechanical overload.
• FIGURE 7-28 Attachment sites for the flexor carpi ulnaris.The origins
are as follows: H umeral head-medial epicondyle via the common flexor tendon. Ulnar head-medial margin of the olecranon and the proximal two-third of the dorsal edge of the ulna.The insertion is the pisiform. (Reprinted with permission from Life Art, Lippincott Williams & Wilkins.)
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STRESSORS AND PERPETUATING FACTORS • Any prolonged, gross gripping, such as occurs when using hand tools, holding ski poles, or grasping a steer ing wheel for long periods of time •
Not correcting an active trigger point will also perpet uate it
PRECAUTIONS • Trigger points here may cause entrapment of the ulnar nerve MASSAGE THERAPY CONSI D ERATIONS • T his muscle works synergistically with extensor carpi ulnaris when performing wrist flexion. It actually shares an aponeurotic attachment proximally with extensor carpi ulnaris. Aponeurotic tissue is tissue from an aponeuroses, a fibrous sheet of connective tissue that serves to attach muscle to bone or other tissues • Tendonitis at the origin of this muscle is called "golfer's
elbow" •
Trigger finger may develop here
• FIGURE 7-29 Trigger points and referral zones for the flexor carpi
ulnaris. The trigger point will set up within the muscle belly, usually half way down the forearm, and strongly refers into the anteromedial wrist with a bit of spillover both above and below the strong referral. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
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Flexors Digitorum Superficia l i s a n d Profu n d u s One deep t o the other, these two muscles make u p the deeper forearm flexor muscles (Figs. 7-30 and 7-3 1 ) . ORIGIN • Profundus: proximal three quarters of the medial and dorsal surface of the ulna; medial aspect of the ulnar coronoid process; and the ulnar half of the interosseous membrane • Supedicialis: humeral head: medial epicondyle via the
common flexor tendon • Superficialis: ulnar head: ulnar coronoid process,
medial aspect • Superficial is: radial head: oblique line of the radius
I N SERTION • Profundus: base of distal phalanx of the medial four fingers •
Superficial is: each tendon splits to encircle the ten dons of profundus as they attach to the sides of the middle phalanx of the medial four fingers
ACTION • Both: flexion of the hand at the wrist • Profundus: flexion of the distal phalanx of the medial
four fingers • Superficialis: flexion of the middle and proximal pha
lanx of the medial four fingers TRIGGER POI NTS AND REFERRAL ZON ES Trigger points usually set into the muscle bellies here some what proximally while referring sensation to a distance. Trigger points in the radial head refer strongly to the middle finger with spillover into the palm and also extending beyond the fi n ger as if exploding. Trigger points in the humeral head refer sensation strongly into the medial two fingers with spillover into the ulnar aspect of the palm and also beyond the fingertips as if exploding (Fig. 7 -32 ) . Again, symptoms of these trigger points will b e identical to those of the other finger flexors. Clients with these trigger points are likely to report having difficulty using scissors or shears when cutting heavy cloth, gardening, or snipping tin. They also may have problems with doing fine movements with fingers, such as placing their hair in rollers. TRIGGER POINT ACTIVATION Trigger point activation in this muscle, again, is identical to that of the other finger flexor muscles. Usually, trigger points here become activated because of acute or chronic mechan-
• FIGURE 7-30 Attachment sites for the flexor digitorum superficialis.
The origins are as follows: Ulnar head-ulnar coronoid process, medial aspect. Humeral head-medial epicondyle via the common flexor tendon. For the insertion, each tendon splits to encircle the ten dons of profundus as they attach to the sides of the middle phalanx of the medial four fingers. (Reprinted with permission from Life Art, Lippincott Williams & Wilkins.)
ical overload of the muscle. Satellite trigger points may develop from key trigger points in the pectoralis minor mus cle. Tightly gripping an object for long periods of time may be considered mechanical overload. STRESSORS A N D PERPETUATING FACTORS • Any prolonged, gross gripping, such as occurs when using hand tools, holding ski poles, or grasping a steer ing wheel for long periods of time • Not correcting an active trigger point may also per
petuate it
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• FIGURE 7-32 Trigger points and referral zones for the flexor digito
rum superficialis and profundus.The trigger points will usually be within the proximal muscle belly with strong referrals to the middle, ring, and pinky fingers. There may be some spillover above these fingers as well as beyond the end of the fingers.This means that the person experiences a feeling of the finger tips exploding. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
PRECAUTIONS • If trigger points set into either or both of these muscles, they may cause entrapment of the ulnar nerve • FIGURE 7-31 Attachment sites for the flexor digitorum profundus.
The origins are as follows: Profundus-proximal % of the medial and dorsal surface of the ulna, the ulnar coronoid process on the medial aspect, the ulnar half of the interosseous membrane. The insertion is the base of distal phalanx of the medial four fingers. (Reprinted with permission from Life Art, Lippincott Williams & Wilkins.)
•
Trigger points left in superficial is may entrap the median nerve, as well
MASSAGE THERA PY CON SIDERATIONS • Tendonitis at the origin of this muscle is called "golfer's elbow. " •
Trigger finger may develop here
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Pa l maris Lon g u s This muscle i s highly variable when i t comes t o its anatomic attachments and placement. According to Travell and Simons, it is usually a slender fusiform muscle with its belly centrally located in the proximal half of the forearm. A fusiform muscle is one that is spindle-shaped with tapering at both ends. Variations include congenital (before or at birth ) absence, often bilaterally; a distally placed muscle belly; a double muscle belly; and a distally placed muscle belly with various attachment sites. Total absence occurs 1 2.7% to 20.4% of the time in Caucasian and black persons, but only from 0.5% to 0.75 % in Asian people. Bilateral absence is nearly twice as common as absence on only one side. When there is only one side missing, it is just as likely to occur on the left side as the right. Absence is a bit more common in females than in males and in whites than in blacks. Anomalie other than absence occur in approxi mately 9% of people. The tendon of this muscle is the only one that is on the outside of the antibrachial fascia, which is the extension of the extensor retinaculum. The flexor retinaculum is between wrist bones, just proximal to the metacarpal bones, and is also called the "transverse carpal ligament." ORIGIN • Medial epicondyle via the common flexor tendon I N SERTION • Palmar aponeuroses •
Transverse carpal ligament (also called the flexor reti naculum)
ACTION • Flexes the hand at the wrist •
Tenses the palmar fascia
•
Assists pronation of the hand against resistance
•
Assists elbow flexion
TRIGGER POI NTS AND REF E RRAL ZON ES With the trigger points occurring within the belly of the muscle, referrals are strongly felt at a distance into the palm of the hand with spillover around that area and up the center of the forearm (Fig. 7-33). Clients with trigger points here often complain of pain in the palm of the hand as well as of difficulty in handling tools due to soreness and tenderness in the palm. There may be tender nodules in the palm of the hand, as wei\. Advanced
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. . . . ..
• FIGURE 7-33 Attachment sites and trigger points with referral zones
for the palmaris longus. (Reprinted with permission from Simons DG, Travell JG, Simons LS. Upper Halfof Body. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins, 1 999. Trave" & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1 . p. 744, Fig. 37.1 .)
cases will also demonstrate palmar contracture, as with Dupuytren's contracture : a contracture of the palmer aponeuroses causing the ring finger and the little finger to bend into the palm and not be able to extend. TRIGGER POINT ACTIVATION Usually, trigger points here develop as satellites because of key trigger points in the distal medial head of triceps brachii, which refers sensation to the area of palmaris lon gus. Direct trauma can also activate trigger points in pal maris longus. According to Travell and Simons, people with Dupuytren's contracture usually have one or more active trigger points in palmaris longus, though there is no experi mental data regarding the contractu res being related to trigger points.
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STRESSORS A N D PERPETUATING FACTORS • Falling onto an outstretched hand •
•
Any prolonged, gross gripping, such as occurs when using hand tools, holding ski poles, or grasping a steer ing wheel for long periods of time Holding a racquet with the end of the handle against the palm
• Leaning on a cane with an angular head pressing into
the palm •
N ot correcting an active trigger point may also per petuate it
PRECAUTIONS • Anatomical variations may cause median nerve entrap ment at the wrist • Anatomical variations may cause ulnar nerve entrap
ment in the area of the ulnar tunnel at the wrist MASSAGE TH ERAPY CON S I D E RATIONS • Tendonitis at the origin of this muscle is called golfer's elbow
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Pronator Teres Although pronator teres shares a common origin with the forearm flexor muscles, it does not act upon the wrist or fingers (Fig. 7 -34) . ORIG I N • Humeral head: proximal to the medial epicondyle •
Ulnar head: medial side of the coronoid process of the ulna
I NSERTION • Lateral radius at the midpoint of the forearm ACTION • Assists forearm pronation •
Assists flexion of the elbow
TRIGGER POI NTS AND REFERRAL ZON E S Trigger points i n this muscle will b e found within the muscle belly with referral sensation quite strongly into the wrist and above on the radial aspect of the forearm. There may be quite a bit of spillover proximal to the wrist all the way to the elbow and into the anterior thumb (Fig. 7-3 5 ) . A client with trigger points i n this muscle is likely to complain of not being able to supinate a cupped hand as when having coins placed into the hand. This person will probably also have shoulder pain due to compensatory movements when trying to supinate, extend, and cup the hand. TRIGG ER POINT ACTIVATION Trigger points here could be activated by a wrist or elbow fracture primarily. Also, overuse of elbow flexion, as when grasping and using hand tools or ski poles for long periods of time, can activate trigger points.
• FIGURE 7-34 Attachment sites for the pronator teres. The origins are as follows: Humeral head-proximal to the medial epicondyle. Ulnar head-medial side of the coronoid process of the u lna. The insertion is the lateral radius at the midpoint of the forearm. (Reprinted with permission from Life Art, Lippincott Williams & Wilkins.)
STRESSORS AND PERPETUATI NG FACTORS • Overloading this muscle by using a screwdriver to unscrew for long periods of time PRECAUTIONS • The median nerve enters the forearm between the two origins of this muscle and could be entrapped MASSAG E TH ERAPY CON S I D E RATIONS • Pronator quadratus is the primary mover muscle during forearm pronation •
Pronator teres is not a wrist flexor • FIGURE 7-35 Trigger points and referral zones for the pronator teres.
The trigger point will in the muscle belly near the origin with strong referral to the anterior forearm just above the wrist. There will be quite a bit of spillover from the actual trigger point down the forearm and into the base of the thumb. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
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WRIST AND HAND Of course, the long tendons from the forearm muscles attach in the hand. These, along with the following hand muscles, act upon the hand and the wrist to provide movement there.
Add uctor a nd Opponens Po l l ici s: Weeder's Th u m b These two muscles can b e quite painful for a person (Fig. 7 - 36 ) . ORIG I N Adductor Pol/icis
• Oblique head: carpometacarpal region of the index
and middle fingers • Transverse head: shaft of the third metacarpal bone Opponens Pol/icis
• Trapezium bone •
Flexor retinaculum (also known as "transverse carpal ligament")
I N SE RTION Adductor Pol/icis
• Base of the proximal phalanx of the thumb Opponens Pol/icis
• Head of first metacarpal, lateral aspect
ACTION Adductor Pol/icis
• Adduction of the thumb toward the index finger Opponens Pol/icis
• Brings thumb across the palm toward the pads of the
ring finger (opposing) TRIGGER POI NTS A N D R E FERRAL ZON ES Trigger points in both muscles usually occur within the mus cle belly. The adductor trigger points are usually closer to the insertion, whereas the opponens trigger points are more likely to be found closer to the origin. The referrals from the two are quite similar, with sensation sent into the anterior radial aspect of the wrist, anterior thumb, and thenar emi nence, and posteriorly to the base of the thumb and the thumb itself with some spillover. Thenar eminence is the Aeshy mound of muscle tissue that covers the first metacar pal proximal to the base of the thumb (Figs. 7-37 and 7-38). The symptom most associated with trigger points in these muscles is pain. Clients with these trigger points may also
• FIGURE 7-36 Attachment sites for the adductor and opponens polli
cis. Adductor pollicis origins: Oblique head-carpometacarpal region of the index and middle fingers. Transverse head-shaft of the 3rd metacarpal bone.The insertion is the base of the proximal phalanx of the thumb. Opponens pollicis origins-trapezium bone, flexor reti naculum (also known as transverse carpal ligament). The insertion is the head of 1 st metacarpal, lateral aspect. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
complain of the thumb being clumsy and their handwriting being illegible due to having difficulty holding a pen. They may also have problems with fine manipulations with the thumbs, such as when buttoning clothing, sewing with a needle, and writing and painting, due to movement that requires a pincer grip using the thumb. TRIGGER POINT ACTIVATION This is usually due to spending long periods of time .using the thumb for strong grasping, as when weeding well-rooted
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• FIGURE 7-37 Trigger points and referral zones for the adductor poll i cis. The trigger point will usually be in the muscle belly just medial to the 2nd metacarpal bone. It strongly refers to the thumb in a pattern that wraps the entire thumb from base to tip and from the anterior surface to the posterior surface. There may be some spillover that sur rounds the strong referral. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
• FIGURE 7-38 Trigger points and referral zones for the opponens pol licis.The trigger point will usually be in the muscle belly near the base of the thumb with strong referrals to the anterolateral wrist and ante rior surface of the thumb. There may be some spillover that surrounds both of the strong referrals. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
weeds. In this situation, the person must hold strongly to the weed while rotating the wrist to loosen it up before pulling it out of the ground. Any other sustained tension using a pincer grip with the thumb opposing the fingers may also activate trigger points.
most commonly mistakenly attributed to carpal tun nel syndrome, DeQuervain's tendosynovitis, and osteoarthritis.
STRESSORS AND PERPETUATING FACTORS • Working with a small instrument held firmly between the thumb and fingers, such as when using a fine paint brush, sewing with a needle, or writing longhand •
A fracture of a wrist or hand bone
•
Weeder's thumb syndrome
PRECAUTIONS • According to Travel! and Simons, symptoms pro duced by trigger points in these thumb muscles are
•
Articular dysfunctions can relate strongly to trigger points in these thumb muscles.
MASSAGE TH ERAPY CON S I D E RATIONS • Be sure to check for trigger points if there was a previ ous fracture to the hand/wrist area and the pain never went away • This area can be very tender, so be sensitive with your
work
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Flexor Pol licis Lo ngus: Lighte n i n g Pa i n This muscle is deeply placed in the forearm on the radial side. Normal flexion of this prime mover requires coordi nated activity of four other thumb muscles (Fig. 7-39 ) . ORIGIN • Radius •
Interosseous membrane
•
Humerus (by a slip of aponeuroses)
I N S E RTION • Base of the distal phalanx of the thumb ACTIO N • Thumb flexion •
Adduction of the first metacarpal bone
•
Flexion and abduction of the hand at the wrist
TRIGGER POI NTS A N D R E F ERRAL ZONES A trigger point may develop in the muscle belly near its distal end, close to the musculotendonus junction, just above the wrist. Its referral pattem is some spillover at the thenar emi nence with strong sensation to the thumb itself and beyond with an explosive feel at the tip of the thumb (Fig. 7-40 ) . Clients with trigger points i n this muscle may complain of trigger finger or trigger thumb here, which is usually more annoying than painful. Other typical complaints include the inability to use the thumb to do certain activities such as placing curlers into the hair. This person's ability to do gross gripping movements will most likely be compromised.
• FIGURE 7-39 Attachment sites for the flexor pollicis longus. Radius,
interosseous membrane, humerus (by a slip of aponeurosis), base of the distal phalanx of the thumb. (Reprinted with permission from Life Art, Lippincott Williams & Wilkins.)
TRIGGER POINT ACTIVATION Activation of trigger points here will be due to using the thumb to do motions such as forceful rocking, twisting, and then pulling. This will strain this and other thumb muscles. STRESSORS A N D PERPETUATING FACTORS • Use of ski poles for long periods of time •
Use of small-handled hammers or other tools
•
Weeding for long periods of time
•
Gripping a steering wheel for long periods of time
PRECAUTIONS • As the origin is deep to flexor digitorum superficialis, it may be difficult for a person to receive work without the superficial muscles having been worked on first MASSAGE THERAPY CON S I D E RATIONS • This area is usually quite tender; be sensitive with your work • Be sure to work on the other thumb muscles, as they
must work together as a coordinated unit
• FIGURE 7-40 Trigger points and referral zones for the flexor pbllicis
longus. This trigger point is within the muscle belly, but quite distal from the origins with strong referral to the thumb on the anterior side with spillover both above and beyond the strong referral. The referral beyond the thumb indicates an experience of the thumb exploding. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
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Extensor I n d icis: Stiff Fingers This muscle is relatively short and deeply placed, while being a synergist to the other finger extensor muscles (Fig. 7-4 1 ) . ORIG I N • Lower fifth o f the dorsal and lateral surface o f the ulna •
Interosseous membrane
INS ERTION • Head of the second metacarpal bone ACTION • Extension of the wrist and the index finger • May assist in abduction of the index finger
TRIGGER POI NTS AND REFERRAL ZON ES With a trigger point set up within the muscle belly, the referral pattern will be strongly to the dorsal side of the wrist, very medially placed, with spillover from there into the index finger (Fig. 7-42 ) . A person with trigger points here will most likely com plain of pain and/or inability to firmly grasp objects such as a sewing needle. Their ability to use the index finger for fine movements will be compromised. TRIGGER POINT ACTIVATION Activation of trigger points will usually be due to activities that overuse forceful and repetitive finger movements. STRESSORS AND PER PETUATING FACTORS •
Plucking guitar strings
•
Holding a violin bow
•
Sewing or doing needlepoint work
•
Playing the piano for long periods of time
•
The tendon being out of place at the metacarpophalan geal joint
• FIGURE 7-41 Attachment sites for the extensor indicis. Lower '/5 of
the dorsal and lateral surface of the ulna, interosseous membrane, head of the 2nd metacarpal bone. (Reprinted with permission from Life Art, Lippincott Williams & Wilkins.)
PRECAUTIONS • According to Travell and Simons, no nerve entrap ments have been observed because of trigger point activity in this muscle MASSAG E TH ERAPY CON S I DERATIONS • Be sure to work the lateral ulna on the posterior side to be thorough with this muscle
• FIGURE 7-42 Trigger points and referral zones for the extensor indicis.
The trigger point will appear within the muscle belly on the posterior surface of the forearm with a strong referral to the posterolateral wrist area. There may be some spillover surrounding the strong referral and extending down the posterolateral surface of the hand. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
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Interossei a n d Lu m bricals: Associates of Heberden's Nodes The interossei lie between adjacent metacarpal bones. The lumbricals are not interosseous muscles, but they function similarly. They are unusual as they anchor to tendons of other muscles rather than to bone. ORIGIN First Interossei •
Ulnar border of the first metacarpal
•
Entire length of the radial border of the second meta carpal
Three Dorsal Interossei •
Lateral aspect of the base of the second and third met acarpals
•
Medial aspect of the base of the third and fourth meta carpals
Three Palmar Interossei •
Medial aspect of the base of the second, fourth, and fifth metacarpals
Lumbricals •
The four tendons of the flexor digitorum profundus at mid-palm
I N S ERTION First In terossei •
Base of the proximal phalanx of the index finger
Three Dorsal In terossei •
Shaft of the proximal phalanx, lateral aspect of the index and middle fingers
•
Shaft of the proximal phalanx, medial aspect of the middle and ring fingers
Three Palmar Interossei •
Base of the proximal phalanx, medial aspect of the index finger
•
Base of the proximal phalanx, lateral aspect of the ring and little fingers
Lumbricals •
Radial side of the extensor aponeuroses on each of the four fingers
ACTION According to Travell and Simons, to understand the actions of these intrinsic hand muscles, it is important to remember that the extensor digitorum strongly extends the proximal
phalanx of each finger but only weakly extends the two dis tal phalanges. The flexor digitorum superficialis attaches to the middle phalanx, flexing the proximal and middle pha lanx. The flexor digitorum profundus attaches to the distal phalanx, flexing it and the more proximal phalanx. The four dorsal and three palmar interossei have oppos ing actions in abduction, adduction, and rotation, but both groups, along with the lumbricals, f l ex the fingers at the metacarpophalangeal joints and extend the distal phalanx. The interossei and lumbricals extend the distal two phalanges when there is any degree of flexion of the proxi mal phalanx present. • The dorsal interossei abduct away from the main ray, or the middle finger •
The palmar interossei adduct toward the main ray
TRIGG E R POI NTS A N D REFE RRAL ZON E S A s usual, trigger points set up within muscle bellies. There is strong referral down the radial or lateral aspect of the index and middle fingers with spillover across the dorsal surface of the hand and down the little finger. There is also spillover into the center of the palm and the palmar surface of the index finger (Fig. 7-43 ) . Clients with trigger points i n the interosseous muscles may complain of having arthritis pain in a finger. The finger will be stiff enough to produce impairment of hand func tions such as buttoning a shirt, writing with a pencil or pen, and grasping. This person may complain of having sore joints that are swollen, as with Heberden 's nodes. Heberden's nodes, which is often identified with osteoarthritis, is a condition in which enlargements of soft tissue (nodes), sometimes partly bony, occur on the dorsal surface of either side of the terminal phalanx at the distal interphalangeal joint. According to Travell and Simons, tenderness is present in Heberden's nodes, but no true synovial or bony swelling. The tenderness may be referred to the joint. In time, the nodes become less tender. Travell and Simons go on to explain that, clinically, it appears that trigger points in these muscles can contribute to joint disease. TRIGG E R POINT ACTIVATION Activation of trigger points in these muscles is usually caused by sustained or repetitive pincer grasping, as when one is a seamstress, painter, sculptor, or mechanic whG must hold small items firmly while moving the hands and fingers.
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First dorsal interosseous
)( )( Heberden's nodes
Abductor digiti minimi
Second dorsal interosseous
• FIGURE 7-43 Attachment sites and trigger points with referrals for the lumbricals and dorsal interossei. (Reprinted with permission from
Simons DG, Travell JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins, 1 999. Trovell & Simons' Myofascial Pain and l . p. 787, Fig. 40.1 .)
Dysfunction: The Trigger Point Manual; vol
STRESSORS A N D PERPETUATI NG FACTORS •
Repetitive or sustained pincer grasping
•
Increased strain due to abnormal hand mechanics asso ciated with distorted joint function of arthritis
PRECAUTIONS •
If Heberden's nodes are apparent, be gentle as the fin gers will be quite sensitive
•
Be very careful if osteoarthritis is present
MASSAGE TH E RA PY CONSIDERATIO N S •
Inactivation of trigger points and elimination of their perpetuating factors is important to early therapy in an effort to delay or abort the progression of some types of osteoarthritis
•
The presence of Heberden's nodes is a common finding in those with trigger points in the interossei
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Abductor Dig iti M i n i m i This muscle has a parallel fiber arrangement to the dorsal interosseous muscles (Fig. 7-44 ) . ORIGIN • Pisiform bone
I N SERTION • Base of the first phalanx of the little finger, medial
aspect ACTION • Abduction of the little finger away from the main ray
TRIGGER POINTS A N D R E F ERRAL ZON ES
Trigger points may set in with the muscle belly and refer strongly to the dorsal side of the little finger, with some slight spill over into the fifth metacarpal and at the hypoth enar eminence. The hypothenar eminence is the fleshy mound of muscle tissue that covers the fifth metacarpal dis tal to the medial carpals (Fig. 7-4 5 ) . Mostly, a person with trigger points here will complain of pain and stiffness in their little finger.
Abductor digiti minimi '/.II-J.I-I-- Flexor digiti minimi brevis Opponens digiti minimi
TRI G G E R POINT ACTIVATION
This will most likely be due to overuse of the little finger with movements that oppose the thumb to grasp objects for long periods of time or repetitively. STRESSORS A N D PERPETUAT I N G FACTO RS • Repetitive overuse of the little finger
• FIGURE 7-44 Attachment sites for the abductor digiti minimi. Pisiform bone, base of the first phalanx of the little finger, medial aspect. (Reprinted with permission from Oatis CA. Kinesiology. Baltimore, MD: Lippincott Williams & Wilkins, 2004.)
• Heberden's nodes on the little finger
P R ECAUTIO N S • I f Heberden's nodes are apparent, b e gentle as the
fingers will be quite sensitive • Be very careful if osteoarthritis is present
MASSAGE THERA PY CONSIDERATION S • Inactivation of trigger points and elimination of their
perpetuating factors is important to early therapy in an effort to delay or abort the progression of some types of osteoarthritis
• FIGURE 7-45 Trigger points and referral zones for the abductor digiti minimi.The trigger point will set up in the muscle belly and refer strongly into the posterior surface of the pinky finger and just a bit above with some spillover. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
C H A PT E R 7
A R M , W R I S T, A N D H A N D
Arm, Wrist, a n d Hand Neuro m u scu lar Thera py Routine For these routines, the client i s supine. Begin with warming, loos ening, and assessment of the upper arm, brachium, or the area between your shoulder and elbow, using compression and petris sage. Note that the video icon indicates routines that are featu red in online video clips, on the book's companion Web site.
BICEPS BRAC H II
�
Lubricate upper arm and hold in a supinated position. 1 . Perform gliding palm strokes or gliding with the heel of hand while extending the client's elbow, moving from i n sertion toward origin; then, muscle strip using your th umbs, again from insertion to origin. Be sure to cover both medial and
• ROUTINE 7-1
lateral aspects of both muscle bellies (Routine 7-1 ).
2. Use broad transverse and longitudinal friction to muscle bellies (Routine 7-2).
3. Isolate tendons of both long and short heads using circular, transverse, and longitudinal friction (Routine 7-3). Isolate ten don of the long head in the bicipital groove. Press through the anterior deltoid to affect the tendon of the short head while working to its origin at the coracoid process (Routine 7-4).
• ROUTINE 7-2
• ROUTIN E 7-3
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• ROUTINE 7-4
4. Work the insertion at the radial tu berosity approximately 1 to 2 inches below the crease of the elbow on the radial side. Find the tuberosity and then pronate the entire arm while pushing up into this tuberosity for the best access; friction and hold the tissue until the tenderness begins to subside (Routine 7-5).
CORACOBRAC H IALIS
e
1. Abduct the arm at a less than gO-deg ree angle to the body
with the palm u p.
2. Use thumb stripping up the inside of the arm from the mid
• ROUTINE 7-5
point of the shaft of the humerus until pectoralis major stops the gliding motion, working from insertion to origin. Now use friction along the length of the muscle (Routine 7-6).
• ROUTINE 7-6
CHAPTER 7
3. Isolate the tendon at its origin on the coracoid process using cirCl,Jlar and transverse friction (Routine 7-7).
BRAC H IALIS
e
1. With client's arm slightly flexed, use thumb strokes medial and
lateral to biceps brachii (working from insertion toward origin). Apply pressure with one thumb at a time, working lateral to biceps brachii for the lateral portion and medial to biceps bra chii for the medial portion. Work any tight bands found with transverse friction and trigger point release (Routine 7-8).
• ROUTINE 7-7
• ROUTINE 7-8
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2 . Isolate brachialis with a pincer g rasp a round the biceps bra chii from both sides and hold for a myofascial release. The arm must be supported for this (Routine 7-9).
3 . Friction the insertion at the ulnar tuberosity. This is located across from the radial tuberosity and just a bit closer to the crease of the elbow on the ulnar side of the upper forearm (Routine 7-1 0).
4. Complete brachialis with sustained compression using the heel of the hand while extending the elbow, and then per form deep effleurage from the elbow to the midpoint of the
• ROUTINE 7-9
anterior shaft of the hu merus to complete (Routine 7-1 1 ).
• ROUTINE 7-10
• ROUTINE 7-11
C H A PT E R 7
BRACH IORADIA LIS
�
Have the client hold an arm at his or her side in a neutral position (thumb side toward the ceil ing). 1 . Warm with compression and petrissage. Use a pi ncer com pression between the thumbs and fingers for a myofascial release (Routine 7-1 2). Note: In isolating brachioradialis with pincer compression, you are also grasping extensor carpi radialis longus, which originates along the supracondylar ridge distal to the brachioradialis attach ment.
Note: Lubricate the forearm.
2. Hold the client's wrist while muscle stripping the brachiora dialis from distal to proximal. Isolate tight bands with d irect susta ined pressure w h i l e pronating and supi nating the client's forearm either actively or passively. Isolate and release trigger points with trigger point pressure (Routine 7- 1 3).
• ROUTINE 7-12
• ROUTINE 7-1 3
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3. Work the orig in along the supracondylar ridge of the humerus with friction and then trigger point pressure as necessary. You can also position the client's hand on the abdomen for access if the client is having difficulty keepi ng his or her arm in a neutral position as you work (Routine 7- 1 4) .
S U P I N ATOR
�
Note: Position the client's arm at the side in neutral.
1. The supinator is located directly beneath the belly of brachio
radialis, attaching from the proximal ulna, wrapping around and inserting on the medial surface of the proximal one-thi rd of the radius (Routine 7-1 5). Work here by pressing throug h
• ROUTINE 7-14
brach ioradiali s and extensor carpi radial is longus usi ng thumb/finger effleurage and friction. Then, use a pincer com pression deep to brachioradialis (Routine 7-1 6).
• ROUTINE 7-15
• ROUTINE 7-16
CHAPTER 7
2. Isolate the supinator attachments to the radius by pressing into ·the radius deep to brachioradi a l i s and extensor carpi radialis longus from each side by displacing those superficial muscles first laterally, then medially (Routine 7- 1 7).
3. Gentle friction here may also be effective work. This can a lso be done in combination with mobilization using passive pro nation a nd supi nation.
4. End with deep thumb stripping through the entire brachiora dialis from the radial styloid process to the supracondylar ridge of the humerus while holdi ng at the wrist to keep the arm in the neutral position. This effectively fi nishes the work
• ROUTI NE 7-17
to the brachioradialis and supi nator muscles (Routine 7-1 8).
• ROUTINE 7-1 S
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e
Position the client's arm with the elbow at a 3�-degree angle and pronated. It may be more comfortable for the client if there is a small bolster used u nder the forearm. 1 . Using the heel of the hand and/or the knuckles, effleurage the muscle bellies from the wrist a rea to their orig in at the lateral epicondyle of the humerus (Routine 7-1 9).
2. Thumb strip the extensors from distal to the lateral epicondyle of the hu merus. If you are having d ifficu lty locating these muscles individually, ask the client to move the appropriate fi ngers so you can feel each muscle moving (Routine 7-20).
3. Now use broad transverse, longitudinal, and circular friction a l on g with trigger point pressu re to m u scle b e l l i es as requ i red.
• ROUTINE 7-1 9
• ROUTINE 7-20
C H A PT E R 7
4. Use broad transverse and circular friction to the lateral epi condyle of the humerus for the extensor orig ins. This com mon tendon is best accessed with extreme pronation of the forearm (Routine 7-2 1 ).
5. From insertion to origi n, use a deep effleurage with the flat of
the knuckles. The heel of the hand can also be used for this stroke.
6. Use longitudinal and transverse friction to the extensor reti naculum and extensor tendons at the wrist.
7. Complete with several deep effleurage strokes of the exten sor a rea, from insertion to orig in using the flat of the knuckles and/or the heel of the hand.
ANCON EUS
e
Position the client's arm so that it is pronated with the elbow at a 30-degree angle.
• ROUTINE 7-21
1. The anconeus is located just dista l to the el bow between the
lateral epicondyle and the olecranon a long the posterior, proximal u lna. Use thumbs to m uscle strip from distal to prox imal, warming. Work also with transverse and longitu d i n a l friction. Hold w i t h trigger point pressure t o any a reas necessary (Routine 7-22).
2. End with more effleurage from distal to proxi mal.
• ROUTINE 7-22
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F LEXORS A N D PRONATOR TERES
e
Position the client's arm so that it is supinated, and hold at the wrist or use a small bolster for comfort. 1 . Warm and thoroughly loosen the area with effleurage, work ing d istal to proximal (Routine 7-23).
2. Thoroughly work the common flexor gro u p using m uscle stripping from the wrist to the common orig in at the medial epicondyle of the hu merus. Specifica lly isolate and identify pronator teres, flexor carpi rad i a l i s, palmaris longus, flexor carpi u l n a ris, flexor d i g itorum s u perficial is, and profundus while thumb strip p i ng. Once the s u perficial layer softens,
• ROUTINE 7-23
begi n to use deeper pressure to influence first flexor digito rum superficialis and then profundus. If you are having diffi cu lty isolating each ind ividual m uscle, instruct the client to move the appropriate fi nger to feel each muscle move as you glide u p the arm (Routine 7-24).
3. Use transverse, longitudinal, and circu l a r friction. With any trigger point found, use trigger point pressure to al leviate it.
4. Work specifically on pronator teres with friction from the lat era l rad i u s at the mid-forea rm toward the epicondyle. It is the first muscle located dista l to the crease of the el bow running
• ROUTINE 7-24
on an o b l i q ue ang l e, as pointed out i n the photogra ph. Alleviate trigger points using trigger point pressure as neces sary, and then mobilize with passive pronation and supina tion while compressing the muscle fibers with your thumb (Routine 7-25).
5. Work more specifically using transverse friction to the com mon tend inous o r i g i n at the med i a l epicondyle of the h u merus. Isolate any adhesions or tender a reas with friction and al leviate trigger points using trigger point pressure.
• ROUTINE 7-25
C H A PT E R 7
6. Use longitudi nal and transverse friction to the antibrachial fascia (the extension of the flexor retinacu l u m proximal to the wrist) and then the flexor retinaculum (transverse carpal liga ment within the wrist). Also, friction the flexor tendons cross ing the wrist, noting that the palmaris longus tendon is out side of the antibrachial fascia.
7. Complete with a deep, broad effleurage from the wrist to elbow.
HAND
C
1 . Use palming, wring ing, t h u m b g l i d i ng, and d i rect pressure on the m uscles of the pa l m a r and dorsal su rfaces of the
• ROUTINE 7-26
hand. Specifically work the extensor retinaculum, the ante brachial fascia, and the flexor retinaculum with t h u m b glid ing and friction (Routine 7-26).
2. Specifically isolate the opponens pollicis and flexor pollicis lon gus muscle bellies and their origins at the base of the thumb with thumb gliding and transverse friction (Routine 7-27).
3. Isolate the adductor pollicis with thumb g l id i n g and trans verse friction as well. Be sure to work the origin along the mid dle metacarpal. You can also use a pincer compression to the muscle belly in conjunction with mobilization (Routine 7-28).
4. Use this same approach to the m uscles of the hypothenar eminence.
• ROUTINE 7-27
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I
M U S C L E S A N D N E U RO M U S C U L A R T H E RAPY ROUT I N ES BY BODY R E G I O N
• ROUTINE 7-28
TRICEPS B RACHII
C
The client is in a prone position with the arm across the table at a 90-degree angle to the body, bent at the elbow so the forearm is off the table. Lubricate. 1. Use compression, effleurage, and petrissage to warm the area
of the posterior u pper arm. Loosen any hypertonicity found there (Routine 7-29).
2. Work the three bell ies of the triceps brach ii with muscle strip ping from insertion at the olecranon toward the origin at the upper posterior shaft of the humerus and the axillary border of the scapula. A good way to locate each origi n is to ask the client to extend his or her arm while you place pressure on the forea rm, not a llowing it to move. You will be able to feel each origin contract (Routine 7-30).
• ROUTINE 7-29
CHAPTER 7
3. Use transverse friction to the origins at: • long head: infraglenoid tubercle of the scapulae, located
between teres minor and major muscles .. medial head: posterior h u merus below (distal to) the spiral groove • lateral head: posterior humerus a bove (proximal to) the
spiral groove (this will requ ire deeper pressure to get through the posterior deltoid)
4. Use transverse and longitudinal friction to the muscle bellies along with trigger point pressure as necessary. • ROUTINE 7-30 Note: The spiral groove on the posterior humerus takes the same course as the distal margin of the posterior deltoid, making it easy to find. It is easy to confirm these attachments by asking the client to extend his or her elbow against resistance.
5. Use circu lar and transverse friction to the common i nsertion
and tendon at the olecranon of the u l na. Remember that this ,
is a long, thick tendon; be thorough as there may be a trigger point there.
6. Use trigger point pressure to the common tendon, if needed (Routine 7-3 1 ). • ROUTINE 7-31
7. Complete with deep, broad effleurage strokes from insertion toward origins (Routine 7-32).
• ROUTINE 7-32
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PA R T I I / M U S C L E S A N D N E U R O M U S C U L A R T H E R A P Y R O U T I N E S B Y B O D Y R E G I O N
Case Study 7 - 1 •
Mary: A Client with Arm, Wrist, a n d H a nd Pai n
Background
fingers. The therapist applied neuromuscular therapy tech
Mary is a program d i rector at a major university. Afraid that
niques. The therapist asked about the ergonomics of Mary's
she had carpal tunnel syndrome, she saw a physiatrist, a doc
workspace and suggested that Mary rearrange it somewhat
tor of physical pain. He put her through a few simple tests and
and begin to sit back into her chair instead of perching on the
concluded that she did not have carpal tunnel syndrome.
edge of it.
Upon finding out that she spent a great deal of time daily at her computer, he referred her for neuromuscular therapy.
Treatment After l istening carefu l l y to Ma ry's story, the therapist asked a few questions regarding where she felt pain and what sensa tions she was experiencing. The therapist then put Mary through a simple test for carpal tunnel syndrome, which was negative. Mary informed her that it was one of the tests the doctor had her do. Mary's description of pain was of her forearm aching from the el bow to the wrist, with a tingling type of pain in her
Critical Thinking Questions 1 . Where would you begin with this client? 2. Which muscles in the arm and u pper arm specifically refer into the wrist and hand? 3. Why wou l d a massage therapist ask a cl ient about the set up of his or her workspace? 4. Please research to find a simple test to check for carpal tunnel syndrome; what is it called? 5. Should muscles i n other areas of the body be checked for trigger point activity? If so, which muscles specifically?
Case Study 7-2 •
Paul: A M a n with Pa i n in His El bow a n d Posterior Shou lder a n d N u m b Fingers
Background
longer n u m b. The therapist worked a l l of the m u scles as
Pa u l was referred to a neuromuscular therapist by a friend
d u ri n g the fi rst session a second t i m e.They had responded
when he was expla ining a bout his n u m b fingers. Pau l had
nicely a n d were j u st a bit sore. The thera p i st focused on
broken his leg the year before and had to use crutches for
the triceps b rach i i for the m aj o rity of the session with
q uite a while. H i s symptoms began d u ring that time and pre
success.
sented as posterior shoulder pain. He had assumed it was
Pau l came to a third session to have this work completed
from the crutches and that it would go away when he was
and ag reed that it would be wise for the therapist to also work
wal king again. Rather than go away, it persisted, and then his
on his other side. They found a similar situation there, with
elbow began to h u rt on the same side. After a month or so,
many tender muscles along with latent trigger points in the
his ring and little finger began to feel n u m b.
other triceps brach i i that referred in a similar pattern to the other side upon palpation. The therapist was able to com
Treatment
plete the work for Pau l at the fourth session.
The therapist began working with Paul by explaining it could be that he had trigger points in one or more of a variety of muscles that referred sensation just as he had described. The therapist worked with Paul's anterior and posterior shoulder, upper arm, and forearm. Although most of the muscles in these areas were quite tender, they finally found the trigger points that referred Paul's sensation to be in his triceps brachii. After the i n i t i a l session, Pa u l was left with some p a i n in his posterior s h o u l d e r and el bow, but his fi ngers were no
Critical Thinking Questions , . Why would the therapist check a l l muscles in the shoulder and arm of the client? 2. Which muscles in the shoulder and arm could have a simi lar referral pattern if there were trigger points there? 3. What could be the reason for trigger points to set into Paul's triceps brachii?
C H A PT E R 7
�
A R M , W R I S T, A N D H A N D
213
REVIEW QU ESTIONS
Short Answer Questions
1 . The extensor muscles of the aIT11 extend which structures ?
1 0. With nerve entrapment in the brachial is muscle, what may actually cause this ? A. An overlooked injury to the shoulder
2. What is the middle finger knows as ?
B. A trigger point
3. Which muscle is a synergist to the triceps brachii ?
C. Performing too many sit ups
4. The adductor and opponens pollicis muscles are two of
the main muscles that make up which structure ? 5 . What is another name for the flexor retinaculum? Multiple Choice Questions
6. Which is the must superficial muscle on the anterior
humerus ? A. Brachialis B. Coracobrachialis C. Tricep brachii D. Biceps brachii 7. Attaching to the coracoid process is the pectoralis
minor muscle in the chest and which two muscles in the arm ?
D. None of the above True/False
1 1 . Epicondylitis is the inflammation of either epicondyle of the humerus and the surrounding tissues. 1 2. The palmaris longus muscle has a large insertion onto aponeurotic tissue in the anterior hand. 1 3 . The wrist flexor muscles have a common insertion at
the lateral epicondyle of the humerus. 1 4. Biceps brachii is the strongest of the elbow flexor muscles. 1 5 . The most common muscle involved in tennis elbow is
the extensor carpi radialis longus. Matching
A. Brachialis and coracobrachialis
a. Aponeurotic tissue
f. Thenar eminence
B. Coracobrachialis and biceps brachii
b. Fusiform muscle
g. Thoracic outlet syndrome
C. Biceps brachii and triceps brachii
c. Main ray
h. Dupuytren's contracture
D. Brachialis and anconeus
d. Musculotendonus junction
8. Biceps brachii can develop satellite trigger points from
key trigger points in which muscle ? A. Infraspinatus B. Supraspinatus C. Brachialis D. Pectoralis major
i. Hypothenar eminence
e. Synergistic 1 6. Referring to the middle finger or toe. 1 7. Muscles that work together to perf0IT11 specific movement. 1 8. The fleshy mound of muscle tissue that covers the first
metacarpal distal to the base of the thumb.
9. If there is nerve entrapment taking place in the bra
1 9. A complex condition caused by conditions in which
chialis muscle, where should the person expect to find a sensation of numbness ?
nerves or vessels are compressed in the neck or the axilla.
A. In the little finger B. In the posterior wrist C. The dorsum of the thumb and its web area D. The lateral border of the brachialis muscle
20. Tissue from an aponeuroses, a fibrous sheet of connec tive tissue that serves to attach muscle to bone or other t issues.
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PA R T I I
I M U SCLES A N D N E U RO M U S C U LA R T H E RAPY ROUTI N E S BY BODY R E G I O N
REFEREN CES I . Prasanna A . Myofasc ial pain as postoperative complication [ Letter]. J Pain Symptom Manage. 1 993;8( 7 ) :450-4 5 1 2 . Duchenne G B . Physiology o f Motion. Kaplan EB, trans-ed. Ph iladelphia, PA: J . B . L ippincott; 1 949:99, 1 00, 1 1 4-1 1 6. 3 . Kosugi K, Shibata S, Yamash ita H . Anatomical study on the variation of extensor muscles of human forearm. 6. M . extensor carpi rad ialis longus. }ikeikai Med }. 1 987;34: 5 1 -60.
4. Hong CZ. Considerations and recommendations regard ing myofasc ial trigger point injection . } Musculoske Pain. 1 994; 2 ( I ) : 29-59.
'
\
)
LOWER TORSO AND ABDOMEN Note that common conditions encountered in this region are included among the key terms.
o
. tissue that has become fibrous and holds together
soft tissue parts that are normally separated
ntenor pelvic til : a condition in which there is a hyperlor dotic curve and the pelvis has tilted forward, causing the pubis to be low and the ischial tuberosities to be high; there is too much flexion at the pelvis J yspn ea . shortness of breath normally due to vigorous activity
Gastrectomy. surgical removal of part of or the entire stomach lateral pelvic tilt a condition in which one hip is higher than the other, causing the leg lengths to appear to be different
•
OVERVIEW OF lOWER TORSO AND ABDOMEN REGION
Pneumothorax: a collection of air or gas in the pleural cavity Pyothorax: pus in the pleural cavity Rotoscoliosis: a condition in which one or more vertebra rotate to one side
Scoliosis: one or more lateral curves in the spinal column Tendinous inscriptions:fibrous bands that appear in rectus abdominis interrupting the muscle fibers three to four times along their length. These give the muscle more strength to keep the abdominal contents from pushing forward.
Trochanteric bursitis: inflammation of the bursa related to the greater trochanter of the femur
Varicosities: multiple varicose or dilated veins present
can be anywhere. Our goal will be to find all active, latent, and associated trigger points and then deactivate them.
In this chapter, we consider the muscles that make up the
The abdominal muscles have a diagonal criss-cross fiber
lower torso, including both the anterior and posterior
arrangement, which, at times, is important to know about.
areas. Included in this area is the musculature that makes
The external oblique fiber direction is downward and for
up the abdomen. These muscles are often completely for
ward, whereas the internal oblique fiber direction is down
gotten by massage therapists when treating low back
ward and backward.
pain. Certain of them can actually be key in the manage ment of low back pain. As always, even though trigger
portion of the body are typically related to postural dysfunc
point referral areas show specific patterns, the referral
tion or injury.
Conditions you may find to treat when working with this
215
216
PA R T I I
M U S C L E S A N D N E U R O M U SC U L A R T H E R A P Y R O U T I N E S B Y B O DY R E G I O N
Quadratus Lumborum:Trochanteric Bursitis This muscle has three fiber groups and directions: almost vertical iliocostal fibers, diagonal iliolumbar fibers, and diag onal lumbocostal fibers, with the last two intersecting cross wise. A condition related to this muscle is trochanteric bursitis, inflammation of the bursa related to the greater
trochanter of the femur (Fig. 8-1) . ORIGIN •
Posterior iliac crest
•
Iliolumbar ligament
INSERTION •
Inferior aspect, medial half of rib 12
•
Transverse processes LI-L4
ACTION •
Controls trunk lateral flexion when in an upright position
•
Stabilizes rib 12 for inspiration and forced expiration
•
Raises hip (unilateral)
•
Extends lumbar spine (bilateral)
• FIGURE 8-1 Quadratus lumborum anatomical attachment sites. ( Reprinted with permission from Hendrickson T. Massage for Orthopedic Conditions. Baltimore, MD: Lippincott Williams & Wilkins;
2003; Fig. 3-36.)
TRIGGER POINTS AND REFERRAL ZONES
Trigger points typically appear within the belly of the mus cle in both the superficial and the deep layers. They will be near the 12th rib, the transverse processes, and iliac crest. Referral sensation can be quite extensive here. There
)
u u v II
is typically strong referral to the lateral and anterior iliac crest, the greater trochanter, the lateral sacrum, and lower buttocks areas. There may be spillover to the lower lateral abdomen above the iliac crest and lower buttocks areas (Figs. 8-2 and 8-3) . Clients with trigger points in this muscle typically com
1
plain of low back pain. Interestingly, trigger points in quad
•
ratus lumborum are frequently overlooked. The client spe cifically will likely report a constant, deep, aching pain
2
when at rest, which can be severe. When sitting or standing
•
without support, this person may complain that the pain becomes excruciating. The client may mention that he or she must press the low back against a wall to cough or sneeze. There may be a sharp knifelike pain or a severed feeling when bending forward. It might be difficult for this person to bend forward and turn or bend from side to side. The cli ent must use his or her arms to help push up and out of a chair. Often a feeling of heaviness in the hips, cramping of the calves, and burning sensation in the legs and feet may accompany trigger points here.
• FIGURE 8-2 Quadratus lumborum trigger points 1 and 2 and referral zones. ( Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
C H APTER 8
LOWER TORSO A N D ABDOMEN
2 17
even a minor leg length difference from side to side will do the same. STRESSORS AND PERPETUATING FACTORS •
Sitting on a wallet
•
Leg length differences
•
Having a high hip/low hip
•
Having an anterior pelvic tilt/hyperlordosis
•
Awkward lifting that involves twisting movements, such as lifting a TV or large dog
•
Sleeping on a mattress that is too soft
PRECAUTIONS •
Apply pressure to the musculature slowly at a 45-degree angle to avoid direct pressure on the lateral ends of transverse processes
• FIGURE 8-3 Quadratus lumborum trigger points 3 and 4 and referral zones. ( Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.l
MASSAGE THERAPY CONSIDERATIONS •
According to Travell and Simons, the quadratus lum borum is the most commonly overlooked source of low back pain
•
TRIGGER POINT ACTIVATION
Acute activation is often due to awkward movements or
•
obvious sudden trauma, such as from an auto accident. The •
An imbalance of quadratus lumborum along with a high hip/low hip situation may lead to rotoscoliosis
this action. Walking on a cast will activate trigger points resulting from having a very large limb length inequality, but having
Imbalance of quadratus lumborum is a major cause of functional scoliosis, which, in turn, perpetuates multi fidus involvement
muscular strain of almost falling can activate as well because quadratus lumborum clenches during the slipping phase of
Have the client breathe into the muscle while provid ing a myofascial melting technique
•
Muscle energy techniques for self-stretching are effec tive client follow-up procedures
2 18
PA R T I I
M U S C L E S A N D N E U R O M U S C U L A R T H E R A PY R O U T I N E S B Y B O D Y R E G I O N
Serratus Posterior Inferior: Nuisance Residual Backache The serrated insertions of this muscle interdigitate with the abdominal oblique insertions. Being anatomically variable, the attachments to one or more ribs, especially to the 9th and 12th ribs, are sometimes missing. Rarely, the entire muscle is absent (Fig. 8-4) . ORIGIN •
Spinous processes of Tll-L2
INSERTION •
Inferior aspect of ribs 9-12
ACTION •
Trunk rotation (unilateral)
•
Extension of lower spine (bilateral)
TRIGGER POINTS AND REFERRAL ZONES
Trigger points typically form within the belly of this mus cle, e pecially at the area of the 11th rib. The referral sensation is usually felt directly encircling the trigger point (Fig. 8-5). A person with trigger points in this muscle will often report a nagging ache in the lower thoracic area. The ache is typically described as annoying, not severe pain. There can be trigger points within the erectors and deep abdomi nal wall muscles, causing more sensation to the same area. TRIGGER POINT ACTIVATION
Being highly susceptible to muscle strain when lifting, turn
• FIGURE 8-4 Serratus posterior inferior anatomical attachment sites. ( Reprinted with permission from Life Art, Lippincott Williams & Wilkins. )
ing, and reaching, trigger points here activate because of overload strain. These trigger points will activate at the same time as those in more superficial muscles. Working with arms overhead while standing on a ladder and having the back hyperextended can activate trigger points in this muscle as well. STRESSORS AND PERPETUATING FACTORS •
Overload from poor posture
•
Chronic coughing
•
Paradoxical breathing
•
Unequal leg lengths
J�� r II
... : . ... • . '' , .
PRECAUTIONS •
' !: ,,- ,
:::-:>.: ...
Be sure to alleviate trigger points in the erector and abdominal wall muscles first
MASSAGE THERAPY CONSIDERATIONS •
The client can lie on a dense rubber ball to clear trigger points here
• FIGURE 8-5 Serratus posterior inferior trigger points and referral zones. ( Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
C H A PTER 8
LOW E R TORSO A N D A B D O M EN
219
External and Internal Obliques: Pseudovisceral Pain We will consider these two muscles together because of their trigger points and referrals being categorized together (Fig. 8-6) . ORIGIN External Oblique
•
Ribs 5-12
Internal Oblique
•
Anterior iliac crest
•
Inguinal ligament
•
Flexion of trunk (bilateral)
•
Lateral flexion and rotation of trunk to same side (unilateral)
TRIGGER POINTS AND REFERRAL ZONES
Trigger points may occur anywhere within the muscle bel lies and may cause as many problems from induced visceral dysfunction or from pain that limits activity as from referred sensation. These referrals quite often confuse the diagnostic process because of the mimicking of visceral pathology.
INSERTION
Referral sensation and patterns from trigger points here are
External Oblique
less consistent from person to person than those for most
•
Iliac crest
•
Abdominal aponeuroses
Internal Oblique
• •
Costal cartilages of ribs 9-12 Abdominal aponeuroses
other muscles. Trigger points on one side of the abdomen can cause sensation on the other side or even bilaterally. Trigger points here have been known to actually stimulate appendicitis. There may be strong referral sensation to the stomach area just inferior to the ribs and into the lower abdomen and groin area. Spillover sensation could be in the lower chest
ACTION •
and anywhere in the abdomen as well.
Compression of abdominal contents (bilateral)
Inguinal ligament
Rectus abdominis
Rectus abdominis (tendinous intersections) Crest of ilium Attachment of external oblique (cut) to iliac crest
• FIGURE 8-6 E xternal and internal obliques anatomical attachment sites. ( Reprinted with permission from Clay JH, Pounds DM. Basic Clinical Massage Therapy: Integrating Anatomy and Treatment. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2008:270; Plate 7-3.)
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These trigger points can be quite enigmatic and therefore a source of diagnostic confusion. It is important to grasp the idea of reciprocal somatovisceral and viscerosomatic effects of trigger points. Trigger points may produce referred sensation, usually in the form of pain and visceral disorders (somatovisceral effects) that closely mimic visceral disease such as gallblad der disease and appendicitis. Meanwhile, visceral disease can strongly influence somatic sensory perception and can activate trigger points in somatic tissue that may even per petuate symptoms long after this person has recovered from the visceral disease. When there are actual trigger points in the oblique mus cles, symptoms will most likely be abdominal pain and/or pressure with bloating, heartburn, vomiting, and diarrhea
\. I )
B
A
Belch button
External oblique
(Fig. 8-7) . TRIGGER POINT ACTIVATION
Trigger points here are usually the result of direct trauma from acute or chronic overload, as from mechanical, toxic, or emotional stress. Activation could also be induced due to being within the reference zone of pain referred from a vis ceral organ, in response to visceral disease. Visceral diseases, in general, and especially peptic ulcers, have been known to be responsible for abdominal trigger points. Trigger points in the abdomen are also likely to develop during an infestation by intestinal parasites. STRESSORS AND PERPETUATING FACTORS •
Compression to musculature and organs due to high hip/low hip and/or shoulder
•
•
Abdominal infestation
•
Pregnancy
•
Obesity
•
Actions involving throwing
PRECAUTIONS •
•
\/
Leaning to one side or forward for long periods of time while sitting in a chair (sustaining a twisted position)
D
c Lateral Abdominals
A
Causes diarrhea
• FIGURE 8-7 E xternal and internal obliques trigger points and referral zones. ( Reprinted with permission from Simons DG, Travell JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore, M D: Lippincott Williams & Wilkins, 1999. Trove" & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1. p. 942, Fig.49. 1. )
All abdominal muscles may have somatovisceral or viscerosomatic trigger points Referral patterns and symptoms should be noted, and proper client follow-up including appropriate referrals be applied
•
MASSAGE THERAPY CONSIDERATIONS •
Both oblique muscles have posterior attachments that
•
Use of a braced fingertip works well applied between each rib
Muscle stripping works best beginning at the iliac crest and applying it toward the insertions
may need work •
Because of the directions of oblique fibers, there may be a contribution to a chronically high hip
•
These muscles are likely to have adhesions that must be addressed
C H A PTER B
LOWER TORSO A N D A B D O M EN
221
Transverse Abdominis: Pseudovisceral Pain This muscle is deep to the obliques, with its muscle fiber direction being almost horizontal (Fig. 8-8). ORIGIN •
Linea alba via the rectus sheath
•
Pubis
INSERTION •
Lateral third of the inguinal ligament
•
Anterior three quarters of the iliac crest
•
Thoracolumbar fascia
•
Inner surface of the cartilages of lower six ribs (inter digitating with diaphragm fibers)
ACTION •
Increases intra-abdominal pressure
,vh'W.jb""....,..,/- External oblique
TRIGGER POINTS AND REFERRAL ZONES
Transverse abdominis
According to Travell and Simons, there may or may not be trigger points in this muscle. If there are, they are typically located laterally, with sensation traveling strongly from the
��-r1---'r--lnternal oblique
iliac crest and just above area into the groin. There may also be spillover patterns that travel up and across the abdomen (Fig. 8-9). Often symptoms from trigger points in the abdominal muscles are confusing and may mimic symptom of other conditions. Travell and Simons state that it is important to
Rectus abdominus
understand the reciprocal somatovisceral and visceros omatic effects of trigger points to ease the confusion. Trigger points in abdominal muscles may produce referred abdomi
• FIGURE 8-8 Transverse abdominis anatomical attachment sites.
nal sensation and visceral disorders that, when happening
( Reprinted with permission from Oatis CA. Kinesiology. Baltimore, MD:
together, may closely mimic a visceral disease. Also, visceral
Lippincott Williams & Wilkins; 2004; Fig.33-6.)
disease can impact somatic sensory perception and may acti vate trigger points in somatic tissues perpetuating pain and other symptoms beyond the recovery time from the initiat ing visceral disease. TRIGGER POINT ACTIVATION
As with the abdominal oblique muscles, trigger points
111
transverse abdominis are most likely to become activated because of acute or chronic overload or as the result of being within a referral zone. Generally, these trigger points occur because of visceral disease, direct trauma, and mechanical, toxic, or emotional stress.
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M U SCLES AND N E U RO M U S C U LA R TH ERAPY ROUTI N E S BY BODY REGION
\/
�
Lateral Abdominals
Causes diarrhea
• FIGURE 8-9 Transverse abdominis trigger points and referral zones. ( Reprinted with permission from Simons DG, Travell JG, Simons L S. Upper Half of Body. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins, 1999. Trave" & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual;
vol 1. p. 942, Fig.49.1C & D.)
STRESSORS AND PERPETUATING FACTORS •
Chronic coughing, diarrhea, vomiting
•
Overuse with actions that compress the abdominal contents
•
Pregnancy or obesity
PRECAUTIONS •
All abdominal muscles may have somatic-visceral or visceral-somatic trigger points
•
Referral patterns and symptoms should be noted and proper client follow-up be applied
MASSAGE THERAPY CONSIDERATIONS •
The three expansive abdominal muscles (two oblique and one transverse) have an individual fascial sheath; each of the three sheaths blend to become the rectus abdominis sheath
C H A PT E R 8
LOW E R T O R S O A N D A B D O M EN
223
Rectus Abdominis and Pyramidalis: Pseudovisceral Pain The long fibers of rectus abdominis usually have three or four transverse tendinous inscriptions or fibrous bands that interrupt the fibers along their length. This is what creates the so-called "six pack abs." These give the muscle more strength to keep the abdominal contents from pushing for ward (Fig. 8-10). The pyramidalis is highly variable, often being absent in individuals. Several studies of more than 100 bodies cited by Travel! and Simons show that it is absent bilaterally in 33% of Japanese, 25% of Scottish, and in 15% to 20% of bodies in general. I (Fig. 93) A unilateral absence was more common than bilateral absence. ORIGIN Rectus
•
Crest of the pubic bone interlacing across the symphysis
Pyramidalis
•
Anterior ramus of pubis near the symphysis
INSERTION Rectus
•
Cartilage of ribs 5-7
Pyramidalis
•
Linea alba midway between the symphysis and the umbilicus
ACTION Rectus
•
Flexion of the trunk (lower thoracic and lumbar spine)
•
Increases intra-abdominal pressure
Pyramidalis
•
Tenses the linea alba
• FIGURE 8-10 Rectus abdominis anatomical attachment sites. ( Reprinted with permission from Bickley LS, Szilagefi P.Bates Guide to Physical Examination and History Taking. 8th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2003.)
224
P A R T II
M U S C L E S A N D N E U R O M U S C U L A R T H E R AP Y R O U T I N E S B Y B O D Y R E G I O N
_1 -
_2-
\/ j
\/ c
I
Dysmenorrhea
Rectus abdominis
McBurney's point
• FIGURE 8-11 Rectus abdominis trigger points and referral zones. ( Reprinted with permission from Simons DG, Travell JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins, 1999. Trave" & Simons'Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1.
pp. 944-945, Fig.49.2A -C.)
TRIGGER POINTS AND REFERRAL ZONES
TRIGGER POINT ACTIVATION
Trigger points in rectus abdominis are found within the muscle belly. T he referrals are usually quite strong and sur
As with the other abdominal muscles, trigger points in this area are usually activated because of visceral disease, trauma,
round the actual trigger points (Fig. 8-11) .
or stress.
In pyramidalis, the trigger points are also in the belly of the muscle, but very close to the origin at the pubic crest.
STRESSORS AND PERPETUATING FACTORS
The referral area is mainly spillover running from the
•
Prolonged driving in a car
umbilicus down to the origin point (Fig. 8-12).
•
Collapsed chest and rounded shoulders
As with the other abdominal muscles, symptoms usually
•
Not using your abdominal muscles to sit up straight
are pressure and pain in the abdominal area. The client may
•
Pregnancy or obesity
fee I fuII or gassy.
CHAPTER 8
L O W E R TO R S O A N D A B D O M E N
225
( I, ,,,
i\� Iii, ((III! l lill (((II) l\\\\) \ \/ Pyramidalis • FIGURE 8-12 Pyramidalis anatomical attachment sites with trigger points and referral zones. ( Reprinted with permission from Simons DG, Travell JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins, 1999. Trovell & Simons'Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1. p.945, Fig.49.2D.)
PRECAUTIONS •
When using techniques in a medial-to-Iateral direc
MASSAGE THERAPY CONSIDERATIONS •
•
Be sure to work the anterior aspect of costal carti lages
tion, be aware that the linea alba may be weak and susceptible to separating, for example, post-pregnancy
•
T he lateral border of rectus abdominis is accessible
An anterior branch of a spinal nerve may become
•
When applying muscle stripping, it works best to do so
entrapped and produce pain that could stimulate gyne cological disease
in shorter lengths
226
P A R T I I/
M US C L ES A N D N E U R O M US C UL A R TH E R AP Y R O U TI N ES B Y B O D Y R E G I O N
lliopsoas:The Hidden Prankster The iliopsoas consists of the psoas major and minor and ilia cus. Travell and Simons refer to this group as the hidden
Psoas minor
prankster in the sense that it serves many critically important functions, often causes pain, and is relatively difficult to access. For instance, unidentified iliopsoas and/or quadratus lumborum trigger points are frequently responsible for a failed
Psoas major
low back postsurgical syndrome. Doctors may consider it failed because they have not correlated referral sensation from trigger points with the pain existing after the surgery. The psoas minor is quite variable, being absent bilater ally in 40% to 50% of people. When present, it is anterior to psoas major (Fig. 8-13). ORIGIN Psoas Major
•
All lumbar transverse processes
•
Bodies of vertebrae T 12-L5
•
Intervertebral discs above each lumbar vertebrae
Psoas Minor
•
Anterolateral aspect of the vertebral body of T12-Ll or L2
Iliacus
•
Inner surface of the ilium (iliac fossa)
•
Anterior lumbar ligament
•
Iliolumbar ligament
•
Lumbosacral ligament
INSERTION Psoas Major and Iliacus
•
Lesser trochanter of the femur
• FIGURE 8-1 3 Iliopsoas anatomical attachment sites. ( Reprinted with permission from Scheumann DW. The Balanced Body: A Guide to Deep
Psoas Minor
•
Pectineal line on the superior ramus of the pubic bone
•
Iliopectineal eminence
•
Iliac fossa
ACTION Psoas Major and Iliacus
Tissue and Neuromuscular Therapy. 3rd ed. Baltimore, MD: Lippincott
Williams & Wilkins; 2007:1 75; Fig. 9-22E.l
TRIGGER POINTS AND REFERRAL ZONES
Trigger points may occur within the muscle bellies anywhere along the length of the psoas major and minor. Iliacus trig
•
Flexion of the hip
ger points also occur within the muscle bellies but usually
•
Flexion of the lumbar spine when bending forward
close to the iliac crest.
•
Extends lumbar spine when standing with normal
•
lumbar lordosis Assists lateral rotation of the hip
with spillover beginning higher in the posterior thorax and
Psoas Minor
•
Referred sensation from this muscle group extends along the spine from the lower thoracic area to the sacroiliac area,
Assists psoas major with extension of the normal lordotic curve of the lumbar spine when flexing at the lumbosacral joint
spreading out more laterally along the length of the referral zone into the upper buttock region. Sensation can also be referred to the anterior thigh and groin (Fig. 8- 14). A person will often complain of low back pain when there are unilateral trigger points in the iliopsoas. The client
C H A PT E R 8
LOWER TORSO A N D ABDOMEN
2 27
TRIGGER POINT ACTIVATION
Trigger points here are most likely activated secondarily to trigger points in other, synergistic muscles. In either case, these trigger points are most likely activated because of sud den overload during a fall. Problems can come about whenever a person sits with the buttocks pushed backward with the torso leaning for ward putting the knees higher than the hips. Studies by Lewit2•3 showed that trigger point tenderness in the psoas may be associated clinically with articular dys function in the thoracolumbar region in general and specifi cally with dysfunction of the lumbosacral junction. Other research by Dobrick4 showed that back pain caused • FIGURE 8-14 Iliopsoas trigger points and referral zones. ( Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
by iliopsoas trigger points is quite common during preg nancy. Dobrick believed that a viscerosomatic reflex was most likely responsible for the close association he observed between painful dysfunctions of the internal female genita lia and increased tension of the iliopsoas muscle. He did not
may explain this condition by running their hand up and
address the importance of the reverse process: somatovis
down the spine rather than across the back to show where
ceral reflex aggravation of gynecological symptoms created
they feel it.
by iliopsoas trigger points, however.
When the trigger points in question are bilateral, the cli ent will experience the pain across the lower back, as when there are active trigger points in the quadratus lumborum.
STRESSORS AND PERPETUATING FACTORS •
Prolonged sitting with knees above the hips or with the hips acutely flexed, as in an automobile with a low
This person may tell you that it feels worse when they stand up and that they have a slight nagging low backache when
bucket seat
lying down. Frequently, this person will also complain of a
•
Hyperlordosis and an anterior pelvic tilt
very deep pain in the front of the thigh that feels like the
•
Sleeping in a fetal position
femur hurts. Often a person with these trigger points cannot
•
Lower limb length inequality or a small hemipelvis
arise from a deep-seated chair or may have to crawl on hands
•
Excessive sit-ups
and knees rather than get up and walk. According to Travell and Simons, a person with a hyper trophied psoas will also have a neighboring section of the
PRECAU TIONS •
The aorta, vena cava, and ureter tube are in the area
large intestine compressed. If constipated, the passage of
medial to the psoas muscle. Friction techniques and/or
hard feces can actually press against the trigger points.
trigger point pressure must be applied here appropri ately
Travell and Simons cite a surgeon who found that ps�as minor syndrome is caused by a tense psoas minor muscle and tendon. This surgeon observed it most often on the right side of girls 15 to 17 years old who had been diagnosed as
MASSAGE THERAPY CONSIDERATIONS •
having suspected appendicitis. T he surgeon attributed the tension of the muscle to its failure to keep up pace with the
•
To check the isolation of the psoas, have the client initiate flexion of the hip against resistance
growth of the pelvis. He stated that he could palpate a strand of the psoas minor, calling it a tendon, through the abdo
The psoas is best accessed with the client's leg in a flexed hip position while lying supine
•
Using a sustained pressure and both deep transverse
men. The pain was aggravated by palpation of this taut so
and longitudinal friction while incorporating knee
called tendon. Consistently, the appendix was normal, and
flexion and extension is the most effective technique
the pain, along with any scoliosis of the lumbar spine (con vex to the side opposite the taut psoas minor), was relieved
When there is chronic low back pain, this muscle group should always be considered within the treat
by softening this muscle.
ment plan
•
2 28
P A RT I I
M U S C L E S A N D N E U R O M U S C U L A R T H E R AP Y R O U T I N E S B Y B O D Y R E G I O N
Intercostals The internal and external intercostal muscles have a criss cross arrangement of fibers at almost a right angle to each other. This is similar to the fiber direction and criss-crossing of the internal and external abdominal obliques and in the same direction. This type of fiber arrangement is what is used in successive plies of an automobile tire. In other words, this makes for a very strong structure. The 11 pairs of external intercostals do not extend the full length of each intercostal space, reaching the costal cartilage anteriorly, except between the lower few ribs. The 11 pairs of internal intercostals are incomplete posteriorly, extending from near the sternum anteriorly to the angles of the ribs posteriorly (Fig. 8-15). ORIGIN (BOTH) •
Inferior aspect of ribs 1-11
INSERTION (BOTH) •
Superior aspect of ribs 2-12
ACTION (BOTH) •
Rotation of the thoracic spine
•
Quiet forced inhalation
•
Forced exhalation
TRIGGER POINTS AND REFERRAL ZONES
Trigger points in these muscles are located anywhere
• FIGURE 8-15 Intercostals anatomical attachment sites. ( Reprinted
between the rib spaces. The referral sensations mostly have
with permission from Moore KL, Agur A. Essential Clinical Anatomy.
a pattern that surrounds the actual trigger point, some of which is spillover (Fig. 8-16).
2nd ed.P hiladelphia, PA: Lippincott Williams & Wilkins; 2002.)
J • FIGURE 8-16 Intercostals trigger points and referral zones. ( Reprinted with permission from Simons DG, Travell JG, Simons LS.Upper Halfaf Body. 2nd ed. Baltimore, M D: Lippincott Williams & Wilkins, 1999. Travel! & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1.p. 863, Fig.4S.1.)
C H A PT E R 8
LOW E R T O R S O A N D A B D O M E N
229
SYMPTOMS
collection of air or gas in the pleural cavity, whereas a pyot
A client with trigger points in this region will most likely
horax is pus in the pleural cavity.
complain of having aching pain somewhere in the rib area. This client may not be able to lie in a position that puts body weight onto the actual trigger point. The client will likely report that any deep inhalation such as that required during exercise or coughing or sneezing is quite painful. There may be a trigger point here on the right side that causes a symptom such as cardiac arrhythmia.
STRESSORS AND PERPETUATING FACTORS •
Impact trauma
•
Excessive or chronic coughing or sneezing
•
Chest surgery, particularly when there has been the use of chest retractors
•
Intrathoracic lesions
•
Paradoxical breathing
TRIGGER POINT ACTIVATION
Activation of trigger points will usually be due to an acute or chronic overloading of the muscles. There may be pos
PRECAUTIONS •
tural considerations as well. A person with scoliosis, for
Be sure to be thorough in this area when there is chest pain present
instance, may have quite a few activated trigger points resulting from the twisting of his or her ribs. Trigger points will also activate because of a fracture of a
MASSAGE THERAPY CONSIDERATIONS •
consider are intrathoracic lesions such as pneumothorax,
A thorough examination of the intercostals should always be done after any chest surgery, especially if the
rib. This may also happen when there has been a breast implant, or after an attack of herpes zoster. Other factors to
ribs were retracted •
There is a trigger point that appears in the intercostals
pyothorax, and pleural effusion (secondary to a tumor),
on the right side that is called the arrhythmia trigger
according to Travel! and Simons.
point
A pneumothorax is a
230
PART I I
M U S C L E S A N D N E U R O M U S C U L A R T H E R A P Y R O U T I N E S B Y B OD Y R E G I O N
Diaphragm The diaphragm is a dome-shaped musculofibrous structure
Xiphoid process
that separates the thoracic and abdominal cavities. It is a fascinating muscle that inserts into itself by way of a cen trally located tendon and has three openings within it for the aorta, esophagus, and inferior vena cava to pass through
Sternal portion Costal portion
(Fig. 8-17) . ORIGIN •
Lower anterior vertebrae bodies of U-U by way of two fibrous arches called crura or arcuate ligaments
•
Lower six rib cartilages
•
Xiphoid process of the sternum Right crus (tendon) of diaphragm
INSERTION •
Lumbar portion
Central diaphragm tendon
ACTION •
Flattens the central tendon, thus increasing thoracic cavity volume during inspiration
TRIGGER POINTS AND REFERRAL ZONES
• FIGURE 8-17 Diaphragm anatomical attachment sites. ( Reprinted with permission from Hendrickson T.Massage far Orthopedic Conditions. Baltimore, MD: Lippincott Williams & Wilkins; 2003; Fig.4-37. )
Trigger points can form anywhere within this muscle and refer sensation in various ways. During vigorous exercise, diaphragmatic trigger points often refer deep anterolaterally near the lower border of the rib cage.
A person with trigger points in this muscle will likely
Referral sensation coming from a trigger point in the
complain of having a stitch in the side when vigorously
central dome portion of the muscle may be felt at the upper
exercising or deep aching pain in the costal margin of the
border of the ipsilateral shoulder. A trigger point in the peripheral portion of the muscle will refer to the adjacent
ribs. The difference in referral sensation from trigger points
costal margin (Fig. 8-18) .
site.
in this muscle depends on the innervation of the stimulated
• FIGURE 8-18 Diaphragm trigger points and referral zones.
C H A P T E R 8/
L O W E R T O RS O A N D A B D O M E N
231
Travell and Simons discuss a series of 17 patients com
may also be marked relief of esophageal spasms when the
plainiRg of chest pain, dyspnea or shortness of breath, and
stooped postural pattern has changed and hypertonicity of
inability to get a full breath as being attributed to the spasm
the diaphragm has been relieved.
of the diaphragm. Nine of these patients complained of pain in the subster nal region and eight described their pain to be in or near the right hypochondrial region. This suggests that the location of the pain/sensation also identified the nerve supply and identified the portion of the diaphragm from which the sen
Most likely there will be increased vital lung capacity in people with emphysema and asthma after the diaphragm has been treated with neuromuscular therapy. STRESSORS AND PERPETUATING FACTORS •
Environmental factors that effect the respiratory sys tem
•
A posture of having a collapsed chest with a forward
sation originated. They concluded that this principle may also apply to referrals from diaphragmatic trigger points.
head
Sometimes clients will describe an attack that was pre cipitted by an anxiety-producing situation in which they
•
felt they had so much difficulty breathing that they feared they might die. Others may simply complain of many and/or long periods of hiccupping.
Low self-esteem usually puts a person
111
the above
mentioned posture •
Cervical whiplash that affects the phrenic nerve
PRECAUTIONS
TRIGGER POINT ACTIVATION
•
Be sure to work within the client's pain threshold
Trigger points in the diaphragm may be activated by exer
•
This area must be thoroughly warmed then worked using gentle sustained pressure
cise, such as fast walking or running, or by a persistent cough. Trigger points may also activate following gastrectomy: sur gical removal of part of or the entire stomach. It should be noted that the aorta, esophagus, and inferior
MASSAGE THERAPY CONSIDERATIONS •
Cervical work should always be performed on those
vena cava pass through the diaphragm. A stooped postural
with breathing difficulties and poor movement of the
position such as that of hyperkyphosis will cause occlusion of these structures, particularly the inferior vena cava. Cases
muscle while originating from C3 to C5
of swelling in the lower extremities and protruding varicosi. ties,
or
diaphragm because the phrenic nerve innervates this •
varicose veins, behind the knees may clear up rap
idly when postural corrections have been made in this area.
•
Especially toward the midline, you must thoroughly
•
Chest and torso compression techniques work well to
soften the obliques to be able to access the diaphragm
Partial occlusion of the inferior vena cava by the dia phragm can cause a pressure build up in the venous return system and create swelling and pressure in the veins. There
Recommend that the client learn to use proper dia phragmatic breathing techniques
aid release of the diaphragm
232
PA R T I I
/
M U SCLES A N D N E U RO M U SCULAR TH ERAPY ROUTI N E S BY BODY R E G I O N
Lower Torso a n d Abdomen N e u ro m u sc u l a r Therapy Routi ne Note that the video icon indicates routines that a re featured i n online video clips, on t h e book's compa nion Web site.
THE LOWER, POSTERIOR TORSO
e
I n itial ly, use no l u b rication. 1. Perform general loosening and warming. Assess musculature
with compression through the sheet.
2 . Skin roll the superficial tissue to warm and assess for any ten
der/congested a reas. This may ind icate ischemia or fascial binding of tissues requiring further specific work i n that area. Be sure to rol l the skin in eight d i rections. Please refer to the online video instructions for this technique, as it is q u ite ben eficial if done properly (Routine 8- 1 ).
3. Perform superficial fascia release technique along the spinous
processes from the sacrum to the inferior angle ofthe scapula. This is done by l ifting the s k i n a bove a spinous process using thumbs and fi ngers to hold it and then giving a q uick tug of the skin. You r index finger and thumb from one hand will be touching the index fi nger and thumb from the other
• ROUTINE 8-1
hand if the tissue is being held properly. Aga i n, please refer to the online video to check on this tech nique if in question (Routi ne 8-2). Note: apply lubrication.
• ROUTINE 8-2
C H AP T E R 8
4. Use a deep effleurage with the forearm a long the erector
spinae, from the lower scapula to the sacrum, to warm and loosen further. Repeat this technique in a superior d i rection as well. Now, petrissage and friction thoroughly (Routine 8-3).
ERECTOR SPINAE AND TRANSVERSOSPINALIS GROUPS
e
Stand at the side of the table, facing the client's h ips, and work at the level of the client's head. 1. Starting at the lower scapula a rea, use thumb stripping, then
petrissage, working longitudinally along the three aspects of the erector spinae, to the sacrum (Routine 8-4).
2. Isolate any tight fibers or trigger points and release with a
combination of cross-fi ber friction, longitudi n a l friction, and trigger point pressure. Take the time to work very thor oughly. • ROUTIN E 8-3
3. Work the lateral surfaces of the spinous processes from the
mid-thoracic spine to the sacrum using transverse and longi tudinal friction with a T-bar. Isolate the attachments of the erectors and transversospinalis muscles (semispinalis, multi fidus, and rotatores) and other muscles. Use a broad enough sweep to affect the tissue (Routine 8-5).
Note: stand at the side of the table, facing the head.
4. I l iocostalis a n d thoraco lu m ba r a poneuroses: Thoroughly
muscle strip the iliocostalis a nd fascia. These structures are very large both in width and in depth.Work from the iliac crest to the attachment at the 1 1 th rib using transverse friction,
• ROUTIN E 8-4
longitudinal friction, and trigger point pressure. (Often the area at the 1 1 th and 1 2th ribs is quite tender.)
5. Iliocostalis thoracis: With thumbs, g lide from lateral to medial
across the iliocostalis, staying between ribs. Begin between ribs 1 1 and 1 2, moving superiorly incrementally until reaching the inferior angle of the scapula.This gliding between the ribs should be deep but tolerable by the client.
• ROUTINE 8-5
LOWER TORSO AND ABDOMEN
233
234
PART I I
M U SCLES A N D N E U RO M USCUL A R T H ERAPY ROUT I N ES BY BODY R E G I O N
6. Beginning again at the 1 2th rib, use transverse friction with
the pads offi ngers movi ng up to a pproximately the 3 rd or 4th ri b while staying on the ropy portion of the m uscle at the a n g l e of the rib. Repeat this u nti l all rib attachments have been add ressed. Cont i n u e treating this a rea using trigger point pressure, a s necessary (Routine 8-6).
7. Serratus posterior inferior: Isolate this muscle with thumb strip
ping and then broad transverse friction from the origin out to the insertion on the ribs. Remember that serratus posterior inferior origi nates from the spinous processes of T1 1 -L2, inserting at ribs 9-1 2. The fiber direction is at an oblique angle, upward and outward. It pays to be thorough at the rib attach
• ROUTINE 8-6
ment, as this is often a tender area (Routines 8-7 and 8-8). Note: stand at the side of the table, facing the low back.
• ROUTINE 8-7
• ROUTIN E 8-8
CHAPTER 8
8. Apply direct sustained pressure into the belly of iliocostalis lu mborum using the fingertips of both hands.The d irection of pressure is at a 4S-degree angle to effect a deep myofascial release (Routine 8-9).
SACROILIAC LIGAMENTS/SACRUM Stand at the head or side of the table facing the sacrum, which ever is more comfortable. 1 . Thoroughly thumb strip the entire surface of the sacrum from superior to inferior. Use skin rolling to warm and loosen areas of restriction, if necessary. If extremely tender, it may help to apply myofascial melti ng tec h n i qu es to the a rea before
• ROUTIN E 8-9
proceeding (Routine 8-1 0).
2. Holding the T-Bar at a 4S-deg ree angle to the lateral aspect of
the spinous processes of the sacrum, use transverse and lon gitudi n a l friction (Routi ne 8-1 1 ). Move a long the spinous processes of the sacrum from superior sacrum to i n ferior, being sure to stop before a pplying any pressure to the coccyx. At the su perior aspect of the sacru m aga i n, move laterally approximately one thumb width and a pply the same tech nique. Then, do a third line down the sacrum another thumb width lateral to the second line. Each of the three lines will become shorter as you move out laterally due to the tapering shape of the sacrum. This friction has now com p l etely covered the posterior surface of the sacrum a long with the
• ROUTIN E 8-10
sacrospinous and sacroiliac ligaments.
• ROUTIN E 8-11
LOW E R T O R S O A N D A B D O M E N
235
236
PART I I
M USCLES A N D N E U RO M U SCU LAR TH ERAPY ROUTI N E S B Y BODY R E G I O N
ILIOLUMBAR LIGAMENT
e
Stand at the side of the table. facing the client's sacrum. 1 . Place the T-Bar between the PSIS. or posterior superior i liac spine. and the spinous process of LS (the soft spot-no sac rum here-just superior to the top of the sacrum and medial to the PSIS). Apply sustained myofascial compression toward the table allowing the tissue to change (Routine 8-1 2).
2 . With the T-Bar stil l i n place over the ligament (it should feel
l i ke a broad. tough band on a superior-medial oblique angle). a p ply gentle transverse friction. • ROUTINE 8-12
QUADRATUS LUMBORUM
�
Stand at the side of the table facing the client's head. 1. Using thumbs. muscle strip quadratus l u m borum from the
iliac crest to the 1 2th rib. Be sure to work in the three different fi ber d i rections of this muscle (Routine 8-1 3).
2. Using the pads of you r thumbs. a p ply transverse friction along
the i nferior su rface of the 1 2th rib. moving from lateral to medial. Use any trigger point pressure necessary there (Routine 8-1 4). • ROUTINE 8-1 3
• ROUTIN E 8-14
C H A PT E R 8
3. Work each insertion at the transverse processes of L 1 - L4
using a thumb for friction and trigger point pressure to isolate and release any tight fibers or trigger points found. Be sure to be gentle, yet d i rect and specific (Routine 8-1 5).
Note: turn and face the client's iliac crest from the side of the table. 4. Clear the i liac crest by applying transverse friction with the
pads of thumbs from the sacrum to the lateral margin of the crest. This treats the origins of longissimus, latissimus dorsi, i liocostalis lumborum, quadratus l um boru m , i nternal obliques, and external obliques, in that order.
• ROUTIN E 8-15
5. Using the fingerti ps of both ha nds, use deep myofascial
releasing to the lateral border of q uadratus l u m borum. Hold the direction in a 45-degree angle with steady pressure for the melting, as done with the iliocostalis. This time, be s u re to be out quite lateral ly on q uadratus l u m borum. Now, move the fingertips in a superior/inferior, longitudinal d i rection while pushing back med i a l ly toward the transverse processes of L 1 -L4 frictioning. Be gentle with this (Routi ne 8-1 6) .
6 . Apply a mobilization technique using t h e body mobilization technique called " i l iac scissors." Please refer to the online
• ROUTIN E 8-1 6
video to help perfect this (Routine 8-1 7).
STRETCHES
�
1 . End with the cl ient supine to apply a knee-to-chest stretch and/or a l umbar roll. Be sure to use the proper stabilization for each.
2. Apply all of the a bove techniques to the other side of the
body.
• ROUTINE 8-17
LOWER TORSO A N D ABDOMEN
237
238
PART I I
M U SC L E S A N D N E U ROMUSCU LAR T H E R A P Y ROUTI N E S B Y BODY R E G I O N
THE LOWER CHEST AND ABDOMEN Have the client lie s u p ine, with the knees s u pported with a bolster.
GENERAL TORSO WORK
e
Have the client lie supi ne. Prior to l u b rication, skin roll the entire a bdomen in all eight directions: superior to i nferior, inferior to superior, medial to lateral, lateral to medial, and obliq uely in fou r d i rections (Routine 8-1 8). 1 . Attune you rself to the client's breathing. Esta b l ish contact with a gentle placement of hands and light rocking. • ROUTINE 8-1 8
Note: lightly apply oil.
2. Continue with general warming and loosening, using effleurage
of the abdomen in a circular motion, clockwise in direction.
EXTERNAL AND INTERNAL OBLIQUES, TRANSVERSE ABDOMINIS, AND INTERCOSTALS
e
Stand at the side of table, working the opposite side of the abdomen. 1 . Use full-handed pulling strokes of effleurage from the direc tion of the a x i l l a to the i l iac crest, warming the m uscles (Routine 8-1 9). Note: do the same to the other side of the body, and then stand facing the abdomen and work on the same side of the body.
2. Once warm, use more specific fi ngertip pressure to affect
intercostals, serratus anterior, i nternal and external obliq ues, and transverse a bdominis. Work the intercosta ls with specific fingertip effleurage all the way to the sternu m .
3. Isolate t h e o b l i q u e s a n d tra nsverse a bdominis with petris
sage. Release any tight bands or fi bers with petrissage and then fi ngertip-sustained pressure. Release any trigger points using trigger point pressure.
4. Move to the other side of the client and repeat this work.
• ROUTINE 8 -19
CHAPTER 8
RECTUS ABDOMINIS AND PYRAMIDALIS
e
Work on the same side with the client still supine. 1 . Begi n with an open a n d ful l-handed g rasp of the rectus abdominis using both hands. Gently grasp and lift the muscle using a gentle rocking motion for a relaxing effect. Petrissage the ful l length of the lateral borders from ribs to the crest of the pubis (Routi ne 8-20).
2. Work with fi ngertip friction and trigger point pressure along
the belly and lateral border (this is the attachment point of the obliques and transverse abdominis) from the ribs to the pubis.
3. Fascia combing: a nchor the tissue and fascia with the thumb
of one hand from a bove. Use hooked fi ngers of the other hand to pull with fingertips.The su perior hand anchoring the tissue stays stationary. Move 2 i nches at a time i n different d i rections combing across or through and isolating tight bands. Work rectus, pyra midalis, the obliq ues, and transverse a bdominis
• ROUTINE 8-20
thoroughly this way. You may wish to review this portion of the o n l i ne video pertai n i ng to this part of the routi ne (Routine 8-2 1 ).
4. Muscle strip the rectus bellies using thumbs from inferior to
su perior. Use finger pads to lig htly transverse friction the lat eral borders and bellies of the m uscle. The therapist may a lso use circular friction on any tight segments a nd/or to isolate the tendinous i n scri ptions. Use trigger point pressure as necessary (Routi ne 8-22).
• ROUTINE 8-21
• ROUTINE 8-22
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5. Use circular friction, transverse friction, and gentle direct pres
sure on the attachment of the abdominal muscles on the costal cartilages and ribs. Also use trigger point pressure, if necessary (Routine 8-23).
Note: be specific with the application of friction. Engagement of these fibers will be on the entire anterior area of the costal carti lages, not just the inferior aspect of the sternal area.
Face the client's feet. 6. Use gentle transverse, longitudinal, and/or circular friction on
the attachment at the crest of the pubic bone. You may also use gentle trigger point pressure as needed, with the pads of
•
ROUTINE 8-23
•
ROUTINE 8-24
•
ROUTINE 8-25
thumbs or fingertips to the pubic crest. This can all be done through the sheet (Routine 8-24).
7. Clear the iliac crest attachments of the obliques with friction.
8. Repeat steps 2 through 6 on the other side of the abdomen.
9. Complete with clockwise abdominal circles of effleurage;
then, place the palms onto the abdomen, gently moving with the client's breath.
ILIOPSOAS
e
With the client still supine, remove the bolster. Have the client raise the knee and rest the foot flat on the table on the side the therapist is working. 1. Using fingertips, approach the psoas at the level of the navel
just lateral to the border of rectus abdominis. Apply pressure to the viscera while moving counterclockwise and pressing toward the table at a 45-degree angle, until you feel the psoas. This muscle will feel harder than the surrounding organs (Routine 8-25).
2. Confirm the pressure on the psoas by having the client lift the
knee toward the chest, with your elbow giving slight resist ance. This lift against resistance will initiate a contraction of the psoas, allowing you to feel the muscle harden. (You may wish to review the corresponding online video.)
CHAPTER 8
3. Pressing into the psoas using as many fingertips as possible alung the length of the muscle, instruct the client to slowly drag the heel and foot of the leg with the raised knee down the table and back up, raising the knee again several times while you apply pressure. This allows the client to do the work, making it easier to assess and work with this very deep mus cle. As the muscle begins to soften, you may also use some gentle transverse and longitudinal friction (Routine 8-26).
4. After several of the above movements, instruct the client to bend the knee again and begin to move the knee in a medial to-lateral motion, changing the movement of the muscle slightly. Continue to apply pressure and friction. These tech niques are quite effective in releasing tightness in this muscle using movement and work well for most people. Be sure to be gentle here and take your time.
5. Release any trigger points found along the way using trigger point pressure.
6. Repeat these techniques following the muscle superiorly under the rib cage and then inferiorly into the broadened, tendinous area just superior to the inguinal ligament. You may have to hold your hands in a more oblique direction for these two areas. Again, you may wish to refer to the online
• ROUTINE 8-26
video for this. Note: to easily access iliacus, have the client lie supine with the foot flat on the table and the knee resting out laterally on your knee that is resting on the side of the table.
7. Using the pads of your fingers, gradually sink into the depres sion of the anterior ilium (iliac fossa) containing the iliacus. Be sure to stay superior to the inguinal ligament. Use gentle, steady myofascial release techniques here incrementally sink ing in deeper and deeper as the muscle relaxes. Some friction can also be used. Try to get to as much of this muscle as possible (Routine 8-27). Note: have the client cross the ankle of the nearest leg over the opposite knee.
• ROUTINE 8-27
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8. Locate the anterior s u perior i l iac spine and move approxi
mately 1 inch i nferiorly, and then V2 to 1 inch med i a l ly to find the iliopsoas tendon attaching to the lesser trochanter. Use tra nsverse friction a n d trigger point pressure as necessary (Routine 8-28).
DIAPHRAGM
�
Have the client l i e supine with knees bent; face the client's head. 1 . Use your t h u m bs to grad ually warm the diaphragm and other tissue under the rib cage by gliding with the thumb pads in a media l-to-Iateral d i rection on both sides at the same time. Repeat enough to warm. Note: now work across the table on the opposite side.
2. Holding both thumb pads together near the midline, yet lat
era l to the xiphoid process, across the body, instruct the client to take i n a deep breath and then exhale. U pon exhalation, sink in and under the r i bs pushing u p agai nst them from
• ROUTINE 8-28
undemeath with your t h u m bs. While h o l d i n g that place, instruct the client to take in another breath and exhale. During the exhalation, work the thumb pads into the tissue under the ribs even deeper. Hold that place and i n struct the cl ient to take in a half breath and hold it. This exposes the diaphragm, making it open out from u nder the rib cage (Routine 8-29). Note: if the client needs to breathe and cannot hold breath any longer, instruct him or her to take one or two shallow breaths and then hold another half breath as you continue the treatment as below.
3. With you r t h u m b pads, use transverse friction to a ny tight
bands of fibers found i n the diaphragm against the posterior aspect of the anterior ribs. Use trigger point pressure when
• ROUTINE 8-29
necessary (Routine 8-30).
4. Work in a n i nferolateral direction, not removing you r thumbs
from the diaphragm until the entire m uscle on that side has been treated.
5. Repeat steps 2-4 from the other side. Note: stretch the iliopsoas and the hip flexors with the client in a prone position or from a supine position off the end of the table, if applicable, to the therapeutic situation.
• ROUTINE 8-30
C H A PT E R 8
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Case Study 8- 1 . Bonnie: A Wo man with a Band of Pa i n Wra p p i n g t h e Lower Back Area Background
The therapist worked with Bonnie's hi ps, back, shoulders,
Bonnie is a retired woman a pproximately 60 years old who
and neck in a prone position. She then had Bonnie turn supine
enjoys ta king dancing lessons. After a lesson one evening, she
on the massage table so she cou l d work on the rectus femoris,
noticed that her back h u rt a bit. The next morning she felt as
psoas, and i liacus.
though there was a big band wrapping her back at about the
Bonnie got off the table without the pain wrapping her
level of her lowest ribs.This persisted for a cou ple of weeks. As
back but decided to conti nue with neuromuscular therapy
she had previously been to a neuromuscu l a r therapist for
sessions for the rest of the month to be certain it would not
help when she had an issue with her neck 3 years ago, she
come back.
called her.
Treatment At her appointment with the neuromuscular therapist, Bonnie pointed out all of her sore areas up her back, into her shoulders and neck. She then explai ned that the worst of it was the area at her lower ribs, stating that it felt like there was a band wrapping it.
Critical Thinking Questions , . Why did the therapist work on any a nterior muscles, spe cifically the psoas and the i l iacus? 2. Which muscle has a referral pattern l i ke the pain Bonnie described? 3. If the therapist understood about the specific referral pat tern, why did she choose to work on other muscles as well?
Case Study 8-2 . Patty: A Personal Tra iner with Low Back Pa i n Background
posterior inferior, and q uadratus l u m borum, which are all in
Patty is a personal trainer, specifically a CrossFit trai ner. She
the low back area. The quadratus l um borum seemed to have
holds several classes each day teaching CrossFit exercises to
the most issues. The therapist then had Patty turn to a supine
her c l i ents. This is a very strenuous type of tra i ning that
position and also worked on her psoas and i l iacus. The psoas
i ncludes kettle bell training. Kettle bel ls are very heavyweights
seemed to be at issue more so than i l iacus. Patty needed
with handles. After one of her kettle bell classes, Patty began
another two sessions until the issue was completely worked
to notice that her low back felt tender and weak. The front of
out.
her thigh also h urt. As she bent down to take off her gym shoes, it actually felt as if her back was severed j u st a bove her hips and she was having a hard time standing u p straight. She sought neuromuscular therapy.
Critical Thinking Questions , . Which symptom or symptoms gave the therapist the idea to work on Patty's q uadratus l u m borum? 2. Which symptom or symptoms gave the therapist the idea
Treatment After hearing Patty out, the therapist began to apply her plan of action. The therapist worked with Patty's erectors, serratus
to work on Patty's il iopsoas? 3. Which muscle has a referral pattern that is similar to Patty's description of pain?
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REVI EW QUESTIONS
Short Answer
9 . Upon inhalation, the diaphragm A. contracts as it rises upward
1 . In how many directions are the fibers of quadratus lum
B. relaxes as it rises upward
borum oriented ?
C. contracts as it pulls downward
2. When clearing the iliac crest from medial to lateral,
D. relaxes as it is pushed downward
which attachments are being treated ? 3 . Regarding the muscle attachments to the iliac crest in
1 0. The ligament that attaches the lumbar spine to the ilium is the
the above question, write them in the correct order
A. Sacrotuberous ligament
from medial to lateral.
B. Sacrospinous ligament
4. In which muscle do trigger points occur because of
C. Iliospinal ligament
overload strain from lifting, turning, and reaching ? S.
Unresolved trigger points in which two muscles are often re ponsible for pain called failed low back post surgical syndrome ?
Multiple Choice Questions
6. Name the muscle that has a referral pattern that can mimic trochanteric bursitis. A. Serratus posterior inferior
D. Iliolumbar ligament True/False
1 1 . The pyramidalis is an anatomically variable muscle. 1 2. Often trigger points in abdominal muscles refer a sensa tion of fullness or gas. 1 3 . Tendinous inscriptions in the rectus abdominis muscle weaken it. 1 4. When a situation or condition is called enigmatic, it is
B. Quadratus lumborum C. Iliocostalis lumborum D. All of the above 7. Which muscles are grouped together under the name "iliopsoas" ? A . Iliacus, psoas major and minor B. Iliacus and psoas major C. Iliacus and psoas minor D. None of the above 8. The internal obliques interdigitate with which muscles at their attachments on the ribs ?
very clear and easy to figure out. IS.
Shortness and tightness in the psoas and iliacus with weak lower rectus abdominis bilaterally lead to a condi tion called lateral pelvic tilt.
Matching
a. Enigmatic
d. Pneumothorax
g. Varicosities
b. Gastrectomy
e. Dyspnea
h. Gastric by-pass
c. Adhesions
f. Pyothorax
i. Spider veins
1 6. Tissue that has become fibrous and holds together other soft tissues
A. Latissimus dorsi and serratus posterior superior
1 7 . Air hunger or shortness of breath
B. Serratus anterior and serratus posterior superior
1 8. Two or more varicose veins
C. Serratus posterior superior and serratus posterior inferior D. Latissimus dorsi and serratus anterior
1 9. Pus in the pleural cavity 20. Surgery to remove part of or the entire stomach
REFERENCES 1 . Eisler P. Die Muskeln des Sammes . jena, Germany: Gustav Fischer; 1 9 1 2 : 5 7 1 - 5 7 5 . 2 . Lewit K . Manipulative Therapy i n Rehabilitation of the Motor System. London, UK: Butterworths; 1 98 5 : 1 3 8 , 2 76, 3 1 5 ) .
3 . Lewit K. Muscular pattern in thoraco-lumbar lesions. Manual Med. 1 986;2 : 1 05- 1 07 . 4. Dobrick I . Disorders o f the i l iopsoas muscle and its role i n gyne cological diseases. ] Man Med. 1 989;4: 1 30- 1 3 3 .
H P, THIGH, AND ANTERIOR KN EE Note that common conditions encountered in this region
especially in runners; also known as iliotibial tract friction
are included among the key terms.
syndrome and iliotibial band friction syndrome
Anterior pelvic tilt: a condition in which a pelvis has too much
Knee-buckling episodes: hypercontraction of the adductor
flexion and is tilted forward
magnus, causing a closure of Hunter's canal, which can result
Chondromalacia (patellofemoral syndrome): a pathological softening of the patellar cartilage from an overuse syn
in knee buckling when the thigh and adductor muscles are contracted. Hunter's canal is a triangular space lying
drome;the patella may begin to move out of the groove of
beneath the sartorius and between the adductor longus and
the femoral condyles, grinding across a condyle with each
the vastus medialis. It extends from the femoral triangle to
movement of the knee
the popliteal space allowing for nervous and blood vessels
Femoral triangle: also known as Scarpa's triangle, an endan
to run through it.
germent site on the anterior, proximal thigh bounded by the
Lumbago: a nonspecific term for dull, aching pain in the
inguinal ligament superiorly, by the sartorius laterally, and by
lumbar region
the adductor longus medially. There are structures within
Osgood Schlatter disease: a condition attributed to adolescent
this triangle that should not be pressed upon, including the
growth spurts, in which the bones, specifically the tibia, grow
femoral artery, vein, and nerve, primarily.
faster than muscles and tendons
Groin strains (pulls): pain from tearing and inflammation of an
Pes anserine: the area on the anterior, medial tibia just inferior
adductor muscle near its origin at the pubic bone
to the tibial tuberosity. This area is raised somewhat and is
Growing pains: an imprecise term indicating ill-defined pain in
the attachment site of the sartorius, gracilis, and semitendi
the musculoskeletal system of young persons. There is no
nosus. The words "pes anserine" mean "goose foot," and this
evidence that the pain is actually related to rapid growth.
area is so named because of the three tendons inserting in a
Hamstring strains ( pulls ). chronic overstretching of the ham
pattern that looks like a webbed goose foot.
strings because of an imbalance between the quadriceps
Piriformis syndrome. a condition that presents with symptoms
and hamstring groups, causing tearing if used strenuously or
similar to sciatica but that is due to nerve and vascular
stretched further
entrapment by the piriformis at the greater sciatic foramen,
Hunter's canal: a triangular space lying beneath the sartorius and between the adductor longus and vastus medialis. It
or due to referrals from trigger points in the piriformis, or due to dysfunction of the sacroiliac joint
extends from the femoral triangle to the popliteal space,
Posterior pelvic tilt: a condition in which the pelvis has too
allowing for nerve and blood vessels to run through it.
much extension and is tilted backward
I liotibial band (ITS) syndrome: a condition involving the contin
Sciatica: pain from the sciatic nerve due to nerve compres
ual rubbing of the iliotibial band over the lateral femoral epi
sion at its root where it emerges from the vertebral column
condyle combined with the repeated flexion and extension
Trochanteric bursitis: inflammation of the bursa that cushions
of the knee during running, causing the area to become
a trochanter
inflamed;one of the leading causes of lateral knee pain,
245
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OVERVIEW OFTHE HIP, THIGH,AND ANTERIOR KNEE REGION This chapter covers the muscles that make up the hip and the anterior, posterior, medial, and lateral thigh, along with the anterior knee areas. Always remember that even though
tri gger point referral areas show specific patterns for most people, a trigger point can be anywhere and the referral can travel anywhere. The goal here will be, as always, to find all active, latent, and associated tri gger points and then deacti vate them. Keep in mind that this will take time along with client compliance.
POSTERIOR HIP This area will include the gluteal muscles, the deeper placed lateral hip rotator muscles, and the tensor fascial latae muscle. This is the area we get our power from as most everything we do takes energy and movement from these muscles. This is a densely layered area, and we will, as always, be working with the superficial tissues first, and then getting incrementally deeper.
Gluteus Maximus:The Swimmer's Nemesis The gluteus maximus is quite large and must work very hard. Travell and Simons refer to it as a workhorse. Its weight is several times that of gluteus medius and minimus together. Its large size and anatomic orientation in humans are unique and an important anatomic basis of upright posture. According to Travell and Simons, the evolutionary changes in this muscle have been associated with the distinctive intelligence and manual dexterity of humans among pri mates (Fig. 9-1). ORIGIN •
Posterior border of the ilium and the posterior iliac crest
•
Posterolateral surface of the sacrum
•
Lateral border of the coccyx
•
Sacrotuberous ligament
INSERTION •
Iliotibial band
•
Gluteal tuberosity of the femur •
ACTION •
Powerfully extends the thi gh at the hip
•
Helps maintain an erect posture
•
Assists lateral rotation of the hip
TRIGGER POINTS AND REFERRAL ZONES Trigger points are likely to occur anywhere within the belly of this muscle but most often near the lower sacrum at trig ger point # 1, the coccyx at trigger poi nt #3, and over the ischial tuberosity at trigger point #2. Referral sensations mostly refer along the lateral border of the sacrum and coccyx and over the ischial tuberosity,
FIGURE 9-'
G luteus maximus anatomical attachment sites. (Reprinted
with permission from Life Art, Lippincott Williams & Wilkins.)
C H A P TE R 9
•
FIGURE 9-2
H I P, T H I G H , A N D A N TERIOR K N EE
247
G luteus maximus trigger points and referral zones. ( R eprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
with a bit of spillover between those locations and below
•
onto the posterior thigh from trigger point # 1. From trigger
•
Medical injections
point ,:2, the referral sensations are to the posterior sacrum
•
Sitting too long in one position
and coccyx, over the ischial tuberosity, and at the lateral
•
Sitting on a wallet
•
Having a small hemipelvis
ilium, with strong spillover between these locations. From trigger point #3, the referral is deep into the crease between the buttocks (Fig. 9-2). TRIGGER POINT ACTIVATION
Impact of a direct blow to the muscle
PRECAUTIONS •
As gluteus maximu is a classic phasic muscle, it weak ens and slackens when under stress
Clients with trigger point in this muscle commonly com plain of pain and discomfort when swimming the crawl stroke, particularly when in cold water. They also often
•
Hip pain is seldom caused by gluteus maximus alone; gluteus medius and minimus are often implicated
complain of pain and restlessness when sitting. Such clients
•
Trigger points in this muscle do not project to a great distance
may tell the therapist that they squirm during prolonged sit ting, trying to avoid the tenderness, or that they slide down in their seat and that no chair is comfortable. STRESSORS AND PERPETUATING FACTORS •
Climbing stairs
•
Walking uphill in a forward bent posture
•
Acute stress from a fall or near-fall
MASSAGE THERAPY CONSIDERATIONS •
These fibers run on an oblique angle
•
The therapist should petrissage this muscle following
•
Gluteus maximus responds well to twisting compres
the fiber direction sion and deep myofascial engagement
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Gluteus Medius: Lumbago Muscle Lumbago is a nonspecific term for dull, aching pain in the
lumbar region. The posterior portion of this muscle lies deep gluteus maximus, whereas the lower portion covers glu
to
teus minimus. The gluteus medius is usually about twice the weight of the gluteus minimus and more than half as heavy as the gluteus maximus (Fig. 9-3). ORIGIN •
Anterior three quarters of the iliac crest on the exter nal surface of the ilium between the anterior and the posterior gluteal lines
INSERTION •
Greater trochanter of the femur attaching at the exter nal superior aspect
ACTION •
Hip abduction (the prime mover)
•
Pelvic stabilization when standing on one leg
•
Assists medial rotation of the thigh (the anterior fibers) •
TRIGGER POINTS AND REF ERRAL ZONES
FIGURE 9-3
G lut eus medius anatomical attachm ent sites. ( R eprinted
with perm ission from Life Art, Lippincott Williams & Wilkins.)
Trigger points, when present in this muscle, are usually found in the upper, fan-shaped posterior portion, just under the iliac crest. Typically, three different trigger point loca
Sola' (p683) has identified unilateral pain in the gluteus medius
tions are found along this course.
as coming from a discrepancy of at least 1 cm in leg length,
Sensations from trigger point # 1 typically refer strongly
as this causes pelvic distortion. Sola also notes that Morton
into the low back just above the posterior iliac crest and down
foot structure, with its long second and short first metatar
into the sacrum, with spillover across the entire buttocks.
sals, contributes to an abnormal weight distribution on the
From trigger point #2, the referral is usually strongly felt pos
foot and causes excessive pronation. This tends to overload
teriorly in the buttocks, with spillover down the thigh. Trigger
the gluteus medius.
point #3 refers strongly into the posterior sacrum, with spill over across the posterior iliac crest (Fig. 9-4). TRIGGER POINT ACTIVATION A client with active trigger points in gluteus medius will most likely complain of pain when walking, especially if he or she has an unsupported Morton foot structure. This per son may have a problem with sleeping on the affected side or lying on his or her back. Also, sitting in a slumped posi
STRESSORS AND PERPETUATING FACTORS •
Compression from sleeping positions
•
Prolonged sitting
•
Sitting in a slouched position
•
Running or walking on a banked surface
•
Running in general
•
Weight bearing on one limb for prolonged periods of time
tion so that the body weight compresses these trigger points is uncomfortable. Trigger points in this muscle are likely to be activated by
•
Forward-head, kyphotic posture
•
Sitting on a wallet
a sudden fall, from sports injuries, running, other repetitive
•
Having a small hemipelvis
activities, and walking in soft sand. One researcher named
•
An uncorrected lateral pelvic tilt
C H A PTER 9
( (
H I P, T H I G H , A N D A N T E R I O R K N E E
249
TrP2
( ( (
'--
I
•
FIGURE 9-4
G luteus medius trigger points and referral zones. ( Reprinted with permission from S imons DG, Travell JG, Simons LS. The Lower
Extremities. Ph iladelph ia, PA : Lippincott Williams & Wilkins;
1 993:1 51; Fig. 8.1 . Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 2.)
PRECAUTIONS •
•
Acute pain in this muscle may be related to lumbar
Support of the arches with Morton toe and foot imbal ances is required for permanent relief of symptoms
disk problems
•
Gluteus medius responds well to bonger ball therapy
Anterior fibers are usually tender; pressure should be
•
This muscle often tightens concurrently with the
appropriately applied MASSAGE THERAPY CONSIDERATIONS •
•
A deep aching trigger point will often be found in the gluteal fascia, approximately 1 VI inches below the iliac crest
piriformis and quadratus lumborum
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Gluteus Minimus: Pseudo Sciatica As Travell and Simons note, pain referred from trigger points in the gluteus minimus down the posterior buttocks, thigh, and calf, as well as down the lateral thigh, lower leg, and ankle, may feel similar to sciatica. Its attachments are similar to, but less extensive in length than, those of the overlying gluteus medius muscle (Fig. 9-5). ORIGIN •
Posterior ilium, between the anterior and inferior glu teal lines
INSERTION •
Anterior surface of the greater trochanter of the femur
ACTION •
Strong assistant of pelvic stabilization when standing on one leg
•
Medial rotation of the hip (anterior fibers)
•
Hip abduction
TRIGGER POINTS AND REFERRAL ZONES This muscle is riddled with trigger points that are difficult to palpate because of its very deep location underlying the
•
FIGURE 9-5
G luteus minimus anatomical attachment sites.
( Reprinted with permission from Life Art, L ippincott Williams & Wilkins.)
gluteus medius. A group of trigger points is typically located down the length of the anterior fibers, with another along the length of the origin. Referral sensation is strongly into the lower buttocks, on the lateral thigh, knee, and lower leg from the anterior fibers. From the trigger points along the origin, referrals are normally felt strongly in the lower buttocks, down the pos terior thigh, and into the posterior lower leg, with spillover up across the hip and surrounding the main referrals at the posterior thigh and lower leg. According to Travel and Simons, the post-lumbar laminectomy pain syndrome is frequently caused by residual trigger points in the gluteus minimus that had been acti vated by the radiculopathy. These active trigger points remain after surgery and can be quite confusing because they mimic the pain for which the laminectomy was per formed (Figs. 9-6 and 9-7). TRIGGER POINT ACTIVATION A person with active trigger points in this region will likely complain of hip pain that may actually cause a limp when walking. Also, lying on the affected side may be quite painful, and rolling over onto that side at night will interrupt sleep. After sitting for a time, the person may find it difficult to arise if there are active trigger points in the anterior fibers. Trigger points here can be constant and excruciating, so much so that a person may find that stretching or changing
•
FIGURE 9-6
G luteus minimus trigger points and referral zones.
( R eprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
CHA P T E R 9
H I P, T H I G H , A N D A N T E R I O R K N E E
positions will not relieve it. Activation of trigger points in this muscle is usually caused by sudden acute or repetitive chronic overload or sacroiliac joint dysfunction. Nerve root irritation may also activate trigger points here. Prolonged immobility will aggravate trigger points. STRESSORS AND PERPETUATING FACTORS •
Injections of medicine
•
Driving for long periods of time
•
Slipping and falling
•
Walking too far or too fast
•
Overuse in running and sports activities such as tennis and handball
•
Distortion to a normal gait, as when there are painful foot blisters (limping)
PRECAUTIONS •
Be aware of any nerve root compression
•
Perform a straight leg raise to differentiate symptoms of gluteus minimus from those of sciatica and piriformis syndrome
MASSAGE THERAPY CONSIDERATIONS •
Gluteus minimus is often implicated in sacroiliac dys function
•
The referral pattern is distinct from that of gluteus medius, in that it radiates down the thigh and leg
•
FIGURE 9-7
G luteus minimus trigger points and referral zones.
(Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
251
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Piriformis:The Double Devil The piriformis is a fascinating muscle regarding its attach
v
ment sites and referral pain. Only its origin is not easily palpated. ORIGIN •
Anterior sacrum
INSERTION •
Greater trochanter of the femur
ACTION •
Lateral rotation of the hip
•
Abduction of a flexed hip
TRIGGER POINTS AND REFERRAL ZONES
•
FIGURE 9-8
Piriformis trigger points and referral zones. (Reprinted
with permission from Medi Clip. Lippincott Williams & Wilkins.)
Trigger points, when present, are likely to occur along the length of the muscle belly, with very strong referral sur rounding them and spillover across the entire posterior hip and a bit into the posterior thigh (Fig. 9-8).
STRESSORS AND PERPETUATING FACTORS Sitting cross-legged
TRIGGER POINT ACTIVATION
•
Retzlaff2 states the following regarding this muscle: "The
•
Driving or sitting for long periods of time
piriformis muscle syndrome frequently is characterized by
•
A slouched standing position
such bizarre symptoms that they may seem unrelated."
•
Sitting on a wallet ("back pocket sciatica" )
Piriformis syndrome present with similar symptoms as sci
•
Chronic infections, such as chronic pelvic inflamma
atica but is caused by nerve and vascular entrapment of the piriformis at the greater sciatic foramen, or due to referrals of trigger points in the piriformis, or due to dysfunction of the sacroiliac joint. Sciatica, on the other hand, is pain from
tory disease or infectious sacroiliitis • •
Travell and Simons take this discussion further by explain ing that a client with trigger points in this muscle will likely
Slipping and almost falling (clenching to help catch oneself)
compression of the sciatic nerve at its root, where it emerges from the vertebral column.
Morton foot structure
PRECAUTIONS •
report pain and paresthesia in the low back, groin, perineum,
Avoid using the olecranon process of your ulna (elbow bone) in applying pressure here or other deep, irritat ing pressure on the sciatic nerve
buttock, hip, posterior thigh and leg, foot, and even in the
•
rectum during defecation. There may also be complaints of
Be sure to stabilize the pelvis during side-lying work
•
The sciatic nerve is variable and may be looped
swelling in the painful limb and of sexual dysfunction.
around the piriformis or emerge through the muscle belly
According to Travell and Simons, it appears that three specific conditions may contribute to the piriformis syn drome: ( 1 ) myofascial pain referred from trigger points in the muscle, (2) nerve and vascular entrapment by the mus
MASSAGE THERAPY CONSIDERATIONS •
Use palpation of the bony landmarks to correctly pal
cle at the greater sciatic foramen, and (3) dysfunction of the
pate or isolate the piriformis. It is located halfway
sacroiliac joint. Moreover, piriformis syndrome may develop
between the PSIS and the tip of the coccyx along the
secondary to sacroiliac arthritis.
lateral border of the sacrum, and then to the greater
Any unaccustomed overload of this muscle can activate trigger points here. Also, repetitive strain and direct trauma are likely to activate trigger points in this muscle.
trochanter •
Use of cross-fiber friction to identify the muscle works well
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The Other Five Short Lateral Hip Rotators Gemellus superior, obturator internus, gemellus inferior, obturator externus, and quadratus femoris are considered the short hip rotators. They work with the piriformis and gluteus maximus to laterally rotate the hip (Fig. 9-9).
INSERTION •
Greater trochanter of the femur
ACTION
ORIGIN •
Gemellus superior and obturator externus: ischium
•
Obturator internus: ilium and ischium
•
Gemellus inferior and quadratus femoris: ischial tuberosity
•
Laterally rotates the hip
•
Stabilizes the hip joint (similar to the action of the rotator cuff muscles of the shoulder)
Iliac crest
====.0=..:-
______
Ilium
--------- Greater sciatic .::..,, =r�=;-..=... foramen Ischium 'r------ Capsule of hip joint r-----
Tendon of p ir ifor mis Greater trochanter Gemellus superior Gemellus inferior Obturator externus
�
___
Obturator internus
Ischial tuberosity •
FIGURE 9-9
Deep lateral hip rotators anatomical attachment sites. (Reprinted with permission from M oore KL, Dalley AF. Clinical Oriented Anatomy.
4th ed. Baltimore, MD: Lippincott Williams & Wilkins, 1999.)
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•
FIGURE 9-10
Deep lateral hip rotators trigger points and referral zones.
TRIGGER POINTS AND REFERRAL ZONES Trigger points are found in the bellies of these muscles. The
STRESSORS AND PERPETUATING FACTORS •
Excessive lateral rotation of the hip, especially when
•
Prolonged sitting or standing
•
Sitting with crossed legs
referral pattern is quite strong to the lower, medial gluteal area, as well as to the rectum, upper lateral hip, and near the ischial tuberosity and into the upper thigh, with some spill over down the posterolateral thigh and anterior thigh. Trigger points may also occur within the dorsal sacroiliac, sacrotuber ous, and iliolumbar ligaments. These have strong referrals to the sacrum and posterior iliac crest area, with some spillover down the lateral hip and entire thigh (Fig. 9- 1 0). TRIGGER POINT ACTIVATION
walking, etc.
•
•
the complaint will be of hot, searing pain or explosive pain
•
MASSAGE THERAPY CONSIDERATIONS •
five deep hip rotators. Any of these may be ischemic and tender due to perpetuating factors that place pres
pain stops. If the client is feeling this degree of pain, how
these muscles. Also, repetitive strain and direct trauma are likely to activate trigger points here.
When working on the posterior hip, it is best to be thorough and complete by including treatment of the
and may have to straighten out the pelvis and leg so that the
As with trigger points in the piriformis, any unaccus tomed overload of this area will activate trigger points in
The sciatic nerve is posterior and superficial to these muscles
into the rectum area. The client will likely be unable to sit
ever, he or she should be referred to a physician.
Degenerated hip joint
PRECAUTIONS
A client with trigger points in this area will complain of deep aching pain in the hips and thigh usually. If he or she has the particularly nasty trigger point in obturator internus,
Pelvic distortion such as small hemipelvis or imbal ance (anterior pelvic tilt or lateral pelvic tilt)
sure on this area of the pelvis •
The massage approach to these muscles is the same as that for gluteus medius and piriformiS. This includes proper alignment to the fibers and use of trigger point pressure
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POSTERIOR THIGH: CHAIR-SEAT VICTIMS The posterior thigh includes the three hamstring muscles.
Hamstrings: Biceps Femoris, Semimembranosus, and Semitendinosus The biceps femoris makes up the lateral portion of the ham
\� \J
v
strings, whereas the medial portion is made up of the two "semi sisters," semimembranosus, which is deep, and semi tendinosus, which is superficial. ORIGIN Biceps Femoris •
Long head: ischial tuberosity
•
Short head: lower half of the linea aspera of the femur
Semimembranosus and Semitendinosus •
Ischial tuberosity
INSERTION Biceps Femoris •
Head of the fibula
Semimembranosus •
Posterior medial tibial condyle
Semitendinosus •
•
FIGURE 9-11
Hamstrings trigger points and referral zones.
(Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
Anterior proximal tibial shaft (pes anserine, or the area on the anterior, medial tibia just inferior to the tibial tuberosity)
ACTION Biceps Femoris •
Long head: extension of the hip
•
Both heads: flexion of the knee and lateral rotation of a
flexed knee Semimembranosus and Semitendinosus •
Extension of the hip
•
Flexion of the knee
•
Medial rotation of a flexed knee
TRIGGER POINTS AND REFERRAL ZONES In all three muscles, the trigger points appear within the
TRIGGER POINT ACTIVATION Clients with trigger points in this area will likely complain of pain when walking and may even limp. Such clients may experience pain when getting up from a chair after sitting with crossed legs and will have to actually push themselves up with their arms. According to Travell and Simons, trigger points in this muscle are common among children, and the condition is often misdiagnosed and dismissed as what is called "growing pains," or ill-defined pain in the musculoskeletal system of
young persons. Activation of trigger points is easy in this muscle due to
muscle bellies, usually in the inferior half. There is typically
the natural imbalance between the hamstring group and the
strong referral from trigger points in the semimembranosus
quadriceps group. This imbalance is caused by the quadri
and semitendinosus to the inferior buttocks and superior
ceps being chronically shortened from prolonged sitting, which in turn causes the hamstring group to be chronically
posterior thigh, with spillover from that area to the lower medial calf area. From the biceps femoris, there is usually
overstretched. Then, placing pressure by sitting on these
strong referral to the posterior knee area, with spillover from
overstretched muscles for long periods of time during the
there up the posterolateral thigh (Fig. 9- 1 1).
day activates trigger points.
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STRESSORS AND PERPETUATING FACTORS •
Uncorrected anterior pelvic tilt along with an uncor
PRECAUTIONS •
knee due to this being an endangerment site
quadriceps. Anterior pelvic tilt is a condition in which a pelvis has too much flexion and it is tilted forward •
Avoid lengthening techniques on the tendons of the hamstring muscles behind and just proximal to the
rected muscle imbalance between the hamstrings and •
Chronic muscle strains, hamstring strains. Hamstring
Avoid deep pressure on the linea aspera above the short head origin
strains (pulls) are chronic overstretching of the ham
strings because of an imbalance between the quadri ceps and hamstring groups, causing tearing if used •
MASSAGE THERAPY CONSIDERATIONS •
Some fibers of biceps femoris continue beyond the
strenuously
ischial tuberosity into the sacrotuberous ligament, giv
Overstretching the hamstrings and not strengthening
ing this hamstring muscle a direct connection to the
them
lower back
•
Trigger point referral patterns from other muscles
•
Picking up objects from the floor without observing
These muscles are active when the trunk is flexed while standing. Thus, factors that may pull the trunk forward
correct biomechanics
are considered perpetuating factors, such as obesity,
•
Adhesions to the adductor magnus muscle
pregnancy, and chronic protracted head
•
Prolonged sitting, especially with legs crossed or the
•
•
sciatic nerve
muscle belly pressing against the edge of the seat •
Lack of stretching the rectus femoris muscle specifi cally
These muscles, when chronically taut can entrap the
•
The insertion of the semitendinosus is one of the three that comprise the pes anserine
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ANTERIOR THIGH The anterior thigh comprises the quadriceps group along with the tensor fascia latae and sar torius.
Tensor Fascia Latae: Pseudotrochanteric Bursitis This is one of two muscles associated with pseudotrochant eric bursitis; the other is the quadratus lumborum. ORIGIN •
Lateral iliac crest
•
Anterior superior iliac spine
INSERTION •
Iliotibial band (also called the iliotibial tract)
•
The iliotibial band continues on to attach to the lat eral condyle of the tibia and head of the fibula
ACTION •
Prevents collapse of the extended knee during ambulation
•
Medially rotates the hip
•
Flexes the hip
•
Assists in hip abduction
TRIGGER POINTS AND REFERRAL ZONES As usual, the trigger points appear within the muscle belly. Typically, strong referral occurs at the lateral hip at the
•
FIGURE 9-12
Tensor fascia latae anatomical attach m ent sites and
trigger points with referral zones. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
greater trochanter and down the lateral thigh over the ili otibial band (Fig. 9-12). TRIGGER POINT ACTIVATION A person with trigger points in this region will complain of pain deep in the hip and down the thigh as far as the knee. Clients will claim that the pain prevents them from walking rapidly or lying comfortably on that side. This pain mimics pain from trigger points in the anterior gluteus minimus, glu
•
Running or walking on a banked or sloped surface
•
Sleeping in a fetal position
PRECAUTIONS •
You must work the muscle anterior to the greater trochanter
•
Muscle fibers found going toward the greater trochanter will be those of gluteus medius and minimus
teus medius, and vastus lateralis muscles and is often mistak enly attributed to trochanteric bursitis. Trochanteric bursitis is inflammation of the bursa that cushions a trochanter. Usually, activation of trigger points here is caused by
MASSAGE THERAPY CONSIDERATIONS •
This is an anterior and lateral muscle; be sure to mus
•
The best positions for engagement of this muscle are
cle test for best placement of technique
chronic overload or sudden trauma, especially when a per son performs inadequate warm-up or is in poor condition.
the side-lying and supine positions; however, it may also be accessed from a prone position
STRESSORS AND PERPETUATING FACTORS •
Any impact on the knee, such as running
•
Prolonged standing
•
Excessive anterior pelvic tilt
•
Morton foot structure, especially when running up or
•
Landing on the feet from a high jump
down hills
•
This muscle responds well to muscle energy techniques for stretching
•
This will be a frequent cause of hip pain in pregnant clients
•
This muscle is commonly tight due to its role in stabi lizing the knee and the iliotibial band
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Sartorius: Surreptitious Accomplice The sartorius is thin, narrow, and ribbon-like and is the longest muscle in the body. It gets its name from tailors sit ting on the floor with crossed legs to work (Fig. 9-13). ORIGIN •
Anterior superior iliac spine (ASIS)
INSERTION •
Anterior proximal tibial shaft (pes anserine)
ACTION •
Assists flexion, abduction, and lateral rotation of the hip
•
Assists flexion of the knee when the hip is flexed
TRIGGER POINTS AND REFERRAL ZONES Trigger points may occur all along the length of this very long muscle, within its belly. The referral zone is along the course of the muscle as spillover only (Fig. 9- 1 4). TRIGGER POINT ACTIVATION Usually, trigger points in this muscle are activated as second ary trigger points by those in synergist muscles. Occasionally,
•
though, trigger points may be activated by acute overload strain, such as groin pulls. Groin strains (pulls) are condi
FIGURE 9-13
S artorius anatomical attachment sites. (Reprinted with
permission from Life Art, Lippincott Williams & Wilkins.)
tions involving pain from tearing and inflammation of an adductor muscle near its origin at the pubic bone. Referral pain from trigger points in this muscle are usu ally felt up and down the thigh and possibly medially in the knee but never deep in the knee. Usually, the client will complain of a superficial, stinging sensation. According to Travell and Simons, pain from sartorius trigger points that refer to the knee area may be mistaken for disease of that joint. Lange3(Fig. 45, Case 27) warns that trigger point sensation from the lower portion of the muscle is eas
J
ily mistaken for pain originating in the knee.
f
STRESSORS AND PERPETUATING FACTORS •
Excessive hyperpronation, as with Morton foot struc ture
•
Prolonged sitting in a cross-legged or tailor's position
PRECAUTIONS •
Remember that this is a very superficial muscle; if you use too much pressure, there will be little effect
MASSAGE THERAPY CONSIDERATIONS •
Superficial, slow effleurage works best to lengthen the muscle belly
•
FIGURE 9-14
Sartorius trigger points and referral zones. (Reprinted
with permission from Medi Clip, Lippincott Williams & Wilkins.)
•
The insertion is one of the three muscles that form the pes anserine
•
The origin and upper third of the muscle belly of sarto rius, along with the tensor fascia latae and rectus femo ris, aid in creating a biomechanically stressed area just inferior to the ASIS. The client may experience' pain sensitivity or tickling there
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This group of anterior thigh muscles is made up of the rectus
tion of the muscle belly, yet the strong referral begins at the
femoris, vastus intermedius, vastus medialis, and vastus lat
midpoint of the anterior thigh, covering an area down
eralis (Fig. 9- 1 5).
toward the knee in a three-pronged fork pattern. Spillover
ORIGIN
may occur around the inferior portion of the strong referral zone as well as above it, all the way to the ASIS. This is why
Rectus Femoris: The Two-Jointed Puzzler •
Anterior inferior iliac spine (AilS)
•
Upper margin of the acetabulum
Vastus Medialis: The Buckling Knee Muscle •
Medial lip of the linea aspera
•
Lower half of the intertrochanteric line
•
Upper portion of the supracondylar line
Vastus Intermedius: The Frustrator •
Anterior and lateral surfaces of the upper two-thirds of the femur
Vastus Lateralis: The Stuck Patella Muscle •
Posterolateral aspect of the upper three-fourths of the femur via an aponeurosis
INSERTION (ALL FOUR) •
The patella and, via the patellar ligament, the tibial tuberoSity
it is called the frustrator. Vastus lateralis can be riddled with trigger points. Travell and Simons have distinguished five separate trigger point patterns, along with separate referral zones for each. Trigger point # 1 is usually in the distal anterior portion of the muscle belly, with strong referral surrounding the lat eral knee. There may be some spillover from that area up to the greater trochanter. Trigger point #2 is usually found in the distal posterior muscle belly, with a strong referral zone to the lateral knee and most of the way up the lateral thigh. There may be some spillover surrounding the strong referral and riding down the lateral lower leg, almost to the ankle. Trigger point #3 is posteriorly placed at the mid point of the muscle belly. There is typically strong referral to the lateral knee, the posterior knee, and up the posterior lateral thigh all the way to the greater trochanter. Some spillover surrounds these strong referrals, as well. Trigger point #4 occurs about dead center in the muscle belly and seems to cause the largest referral zone. The strong referral will be down the center of the lateral thigh from the ilium
ACTION
to the distal lateral knee, getting quite large right around
Rectus Femoris
the actual trigger points. There may be some spillover
•
Extends the knee
around this referral. Trigger point #5 is in the proximal
•
Assists flexion of the hip
muscle belly, with both a strong referral and spillover sur rounding it.
Vastus Medialis, Vastus Intermedius, and Vastus Lateralis •
Extend the knee
TRIGGER POINTS AND REFERRAL ZONES This group is susceptible to many trigger points. Rectus fem
Interestingly, according to Travell and Simons, there may be a trigger point on the distal attachment of the fibular col lateral ligament that refers to the proximal attachment of the same ligament on the lateral knee (Figs. 9- 1 6 to 9- 1 9).
oris is called the two-jointed puzzler because the trigger
TRIGGER POINT ACTIVATION
point will usually occur in the extreme proximal muscle
Clients with trigger points in these muscles usually com
belly, yet the referral zone is to the knee with some spillover
plain of pain; however, if there are trigger points in vastus
from the knee up the anterior thigh to the midpoint.
medialis, they may cause weakness there and the knee will
muscle belly at the more distal portion. Pain strongly refers
buckle unexpectedly when walking. Such clients are likely to say that the pain in the knee joint feels similar to a
to the medial knee and from there up the medial thigh.
toothache.
Trigger points in vastus medialis usually occur within the
Both will have some spillover around them. According to
A person with trigger points in rectus femoris may com
Travell and Simons, active trigger points here can cause the
plain of waking up in the night feeling pain in front of the
knee to buckle. As in the case of trigger points in rectus femoris, the trig
tell the therapist that the knee feels weak when walking
ger point in vastus intermedius occur in the uppermost por-
down stairs.
knee cap and just above it in the thigh. He or she may also
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- Tensor fascia lata
- Iliopsoas - Pecti neus
- Adductor longus
��+-- Gracilis
Vastus lateralis
---
-�+-- Sartorius Vastus intermedius
'---+-- Rectus femoris Vastus medialis -------1-- Vastus lateralis
---+-- Vastus medialis ------I-- lIiotibial tract
Rectus femoris -----t' tendon
;- ..... ----+-- Patella
-
-'-
Patella -----"-1--'--
Groin (inguinal) Thigh (femoral) Adductor longus
Rectus femoris
--+-- Gracilis --1-- Sartorius
Vastus lateralis
---t-- Vastus medialis
Patella ----;--�
-11--
-
•
-
Tibial tuberosity
FIGURE 9-15 Quadriceps group a natomical attachment sites. (Reprinted with permission from Premkumar K. The Massage Connection: Anatomy and Physiology.
2nd ed. Baltimore, MD: Lippincott Williams & Wilkins, 2004.)
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Vast us medialis
FIGURE 9-16
Rectus femoris t rigger points and referral zones.
FIGURE 9-17
Vastus lateralis trigger point s and referral zones.
(Reprinted with permission from Medi Clip, Lippincott Williams &
(Reprinted with permission from Medi Clip, Lippincott Williams &
Wilkins.)
Wilkins.)
FIGURE 9-18
Vastus medialis trigger points and referral zones.
FIGURE 9-19
Vastus intermedius trigger points and referral zones.
(Repri nted with permission from Medi Clip, Lippincott Williams &
(Reprinted with permission from Medi Clip, Lippincott Williams &
Wilkins.)
Wilkins.)
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A person with trigger points in the vastus intermedius
•
will have difficulty being able to fully straighten the knee,
adolescent growth spurts in which the bones, specifi
especially after it has been immobile for some time when sitting. The pain will be felt during movement, rarely when
Osgood Schlatter disease is a condition attributed to
cally the tibia, grow faster than muscles and tendons •
at rest. If there is a latent trigger point in either the rectus femo
Hyperpronation along with structural misalignment of the pelvis contribute to chronic tightness in the vastus lateralis and trigger points in the vastus medialis
ris or vastus lateralis and a person uses that site to inject medication such as insulin, he or she will most likely acti vate that trigger point. Mostly activation of trigger points in
PRECAUTIONS •
The origin of rectus femoris may be an optical illusion
the quadriceps group will be due to an acute overload from
as to its location on the body. Be sure to always use
stepping into a hole or stepping off the curb or stumbling.
bony landmarks as the guideline for locating the origin
Direct trauma could also activate trigger points here. Also,
at the AIlS
acute or chronic overload could occur resulting from exer cise, either too much of it or doing it improperly.
MASSAGE THERAPY CONSIDERATIONS •
STRESSORS AND PERPETUATING FACTORS •
Exercises such as deep knee bends or knee extensions
•
Sitting with one foot tucked under the buttock for
Trigger points in rectus femoris refer sensation to the front of the affected patella
with a weight on the ankle •
Rectus femoris is the only quadriceps muscle to cross two joints
•
It takes both hip hyperextension and knee flexion to properly stretch the rectus femoris
long periods of time
Trigger points in vastus medialis create weakness; hence, it is called the buckling knee muscle
•
Jumping, running downhill, or skiing
•
Hyperlordosis affecting the tone of rectus femoris,
•
Chondromalacia (patellofemoral syndrome) is a path
patellar pathologies or functional disorders involving
ological softening of the patellar cartilage from an
the quadriceps muscles
which may in turn affect the hip joint mechanics
overuse syndrome •
•
•
•
Q-angle measurement may be important if there are
Vastus lateralis and medialis work synergistically to
Vastus lateralis commonly adheres to the iliotibial
properly track the patella within the patellar groove of
band
the femur (between the medial and lateral condyles)
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LATERAL THIGH The lateral thigh includes the iliotibial band, which i s superficial t o the vastus lateralis muscle.
Iliotibial Band The iliotibial band is also known as the iliotibial tract or Maissiat's band. The iliotibial band is a thickening of the fascia lata in the lateral thigh, actually a longitudinal fibrous reinforcement of the fascia lata. The fascia lata is the fascial sheath that wraps the entire thigh and hip. As it is not a muscle, it has no origin, insertion, or action. Tensor muscle of fascia lata
It is attached to the midpoint of the external lip of the iliac crest and to the lateral condyle of the tibia. Some anato mists agree that it also attaches to the head of the fibula. The part of this thick band that lies deep to the tensor fascia latae actually joins the lateral part of the capsule of the hip joint (Fig. 9-20). CLINICAL SIGNIFICANCE A common thigh injury usually associated with running is iliotibial band friction syndrome, which is one of the lead
ing causes of lateral knee pain, especially in runners. It can also be caused by biking, hiking, or weight lifting, such as doing squats. The continual rubbing of the band over the lateral femoral epicondyle, combined with the repeated flexion and extension of the knee during running, may cause the area to become inflamed. Symptoms may range from a
I liotibial band
stinging sensation j ust above the knee, on the lateral knee, or along the entire length of the iliotibial band to swelling or thickening of the tissue at the point where the band moves over the femur. The pain may not occur immediately during activity, but may intensify over time, especially as the foot strikes the ground. Pain may persist after activity as well. Pain may also be present below the knee, where it attaches to the tibia. This could also occur where the ili otibial band connects to the hip, though this is far less likely to be from a sports inj ury. Usually, this will be due to preg nancy, as the connective tissues loosen and the woman gains weight. This may also happen with an elderly person.
•
FIGURE 9-20
B altimore, MD: Lippi ncott Williams & Wilki ns; 2003; Fig. 7-46.)
PRECAUTIONS •
along with that of the two muscles that attach to it, to help stabilize the knee joint during running
Begin work in this area very gently, as this can be extremely tender even if there is no iliotibial band fric tion syndrome
MASSAGE THERAPY CONSIDERATIONS •
•
•
There are two muscles that attach to the iliotibial band: the tensor fascia latae and the gluteus maximus
•
I liotibial band anatomical attach ment sites. (Reprinted
with permission from H end rickson T. Massage for Orthopedic Conditions.
It is important to first control the pain and inflamma tion by using RICE along with massage Stretching the iliotibial band is the next step for this client
Most anatomists agree that the iliotibial band crosses
It may also be important for this client to strengthen the hip abductors, especially gluteus medius, as they
the knee j oint somewhat anteriorly, making its role,
control the tightness in the iliotibial band
•
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MEDIAL THIGH In this section, we consider the adductor muscles, which are medially based.
Add uctors: Obvious Problem-Ma kers The adductors include gracilis, pectineus, adductor brevis, adductor longus, and adductor magnus.
GRACI LIS Gracilis is a superficial muscle that extends the length of the medial aspect of the thigh, crossing two joints, the hip, and the knee (Fig. 9-2 1 ). ORIGIN •
Anterior pubis at the junction of the body of the pubis and the inferior pubic ramus
INSERTION •
Proximal anterior, medial shaft of the tibia below the tibial condyle (pes anserine)
ACTION •
Adducts the hip
•
Assists flexion and medial rotation of a flexed knee
TRIGGER POINTS AND REFERRAL ZONES The trigger points, when present in this muscle, usually occur along the length of the muscle belly, with strong refer ral to the upper medial thigh. Some spillover may occur surrounding the strong referral of sensation all the way to the medial knee (Fig. 9-2 2 ). TRIGGER POINT ACTIVATION The main complaint of a client with trigger points in this muscle is likely to be of hot, stinging pain in the medial thigh. This will rarely be described as prickling. It may be constant at rest, with no change of position that reduces the pain. Walking often tends to relieve the pain. Trigger points in this area are usually activated by sudden overload but could also be due to osteoarthritis of the hip or hip surgery, according to Travell and Simons.
•
FIGURE 9-21
G racilis an atomic al attachment sites. (Reprinted with
permission from Life Art, Lippincott Williams & Wilkins.)
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STRESSORS AND PERPETUATING FACTORS •
Slipping on ice and spreading the legs apart to try to
(
recover balance •
Playing aggressive sports
•
Horseback riding
•
Skiing or long bicycle trips
•
Running up or down hill
PRECAUTIONS •
As with all adductor muscles, be sure to gain informed consent from the client before proceeding with the massage session because of the very personal place to which they attach
MASSAGE THERAPY CONSIDERATIONS •
The insertion is one of three muscles that form the pes
•
Chronic shortness of this muscle may contribute to
anserine medial knee pain and pes anserine tendinitis •
This muscle re ponds well to muscle energy techniques, and it may work best to apply this technique before work ing directly on the gracilis when oversensitivity is present
•
FIGURE 9-22
G racilis trigger points and referral zones. ( Reprinted
with permission from Medi Clip, Lippincott Williams & Wilkins.)
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Pectineus: The Fourth Adductor This muscle comprises most of the medial part of the floor of the femoral triangle. This triangle is bounded by the ingui nal ligament above, the sartorius laterally, and the adductor
(
longus medially.
(
ORIGIN •
Crest of the superior ramus of the pubic bone lateral to the pubic tubercle
INSERTION •
Pectineal line on the medial posterior femur (between the le 'ser trochanter and the linea aspera)
f
ACTION •
Flexes and adducts the hip
•
Assists medial rotation of the hip
TRIGGER POINTS AND REFERRAL ZONES The trigger point typically occurs in the muscle belly, with strong referral surrounding it. There may be spillover sur rounding the strong referral up beyond the inguinal liga ment and down to the mid-thigh medially (Fig. 9-23).
•
FIGURE 9-23
Pectineus anatomical attachment site and trigger points
with referral zones. (Reprinted with permission from Simons DG,Travell JG, Simons LS. The Lower Extremities. Phi ladelphia, PA: Lippincott William s
& Wilkins; 1 993:237; Fig. 1 3 . 1 . Myofascial Pain and Dysfunction:The Trigger Point Manual; vol 2.)
TRIGGER POINT ACTIVATION Complaints related to trigger points in this muscle usually
•
involve other related muscles and are rarely about this mus
ened position, such as sitting cross-legged or with hips
cle only. T he client may describe deep-seated groin pain, especially during weight-bearing activities that cause abduc tion of the thigh. This client may also inform the therapist of limited abduction at the hip, especially when seated in the lotus position. Trigger points in this muscle are usually activated by any event that causes united, strong resistance to combined adduction and flexion of the thigh at the hip, such as lifting and moving heavy objects. Activation may also occur because of disease of the hip joint or after surgery on the hip.
in a jackknifed position PRECAUTIONS •
Unaccustomed, vigorous sexual activity
•
Certain gymnastic exercises
•
Horseback riding
•
Advanced osteoarthritis or fracture of the neck of the
•
Lower-limb length inequality, contributing to chronic overload of the muscle
Be sure to gain informed consent before working on this muscle
MASSAGE THERAPY CONSIDERATIONS •
Pectineus has the same nerve innervation as psoas, as well as the same angle of pull, making this as powerful a hip flexor as the psoas
•
This is a common site of groin pulls due to two primary actions it performs at the same time, creating overload demand on this muscle
•
femur •
Be aware of the femoral triangle and femoral pulse when working on this muscle
STRESSORS AND PERPETUATING FACTORS •
Sustained posture that places the muscle in a short
•
The trigger point referral pattern is a common source of what clients may refer to as deep hip joint pain Have the client point out problematic areas to be sure their idea of anatomy is correct
C H A P T ER 9
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Longus Adductor longus is the more superficial and prominent of these two muscles. ORIGIN Adductor Brevis •
Anterior inferior ramus of the pubis
Adductor Longus •
Anterior pubis just lateral to the symphysis pubis
INSERTION Adductor Brevis •
Linea aspera just below the lesser tubercle
Adductor Longus •
Linea aspera on the middle third of the femur
ACTION •
Adduct the hip
•
Assist flexion and medial rotation of the hip
TRIGGER POINTS AND REFERRAL ZONES According to Travell and Simons, there is no distinction between the patterns of referral from trigger points in the adductor longus and brevis muscles. The trigger points typi cally occur within the muscle bellies. Strong referral pat terns occur to the area of the greater trochanter above the trigger points as well as to the superior knee area below the
•
FIGURE 9-24
A d d uctor b revis and longus anatom ical attachment
sites and trigger points with referral zones. (Reprinted with permission
from Medi Clip, Lippincott William s & Wilkins.)
trigger points. Spillover may occur from the superior strong referral all the way down the medial aspect of the thigh and lower leg to the medial malleolus (Fig. 9-24).
•
Playing aggressive sports
TRIGGER POINT ACTIVATION
•
Horseback riding
Clients with trigger points in this region are likely to com
•
Skiing or long bicycle trips
plain of pain in the groin and medial thigh only during vig
•
Running up or down hill
orous activity or muscular overload rather than at rest. This pain may be increased by weight bearing and by sudden twists of the hip. The client may also sense some restriction
PRECAUTIONS •
working in this area
of abduction and lateral rotation of the thigh. Trigger point activation will usually be due to sudden overload but could also be due to osteoarthritis of the hip or
Always gain informed consent from your client when
MASSAGE THERAPY CONSIDERATIONS When muscle stripping these muscles, use sartorius
from hip surgery, according to Travell and Simons.
•
STRESSORS AND PERPETUATING FACTORS
•
Trigger points here may create stiffness in the knee
•
Trigger point involvement of these muscles is a com mon cause of groin pain
•
Slipping on ice and spreading the legs apart to try to recover balance
and gracilis as landmarks
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Adductor Magnus The adductor magnus is a large and deeply placed muscle. From a medial position, it is posterior to the pectineus and adductor brevis and longus muscles in the medial thigh. Some anatomists have nicknamed this muscle the fourth hamstring due to its strong a sistance of hip extension and posterior location in the medial thigh (Fig. 9-25). ORIGIN •
Inferior pubic ramus
•
Ischial ramus between the ischial tuberosity and the
•
Ischial tuberosity
inferior pubic ramus
INSERTION •
linea aspera
•
Adductor tubercle on the medial condyle of the femur
ACTION •
• •
Adducts the hip
Anterior fibers : assist flexion of the hip Posterior fibers: assist extension of the hip
TRIGGER POINTS AND REFERRAL ZONES
•
FIGURE 9-25
A d d uctor mag nus anatomical attachment sites.
(Repri nted with permission from Life Art. Lippincott Williams & Wilkins.)
There are three common areas for trigger points to occur in the muscle bellies. The first is in the lower portion attaching to the linea aspera centered in the muscle belly. The second is at the ischial and pubic attachments, and the third is along the length of the muscle belly of the most medial por tion that runs vertically down to the adductor tubercle. Very strong referral typically occurs down the entire length of the medial aspect of the thigh, from the inguinal ligament to the knee, from the first trigger point. Some spillover may occur surrounding this site. From the second trigger point, explosive pain may occur up into the rectum, bladder, vagina, etc., with some spillover possible, connecting those strong referrals. Note: if a client experiences such extreme pain, you should refer him or her to a physician immediately. The client should
sexual intercourse. Another complaint may be of medial thigh and groin pain. Such a client may also tell the thera pist that the only way to be comfortable when lying down is to be on his or her side with a pillow between the legs. Trigger points are usually activated by sudden overload but could also be activated by osteoarthritis of the hip or hip surgery, according to Travell and Simons. STRESSORS AND PERPETUATING FACTORS •
Slipping on ice and spreading the legs apart to try to recover balance
•
Playing aggressive sports
•
Horseback riding
•
Skiing or long bicycle trips
From the third trigger point, strong referral may occur
•
Running up or down hill
around the trigger point or points themselves, with some
•
Sitting in a chair for long periods of time
spillover surrounding it (Fig. 9-26).
•
be cleared by the physician before receiving massage.
TRIGGER POINT ACTIVATION A client with trigger points in this muscle may complain of intrapelvic pain that may be specifically localized or diffuse and that may be described as being deep inside. Occasionally, the client may indicate that the pain occurs only during
Chronic hamstring strain and fascial distortion that affects the tonus of adductor magnus
•
Pelvic misalignment and leg length inequality
PRECAUTIONS •
T he adductor hiatus is an opening in the adductor magnus muscle through which femoral vessels pass
C H A P T ER 9
•
FIGURE 9-26
aware of pressure and the massage therapy approach Hypercontraction can cause knee-buckling episodes. Knee-buckling episodes are caused by hypercontrac tion of the adductor magnus, causing a closure of
. . .
As always, when working in this area, gain informed consent from your client
....
..
MASSAGE THERAPY CONSIDERATIONS •
•
Hunter's canal, which can result in knee buckling when the thigh and adductor muscles are contracted •
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A d d uctor magnus trigger points and referral zones. (Reprinted wit h permissi on from Medi Clip, Lippincott Williams & Wilkins.)
It is commonly tender, and the therapist should be •
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•
Chronic hamstring strain may actually be adductor magnus posterior fiber strain The adductor magnus may be best accessed with the client in a side-lying position Trigger points here may involve somatovisceral rela tionships with referral patterns simulating lower abdominal and groin pain with dysfunction, according to Travell and Simons
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H i p, T h i g h, a n d Anterior Knee N e u ro m usc u l a r Thera py Routi ne Note t h a t the video i c o n ind icates routines that a r e featured i n o n l i n e video c l i ps, o n t h e book's companion Web site.
GLUTEUS MAXIMUS
�
Use no oil at this point. 1 . Beg i n with w a r m i n g and loose n i n g of the g l utea l reg i o n
t h r o u g h the sheet. U s e com pression w i t h p a l m s a n d loose fists; then, petrissage and also use c i rcular friction.The g l uteus maximus m u st be thoroug h ly relaxed throughout the session to be a b l e to work with the deeper posterior h i p m u scles effectively. •
ROUTINE 9-1
•
ROUTINE 9-2
•
ROUTINE 9-3
Note: Drape to expose the entire h i p. 2. Work with pi ncer compression a n d petrissage para l lel to the
fi ber d i rection for specific freeing of the g l uteus m a x i m u s fi bers (Routine 9-1 ). Next, a pply tran sverse friction to address any tight bands of fi ber and then trigger point pressure.
3. Fingertip c i rc u l a r friction and tran sverse friction a l o n g the
sacrum a n d ilium w i l l h e l p to clear the orig i n . Also, friction the i n sertion o n the g l uteal tu berosity of the fem u r (Routi ne 9-2).
Note: Now lu bricate the a rea. 4. Use a deep g l i d i n g with the fi n g ers together or the el bow
through the orig i n and across the fi bers in a superior-to-i nfe rior d i rection to clear the semicirc u l a r area a l ong the i l i u m a n d sacrum.
GLUTEUS MEDIUS
�
Note: This muscle has varying fi ber d i rections, a l l of which end at a common location on the g reater trochanter. Stand at the side of the table. 1 . Isolate the muscle with tran sverse and longitu d i n a l friction,
being precise to the fi ber d i rections i n each segment of this m u scle (Routine 9-3). Work the belly, a n d then follow to the orig i n a n d then to the i n sertion. Isolate a ny trigger points with friction,and then a pply trigger point pressure.(Remem ber that this muscle usually has m a ny trigger poi nts.)
C H A PTER 9
2. Work a long the origin at the i l i a c crest a n d then the i n sertion
at the superior aspect of the g reater trochanter with trans verse and longitudi n a l friction, being precise and thorough. Isolate any trigger points with trigger point pressure.
GLUTEUS MINIMUS
e
The approach for this muscle will be the same as that for g l uteus med i u s (Routine 9-4). These two muscles get worked together after medius has been clea red. G l uteus m i n i m u s is deep to med ius. M i n i m u s trigger points can be q u ite painfu l and tend to refer down the posterior thigh. 1 . Work between the middle a n d lower g l uteal l i nes for the ori
•
ROUTINE 9-4
•
ROUTINE 9-5
gin and the anterosuperior aspect of the g reater trochanter for the insertion using the identical tec h n iques as used for g l uteus medius.
PIRIFORMIS 1 . Locate the anatomical l a n d m a rks fi rst: the orig i n from the
midpoint of the lateral edge of the sacrum ha lfway between the PSIS and the tip of the coccyx, and the i nsertion at the superomedial aspect of the greater trochanter (Routine 9-5). Note: be sure to gain the permission of the client before palpating these landmarks.
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2. Palpate the belly at its midpoint, isolating it with transverse
and longitudina l friction. Then, fol low toward the origin then the insertion (Routine 9-6).
3 . Isolate a n d relieve trigger points with trigger point pressure.
Feel for each trigger point to soften and relax as you hold it.
DEEP LATERAL HIP ROTATORS: GEMELLUS SUPERIOR, OBTURATOR IN TERNUS, GEMELLUS INFERIOR, OBTURATOR EXTERN US, AND QUADRATUS FEMORIS
•
ROUTINE 9-6
•
ROUTIN E 9-7
•
ROUTINE 9-8
, . Isol ate each m u s c l e from its origin at the lateral sacrum, ischium, or i s c h i a l tuberosity to its i n sertion at the g reater trochanter through the g l uteus maximus using deep trans verse and longitu d i n a l friction a long with any trigger point pressure necessa ry. Work with the entire length of each mus cle, beg i n n i n g at the muscle bell ies and working toward the orig i n s and then toward the insertions (Routine 9-7).
e
SACROTUBEROUS LIGAMEN T AND FINISHING THE HIP
, . Work with each of the tendinous attac h ments a ro u n d the greater trochanter using tran sverse a n d longitudinal friction.
2 . Using fi n gertips together, deeply clear those attachme nts
around the semicircular area ofthe greater trochanter attach ment site.
3 . Palpate the sacrotuberous l i g a ment between the lower sac
rum and the ischial tuberosity. Work with tra nsverse and lon gitudinal friction on the posterior, medial, and lateral aspects of this large liga ment (Routine 9-8).
C H A PTER 9
4. Use deep length ening strokes of the h i p in a s u pe rior-to inf�rior d i rection with forearm lengthening.
5. Complete with relaxing, loosening vi bration to the posterior
h i p.
POSTERIOR THIGH
e
Hamstrings: Biceps Femoris, Semimembranosus, and Semitendinosus
1 . Loosen and warm the ha mstri ngs using c o m p ression a n d
petrissage, and then l u b ricate.
•
ROUTINE 9-9
•
ROUTINE 9-10
2. Perform effleurage to each hamstring muscle, from insertion
to the origin. Begin massaging with a broad su rface, such as loose fists, and then become more specific, using thum bs, once the muscles beg in to loosen and warm up (Routine 9-9).
3. Use transverse and longitu d i n a l friction on each hamstring
while isolating any tight areas and trigger points. Apply trig ger point pressure as necessary (Routine 9- 1 0). (Be s u re to i nc l ude the short head of the biceps femoris at the lower l i nea aspera.)
4. Clear the origins and insertions with friction.
5. Use a deep lengthening stroke with a forea rm to each i n d i
v i d u a l hamstring from i nsertion to orig i n . You m a y a l so use the heel of the hand or a loose fist for variety.
6. Complete with loosening vibration.
Stretches
�
Turn the cl ient to a supine position. Please refer to the online video to review these. 1 . Stretch the g l uteus maximus by lifting the client's legs off the
table, flexing at the h i ps, and moving the knees toward the chest.
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2. Stretch the p i riformis by moving the client's knee toward the
opposite shoulder with adduction a n d medial rotation of the thigh (Routine 9- 1 1 ).
3. Stretch the ha mstrings by performing a strai g ht l e g raise to
90 degrees.
ANTERIOR THIGH The c l ient should be i n a supine position with a bolster under the knees. Warm t h roug h the sheet u s i n g c o m p ression; then l u bricate.
Knee
e
Place the bolster under the a n kle to hyperextend the knee. 1 . Use general fi ngertip friction a round the knee, including the
medial and the lateral retinaculi without a pplying any pres sure to further hyperextend the knee.
ROUTINE 9-11
2. Stabilize the pate l l a inferior to the knee and work the superior
and lateral border of the pate l l a using transverse and longitu dinal friction where the q ua d riceps tendon and the retinacu lum attach (Routine 9-1 2). Repeat this type of friction, working along the inferior and medial borders, where the retinaculum a n d pate l l a r l i g a ment attach, while sta b i l izing the pate l l a superior t o t h e knee.
3. Now friction a g a i n . This time, sta bil ize one side at a time w h i l e
pushing the pate l l a first lateral ly, t h e n medial ly, to expose a portion of the posterior su rface of the patella. While stabil iz ing the opposite side, use a fingertip pointing up toward the
ROUTINE 9-12
ceiling to friction the posterior su rface (Routine 9-1 3). Note: the knee must be slightly hyperextended to be able to freely move the patella. After you apply the friction, place the bolster back under the knees.
ROUTINE 9-13
CHAPTER 9
Quadriceps Tendons
�
1 . Work the tendons to 5 i nches s u perior to the knee using m u s cle stripping, tran sverse a n d longitudinal friction. Apply trig ger point pressure as needed.
Quadriceps Bellies
�
1 . Treat each individual quadriceps muscle belly with broad eff leurage fol l owed by transverse and longitud i n a l friction work ing from distal to proximal. Use any trigger point pressure necessary as well (Routines 9-1 4 and 9-1 5). •
ROUTINE 9-14
2 . Vastus intermedius can be addressed more d i rectly b y work ing through the rectus femoris and/or d i splacing rectus femo ris med ially and then laterally.
Tensor Fascia latae
�
1 . Perform m u scle stripping along the entire length from the i l iotibial band to the ASIS.
2. Apply tran sverse a n d longitud i n a l friction a n d use trigger point pressure along the entire muscle bel ly.
Sartorius
ROUTINE 9-15
�
1 . Perform muscle striping, friction, a n d trigger point pressure specifically to this muscle along its entire length, working from distal to proximal (Routine 9- 1 6).
ROUTINE 9-16
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Hip Flexor Tendons at Their Origin , . M u sc l e strip, friction, a n d use trigger point pressure to the u pper 6 i nches of the muscles a n d tendons, being s u re to i nclude the tensor fa scia latae, the sartorius, and the rectus femoris. Work from distal to prox i m a l . Note: this can b e a very sensitive area both physically a n d emo tionally; be careful with the amount of pressure being used and pay attention to the client's facial expressions as you work.
2.
Use transverse a n d longitudinal friction on each orig i n spe cifical ly. (Tensor fascia latae: ASIS and the anterior i l iac crest; sartorius: ASIS; rectus femoris: A i l S.) Note: a general rule of isolation of the AilS is 1 inch distal and Y2 to
1 inch medial from the ASIS (Routine 9- 1 7).
Remove the bolster from under the knees. 3. Use a myofascial release to the hip flexor tendons from proxi
mal to d i stal. Facing the feet, beg i n just below the ASIS. Use the flat part of the forearm just distal to the elbow and apply slow, deep pressure to lengthen to a bout 8 to 10 i nches below the h i p.
Replace the bolster u nder the knees. 4. Use deep effleurage to the q u a d riceps muscle bell ies with a
forearm working from distal to prox i m a l . Pa l pate before a n d after to feel t h e change i n the fascia a n d the m u scles. Repeat as needed.
s . Complete with a loosening vibration to the entire area.
•
ROUTINE 9-17
CHA P T E R 9
Stretches
e
Have the cl ient assume a prone position. Please refer to the o n l i n e video t o review these. 1 . Stretch the quadriceps, tensor fascia latae, and sartorius by
bending the client's knee beyond 90 deg rees with your infe rior hand while sta bi lizing at the PSIS with you r superior ha nd. Bring the cl ient's foot as close to h i s or her hip as possible.
LATERAL THIGH Tensor Fascia Latae and the Iliotibial Band
�
Place the cl ient in a side-lying position with the inferior leg for ward and bent at the knee a n d the superior leg straight. Place a pil low under the straight leg for support. Lubricate the area. 1 . Warm the tensor fascia latae and the i l iotibial band using
compression, pa l m a r friction, a n d broad effl e u rage with a forearm or heel of the hands (Routine 9-1 8).
2. Perform transverse friction to t h e i n sertion o f t h e tensor fas cia latae and the entire i l ioti bial band from just anterior of the greater trochanter to the lateral tibial condyle and fi b u l a r
• ROUTIN E 9-18
head. B e careful when working on hypersensitive a reas a n d u s e trigger point pressure as needed (Routine 9 -1 9).
3. Friction t h e insertion o f the g l uteus m a x i m u s o n the i l ioti bial
band specifical ly.
4. Use of repeated oblique muscle stripping may be effective to help clear the i l iotibial band, where it adheres to the vastus lateralis. Friction a long the length of both the a nterior a n d posterior borders o f the i l i otibial band is a l so very effective.
5. Perform broadening p a l m strokes followed by forearm length ening from distal to prox i m a l along the entire length of the thigh. Repeat as needed.
• ROUTIN E 9-19
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Stretches
M U S C L E S A N D N E U RO M U S C U L A R T H E R A P Y RO U T I N E S B Y B O D Y R E G I O N
e
Perform these stretches with the c l ient in the same position as a bove. Please review the o n l i n e video for these. 1 . Stretch the tensor fascia latae and sartorius by bringing the
client's hips off the table while the u p per body rem a i n s on the table. The client reaches overhead to hold the table. The cli ent's lower leg i s bent so the knee is a l most touc h i n g h i s or her chest. Now c a refully lower the client's superior leg off the table while sta b i l izing at the client's h i p with your superior ha nd. Press the leg down toward the floor to provide the actual stretch.
MEDIAL T H I G H Adductors
e
Note: be sure to educate the cl ient as to this treatment protocol using pictu res from anatomy books or charts before performing the work. The client should be i n the side-lying position with the supe rior knee bent and forward. Place a pil low under that knee. The inferior leg should be stra ig ht and will be the leg being worked on. Be sure to d ra pe a p p ro p riately. Apply l u brication. 1 . Warm, loosen, a n d assess the medial thigh using compression
ROUTINE 9-20
and then broad effleurage from d i stal to proxi m a l .
2. Use fi ngertip tran sverse friction a n d circu l a r friction t o the medial proximal shaft of the tibia, working the insertion of the pes anserine tendons:the sartorius, gracil is, and semitendinosus (Routine 9-20).
3. Work the pes anserine tendons with t h u m b stri p p i n g i n a
superior d i rection (Routine 9-2 1 ).
ROUTINE 9-21
CHA P T ER 9
Note: Stand behind the client, facing his or her feet. 4. Hook your fingers beh i n d the tibial condyle a n d the medial
epicondyle of the fem u r. Pull gently to glide superiorly on the med ial aspect of the epicondyle 5 to 6 inches into the thigh to help release a n d lengthen the tendon attachments of the pes anserine (Routine 9-22).
5. Beg i n n i n g with broad effleurage and then changing to t h u m b
stri pping, work w i t h t h e adductor m a g nus from the adductor tubercle at the medial femoral epicondyle toward the isch ial tuberosity. You will be medial to the g racilis. Use friction a n d trigger p o i n t pressure as needed. Note: Adductor work is to be done medial to the femoral artery pulse. First, locate the boundaries of the femoral triangle: the inguinal ligament at the superior border, the sartorius at the lat eral border, and the adductor longus at the medial border. Palpate the femoral pulse using the flat pads of fingers.
6. Isolate the gracil is, sartorius, pectineus, a n d the adductors with
broad effleurage and transverse friction to the muscle bel l ies.
• ROUTINE 9-22
Begin at the knee and work toward the origin (Routine 9-23).
ROUTINE 9-23
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7. Beg i n n i n g with the g racil is, isolate the m u scle by providing resistance at the knee while the cl ient raises the leg toward the cei l i ng. The gracilis w i l l pop out.
8. Now work a long the entire muscle length using integrated tec h n iq u es such as m u scle stripping, petrissage, and friction. Th is muscle tends to be sensitive and may require stretching or tense a n d relax tec h n i q ues first. Apply any trigger point press u re as needed (Routine 9-24).
9. The add uctors and pectineus a re to be isolated both medial
• ROUTINE 9-24 ( Toward the isch ium.)
and lateral to the graci l is. The pecti neus a n d add uctor brevis and longus w i l l be anterior to the g ra c i l i s, whereas the add uc tor mag nus will be posterior to it.
1 0. Beg i n n i n g a bout 4 i nches above the knee and a n g l i n g toward the pu b i s, m u sc l e strip the muscle b e l l i es of the anterior add uctors (Routine 9-25). Then, angling toward the isch i a l tuberosity, m u scle strip the m u s c l e bell ies o f t h e add uctor magn us, beg i n n i n g at the knee this time (Routine 9-26). Also, a pply friction and trigger point pressure as necessa ry.
1 1 . To clear these musc les at their origin, first gain a clear u nder
• ROUTINE 9-25 (Toward the Pubis.)
sta n d i ng of their anatomy to facil itate your work. You must be able to visual ize and ca refu lly feel these origins without being i ntrus ive. Place the cl ient i nto a s u p i n e position; no bolster is necessa ry. Drape the client ca refu lly to a l l ow one leg at a time to be bent at the knee a n d externally rotated to rest upon your knee. You r knee is on the table, under a towel or the sheet.
1 2. Beg i n n i ng at about 3 i nches inferior to the pu bis, t h u m b strip specifically u p the g ra c i l i s until the lateral pubic tubercle is reached; then friction there. If you locate any trigger poi nts, apply trigger point pressure. Note: You may find that you must hold the extra tissue at your starting point so it does not bunch up against the pubis when you arrive there.
1 3. Without looking at the a rea, move you r t h u m b s u periorly and latera lly onto the pubic crest to friction the pecti neus. • ROUTINE 9-26
CHAPTER 9
1 4. Place your thumb back onto the orig i n of gracilis at the lat eral pubic tubercle. Move slig htly s u periorly and latera lly (approximately one thumb width) w h i l e stayi n g o n the pubic ra mus to friction the adductor longus origin.
1 5. Now move your thumb very slightly latera l l y a n d inferiorly (only half the width of the thumb) to friction the orig i n of the adduc.tor brevis. This will be deep to a portion of adductor longus, and more pressure will be necessa ry.
1 6. Without looki ng at the area, fi n d the ischial tu berosity a n d
friction t h e anterior a n d posterior su rfaces a n d along the ischial ra mus to complete the work o n the origins.
1 7. Complete the med ial thigh with some forearm lengthening strokes followed with light vibration (Routine 9-27).
Stretches Have t h e c l i e n t rem a i n in a s u p i n e position. Please review t h e o n l i n e video c l i p for these. 1 . Keeping the client's toes poi nted toward the cei l i ng, bring one leg out into a bduction off the table.
• ROUTIN E 9-27
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Case Study 9-1 •
Jared: A Cl ient with Chronic Ha mstri ng Pa i n
Background
Critical Thinking Questions
At the end of his fou rth year of college footba l l as a fullback,
, . Is there an i m ba la nce a neuromuscular therapist must
Jared h a d been p l agued with c h ro n i c hamstring stra i n . He had been assessed a n d constantly treated by the team's kine siologist a n d ath l et i c tra i ner unsu ccessfu l l y. He was a ble to keep playing this way, but the stra i n and pain returned con stantly a n d his ha mstrings always felt tight. Realizing that he was to be d rafted into a professional team i n 4 weeks, Jared decided to seek outside help and was referred to a neuromus c u l a r therapist. After discussing the situation with the neu
address in this situation?
2. If there is a n i m b a l a n ce, what exactly is it? 3. Why would it be i mportant to work on the i l iopsoas and tensor fa scia latae for this condition?
4. Why not just work on and stretch the hamstrings? 5. With this type of condition, why do the hamstrings always feel tight?
romuscu l a r thera pi st, Jared decided to have a session every
5 days for the next 4 weeks. He was successful in changing his cond ition a n d was d rafted i nto a professional team.
Case Study 9-2 •
Bruce: A R u n n e r with Lateral Leg Pa i n
Background Bruce l i kes to tra i n for a n d run in m a rathons. He has been doing this for 5 years, but each year his outer thigh and knee on the right has become more and more sensitive and painful. H e was referred to a neuromuscular therapist for h e l p.
Treatment After listening to Bruce expl a i n his tra i n ing as wel l as h i s pain, the therapist began by educating him a bout the i l iotibial band's a natomy a n d fu nction. The thera pist d i d a postural assessment of the h i ps a n d legs to confirm that Bruce's right hip a ppeared h igher than his left. Treatment consisted of working on Bruce's thighs in their enti rety with emphasis placed o n the i l ioti b i a l band. Bruce began stretch i ng h i s i l ioti b i a l band a n d tensor fascia latae a n d doing strengthening exercises for h i s add uctors at home.
After several weeks, Bruce was able to return to full train i n g, which now i ncluded h i s stret c h i n g a n d strengthening exercises. He a lso returned to the therapist once per month to m a i nta i n h i s h i g h level of muscular health.
Critical Thinking Questions , . Which structure is the most obvious to work on to help a l l eviate Bruce's p a i n ?
2. I n w h a t ways could this structure c a u s e pain i n t h e lateral thigh and knee?
3. S h o u l d the thera p i st perform a postural a n a lysis of the h i ps and legs? Why or why not?
4. If there are trigger points i nvolved, which muscles should be exa m i ned?
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� .REVIEW QU ESTIONS
Short Answer Questions 1.
What is the difference between sciatica and piriformis
1 0. Which three muscles insert onto the greater tro chanter ? A. Gluteus maximus, gluteus minimus, piriformis
syndrome?
B. Gluteus maximus, gluteus medius, gluteus minimus
2. Which muscle is nicknamed the fourth hamstring and why ? 3.
D. Gluteus medius, gluteus maximus, gemellus supe
What function does the iliotibial band serve ?
4. Explain why there is a natural imbalance between the quadriceps group and the hamstring group. 5.
C. Gluteus medius, piriformis, gluteus minimus
What is the postural dysfunction that the above imbal
rior True/False 1 1. 1 2.
ance leads toward ? Multiple Choice Questions 6.
imus B. Sartorius, gracilis , tensor fascia latae C. Rectus femoris, vastus medialis, vastus lateralis D. Sartorius, tensor fascia latae, rectus femoris
7. Which two muscles insert into the iliotibial band? A. Gluteus maximus and tensor fascia latae B. Gluteus maximus and gluteus minimus C. Gluteus medius and tensor fascia latae D. Piriformis and gluteus maximus
8. The quadriceps muscle that spans two joints is called which of the following? A. Vastus lateralis B. Vastus Intermedius C. Rectus femoris D. Biceps femoris
9. Which three muscles comprise the pes anserine inser tions? A. Semitendinosus, sartorius, adductor brevis B. Sartorius, gracilis, semitendinosus C. Semimembranosus, gracilis, sartorius D. Gracilis, sartorius, biceps femoris
The piriformis and five deep lateral hip rotators all originate on the ischium and ischial tuberosity.
1 3.
All four of the quadriceps originate on the linea aspera of the femur.
Whic� three muscles are hip flexors ? A. Tensor fascia lame, gluteus medius, gluteus min-
The biceps femoris muscle has two origins.
1 4. The ischial tuberosity has four muscles originating on it. 15.
The quadratus femoris originates on the ASIS.
Matching
a. Lumbago
f. Chondromalacia
b. Trochanteric bursitis
g. Patella fusion
c. I liotibial band syndrome
h. Piriformis syndrome
d. Osgood Schlatter disease
i. Stewart syndrome
e. Hunter's canal 1 6.
Which condition creates a problem with the patella ?
1 7. Which condition creates a problem below the patella, on the tibia! 1 8. What is the name of the area used to take a femoral pulse? 1 9. Which condition from the above list is often confused with sciatica? 20. Which of the above listed conditions most often causes lateral knee pain in runners?
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REFERENCES I . Sola AE. Trigger point therapy. I n : Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine . Philadelphia, PA: W. B. Saunders; 1 98 5 :674-686. 2. Rctzlaff EW, Berry AH, Haight AS, et al. The piriformis muscle syndrome. ] Am Osteopath Assoc . 1 97 4 ; 7 3 : 799-807.
3. Lange M. Die Muskelharten (Myogelosen) . Munich, Germany: J . F. Lehmanns; 1 93 1 : 1 44- 1 4 5 .
LEG WITH POSTER OR KNEE, AN KLE, AND FOOT t
�
KEYTERMS
Note that common conditions encountered in this region are i ncl uded Clmong the key terms. Achilles tendonitls:a painful injury of the Achilles tendon that includes inflammation, usually at or near the tenoperiosteal or m usculotendinous junction Ankle sprain: injury to ligaments in the ankle,and possibly the tendons crossing the ankle to the foot, i nvolving them being overstretched and/or torn due to the ankle being forcefully turned while in use.This trauma to the joint causes pain and disability depending on the degree of injury to the liga ments.There will be pain,tenderness, swelling, discoloration to the area,and limitation of motion. Articular dysfunction: a condition of either hypermobility or hypomobility of the foot that can seriously disturb foot mechanics and produce imbalances that may cause pain i n many locations o f the body Baker's cyst a fluid-filled extension of the synovial membrane at the knee protruding into the popliteal fossa Bunion. a cond ition in which the joint capsule becomes stretched at the metatarsal phalangeal joint of the hallux and then becomes callused there and the big toe becomes later ally deviated; this lateral deviation is also known as "hallux valgus" Claw toe a condition in which the metatarsalphalangeal
joints of the four lesser toes are markedly extended and the proximal and distal interphalangeal joints are fixed in flexion, producing a claw curvature. If only a mal let toe,then only the distal interphalangeal joint is flexed.True claw toe deformity is often associated with cavus foot deformity and neuromus cular conditions.The claw toe deformity tends to create a more severe functional d isability than the hammer toe. This condition usually develops because of m uscle i m balance ini tiated by compensatory mechanisms.
Hammer toe: persistent flexion at the interphalangeal joint of the great toe,and/or persistent flexion of the proximal inter phalangeal joint with extension of the distal interphalangeal joint of one of the four lesser toes.This condition usually develops because of m uscle imbalance i n itiated by compen satory mechanisms. Hyperuricemia: abnormal amount of uric acid in the blood Inversion sprain of the ankle' an ankle sprain in which the foot
and the ankle roll laterally,drastically inverting the foot at the ankle and damaging ligaments on the lateral ankle.The most often damaged ligaments in this condition are the lateral talofibular ligament and the lateral calcanealfibular ligament. Muscle spasms and cramps: i nvol u ntary contractions of skeletal
m uscle. Spasms are considered low-grade and long-lasting, whereas cramps are considered short-lived and very acute. Pes cavus a condition i mpacting the structure of the foot i n which there i s an abnormal hollowness o r concavity o f the sole of the foot Pes planus: a condition in which the foot lacks the three arches: the medial and lateral longitudinal arches,as well as the transverse arch; also known as "flat feet" Phasic muscle' a m uscle with large motor u nits that activate on demand for rapid, powerful,short-term motion; responds quickly and fatigues quickly,and usually weakens without shorten ing; also known as a "fast-twitch m uscle" Plantar fasciitis: a painful condition that i ncludes inflamma tion to the plantar fascia due to injury. Often,this type of injury is d ue to long-standing hyperpronation. Polymyalgia rheumatica: a poorly u nderstood condition that
most often occurs in patients over 50 years of age and that (continued)
285
is four times more frequent in women. It is characterized by pain in the muscles of the shoulder and pelvic girdle, absence of i nflammatory arthritis, absence of signs of muscle disease such as atrophy or weakness, and prompt and dra matic response to low doses of corticosteroid therapy. Shin splints: a leg condition involving some combination of an
injury to tibialis anterior or tibialis posterior and a possible hairline fracture to the tibia and that is usually due to overuse and/or misalignment of the ankle (often hyperpronation)
OVERVIEW OF THE LEG WITH POSTERIOR KNEE, ANKLE, AND FOOT REGION This chapter presents the muscles that make up the leg, ankle, and foot, along with the posterior knee. Remember, as always, that even though there are specific trigger point areas along with referral zones presented, a trigger point and
Stress fractures of the foot/ankle: fractures caused by overuse or other trauma, such as a blow to the foot or ankle,that causes a fracture to one or more of the bones i n foot or ankle Tarsal tunnel syndrome: neuropathy of the distal portion of the tibial nerve at the ankle due to chronic pressure on the nerve at the point it passes through the tarsal tunnel,typi cally accompanied by pain and numbness of the sole of the foot and weakness of plantar flexion of the toes
referral can be anywhere. Those presented are where the majority will be found. With that in mind, the goal here is to find and deactivate all trigger points for a client. Note that many of the conditions encountered when working on this portion of the body are caused by postural dysfunction and/or injury.
ANTERIOR LEG AREA The anterior area of the leg is commonly referred to as the shin. The muscles presented here consist of those that provide ankle and toe extension. They lie on the lateral side of the tibia, while being medial to the fibula. There are no muscles medial to the sharp ridge of the tibia that . is called the "shin bone ." The reason for this is that the tibia is a triangular-shaped bone.
Tibialis Anterior: Foot-Drop Muscle The tibialis anterior is a superficial muscle and the most medial muscle found on the leg. Tibialis anterior forms a stirrup along with peroneus longus to allow movements of inversion and eversion.
between the actual trigger point and the strong referral (Fig. 1 0- 1 ) .
ORIGIN
The main complaint from a client with active trigger points here is usually pain on the anteromedial aspect of the ankle and in the big toe. Trigger points in this region are often associated with falling due to dragging the foot, which causes tripping. These trigger points are also associated with weak ankles and/or pain from bunions. A bunion is a condition in which the joint capsule becomes stretched at the metatars alphalangeal joint of the hallux and then becomes callused there and the big toe becomes laterally deviated; this lateral deviation is also known as "hallux valgus." Trigger points here are usually brought on by an overuse injury, such as repetitive microtrauma from walking on rough or slanted surfaces or running on hard surfaces. Ankle sprain or fracture may activate trigger points here as well. Ankle sprain is an injury to ligaments in the ankle, and pos sibly the tendons crossing the ankle to the foot, involving them being overstretched and/or torn because of the ankle
•
Lateral condyle and upper half t o two-thirds o f the lateral tibia
•
Interosseous membrane
I NSERTION •
Medial and plantar surfaces of the medial cuneiform
•
Medial base of the 1 st metatarsal
ACTION •
Dorsiflexion of the ankle
•
Supination (inversion and adduction) of the foot
TRIGGER POI NTS AND REFERRAL ZONES Trigger points most commonly occur within the superior half of the belly of this muscle. Strong referral typically occurs to the dorsal aspect of the great toe, with spillover 286
TRIGGER POINT ACTIVATION
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STRESSORS AND PERPETUATING FACTORS
¥
.: . ... '.' ..' " .,. ..-: . .....
•
Direct trauma to the muscle, such as a blow
•
Overload/overuse trauma that causes shin splints. Shin splints are a leg condition involving some combina tion of an injury to tibialis anterior or tibialis posterior and a possible hairline fracture to the tibia. They are usually caused by overuse and/or misalignment of the ankle (probably hyperpronation )
•
Often overpowered b y the stronger plantar flexors
•
Catching the toes on an obstruction (tripping during the contraction phase ) can cause eccentric contrac tion overload that will perpetuate trigger points
::� �:. " , ,,'
PRECAUTIONS •
B e sure t o medially rotate the leg and press into the tibia while working on this muscle so as not to cause shin splinting
MASSAGE THERAPY CONSIDERATIONS
• FIGURE 10-1 Tibialis anterior trigger points and referral zones.
•
Because o f weak dorsiflexion, the client may experi ence dragging of the toes or ankle weakness and trip ping or falling when walking or climbing stairs
•
The elderly are more prone to balance problems
•
Tibialis anterior is a phasic muscle that commonly weakens from overload. A phasic muscle, also known as a "fast-twitch muscle," has large motor unit that activate on demand for rapid, powerful, short-term motion. Phasic muscles respond quickly and fatigue quickly, usually weakening without shortening
•
This muscle responds well to myofascial lengthening techniques and/or effleurage that begins superficially and becomes incrementally deeper
(Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
being forcefully turned while in use. This trauma to the joint causes pain and disability, depending on the degree of injury to the ligaments. There will be pain, tenderness, swelling, discoloration to the area, and limitation of motion.
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Extensor Longus Group: Muscles of Classic Hammer Toes The extensor longus group includes the major muscles that give us toe extension. They lie lateral to the tibialis anterior on the leg. One condition associated with these muscles is hammer toes, which is a condition of persistent flexion at the interphalangeal joint of the great toe and/or persistent flexion of the proximal interphalangeal joint with extension of the distal interphalangeal joint of one of the four lesser toes. This condition usually develops because of muscle imbalance initiated by compensatory mechanisms (Figs. 1 0-2 and 1 0- 3 ) .
Extensor digitorum longus
ORIGIN Extensor Digitorum Longus •
Lateral condyle of the tibia
•
Upper three-fourths of the anterior fibula
•
Interosseous membrane
Extensor Hallucis Longus •
Middle portion of the anterior shaft of the fibula
•
Interosseous membrane
INSERTION
Anterior view • FIGURE 10-2 Extensor digitorum longus anatomical attachment sites. (Reprinted with permission from Premkumar K. The Massage Connection: Anatomy and Physiology. 2nd ed. Baltimore, MD:
Lippincott Williams & Wilkins; 2004.)
Extensor Digitorum Longus •
Dorsal aspect of the middle and distal phalanges of the lateral four toes
Extensor Hallucis Longus •
Dorsal aspect of the base of the distal phalanx of the great toe
ACTION Extensor Digitorum Longus •
Extends the lateral four toes
•
Assists dorsiflexion of the ankle
Extensor hallucis longus
Extensor Hallucis Longus •
Extends the great toe
•
Assists dorsiflexion of the ankle
TRIGGER POINTS AND REFERRAL ZONES Trigger points in these muscles usually appear within the muscle bellies, more proximal than distal. Strong referral normally occurs from extensor d igitorum longus to the mid dorsum of the foot, with spillover into the lateral four toes and a bit proximal to the ankle. From trigger points in the extensor hallucis longus, strong referral usually occurs to the dorsal aspect of the metatarsal of the great toe, with spill over down the great toe and also between the actual trigger point and the strong referral (Figs. 1 0-4 and 1 0- 5 ).
Anterior view • FIGURE 10-3 Extensor hallucis longus anatomical attachment sites. (Reprinted with permission from Premkumar K. The Massage Connection: Anatomy and Physiology. 2nd ed. Baltimore, MD:
Lippincott Williams & Wilkins; 2004.)
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TRIGGER POI NT ACTIVATION Clients with trigger points in these muscles commonly com plain of pain on top of the foot. Such clients may also expe rience the foot slapping down when walking or the toes dragging, causing the client to trip. Clients may also experi ence night cramps and, in children, growing pains, which is an imprecise term indicating ill-defined pain in the muscu loskeletal system of a young person. There is no evidence that the pain is actually related to rapid growth. Tripping and falling down may activate trigger points here, as will having to keep the ankle at an acute angle for long periods of time. Excessive jogging or running, unac customed walking on uneven ground or soft sand, or kicking a ball repeatedly can overload these muscles and cause trig ger points. Also, direct gross trauma to the muscles or inac tivating the ankle for long periods of time may also induce trigger points.
STRESSORS AND PERPETUATING FACTORS
• FIGURE 10-4 Extensor digitorum longus trigger points and referral zones. (Reprinted with permission from Medi Clip, Lippi ncott Williams & Wilkins.)
• Sitting on the legs with the ankles in plantar flexion • Driving with the foot on the gas pedal for long dis
tances • A steep accelerator pedal that maintains the ankle in
an acute angle of dorsiflexion • Nervous toe tapping can create overuse syndrome • Having to wear a cast to immobilize the ankle
PRECAUTIONS • Extensor digitorum longus i s frequently a source o f
anterior compartment pain symptoms rather than tibi alis anterior
MASSAGE THERAPY CONSI DERATIONS • Specific dorsal muscle stripping techniques can free
the anterior compartment tendons from retinaculum adhesions • Travell and Simons speak of trigger point pain symp
toms as being called night cramps in the long extensors of the toes and growing pains in children
• FIGURE 10-5 Extensor hallucis longus trigger points and referral zones. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
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DORSAL FOOT AREA The dorsal foot is the top of the foot, where the intrinsic muscles are located that perform toe extension and stabilization.
Extensor Digitorum Brevis, Extensor Hallucis Brevis, and the Dorsal Interossei: Sore Foot Muscles Extensor digitorum brevis and extensor hallucis brevis are
Extensor Hallucis Brevis
more superficial muscles, whereas the dorsal interossei are
• Dorsal surface of the proximal phalanx of the second,
deep. Together, they can create quite a bit of pain in the feet
third, and fourth toes, often uniting with the tendons
(Figs. 10-6 and LO-7 ) .
of extensor digitorum longus
ORIGIN
Dorsal Interossei
Extensor Digitorum Brevis and Extensor Hallucis Brevis • Superior surface of the calcaneus distal to the groove
for the peroneus brevis tendon (together they form four muscle bellies)
• Base of the proximal phalanx on the side of the toe
toward which it pulls
ACTION Extensor Digitorum Brevis and Extensor Hallucis Brevis
Dorsal Interossei
• Toe extension
• Each is attached to the two adjacent metatarsal bones,
and all are located between all of the metatarsals
Dorsal Interossei • Abduction of the second toe medially
INSERTION
• Abduction of the third and fourth toes laterally
Extensor Digitorum Brevis • Dorsal surface of the proximal phalanx of the great toe,
often uniting with the tendon of extensor digitorum longus
Extensor hallucis brevis
Extensor digitorum brevis
• FIGURE 10-6 Extensor digitorum brevis and extensor hallucis brevis
• FIGURE 10-7 Dorsal interossei anatomical attachment sites.
anatomical attachment sites. (Reprinted with permission from
(Reprinted with permission from Medi Clip, Lippi ncott Williams &
Hendrickson T. Massage for Orthopedic Conditions. Baltimore, MD:
Wilkins.)
Lippincott Williams & Wilkins; 2003.)
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TRIGGER POINTS AND REFERRAL ZONES Trigger points appear within the muscle bellies i n all cases here. The referral pattern for the two extensor muscles is usually very strong, surrounding the actual trigger points with spillover around the strong referral extending down to the base of the toes. From the trigger points in the dorsal interossei is a strong referral to the dorsal aspect of the toes, with spillover across the metatarsals (Figs. 1 0-8 and 1 0-9).
TRIGGER POINT ACTIVATION The main complaint from clients with trigger points in this area is typically a deep, aching pain in the feet. They may also have a slight limp when walking. Wearing shoes that restrict toe motion by being too tight
• FIGURE 10-8 Extensor digitorum brevis and extensor hallucis brevis trigger points and referral zones. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
may activate trigger points here. A fracture to an ankle bone, especially if it must be immobilized, can also activate trigger points in these muscles, along with injury that falls short of fracture. Also, walking or running on uneven sur faces may activate trigger points here.
may cause pain in many locations of the body
PRECAUTIONS
STRESSORS AND PERPETUATING FACTORS
• If a n ankle o r foot fracture i s suspected, b e sure t o have
• Fracture to an ankle bone
it evaluated by a physician prior to treatment
• Wearing a cast that immobilizes the foot
MASSAGE THERAPY CON SI DERATIONS
• Stubbing the toes • Morton foot structure
• A therapist should b e aware o f dorsal compartment
syndromes and the ramification of massage
• Hyperpronation of the feet • Articular dysfunction: a condition of either hypermo
bility or hypomobility of the foot that can seriously
A
disturb foot mechanics and produce imbalances that
B
• Articular dysfunction in the foot can disturb the
mechanics and produce imbalances that cause pain
Dorsal and plantar interossei, plantar view
• FIGURE 10-9 Dorsal interossei trigger points and referral zones. (Reprinted with permission from Simons DG, Travell JG, Simons LS. The Lower Extremities. Philadelphia, PA: Lippincott Williams & Wilkins; 1993:525; Fig. 27.3. Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 2.)
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MUS C L ES A N D N EU RO MUS CU L A R T H E R A P Y ROU T I N ES B Y BO D Y R E G IO N
PLANTAR FOOT AREA The plantar area is the bottom or sale of the foot, where the muscles are located that perform toe adduction, abduction, and flexion. These muscles are both superficial and deep.
Abductor Hallucis, Abductor Digiti Minimi, and Flexor Digitorum Brevis: Sore Foot Muscles These are the short, superficial muscles in the feet that cause soreness (Fig. 1 0- 1 0).
ORIGIN Abductor Hallucis • Medial process of the tuberosity of the calcaneus
Abductor Digiti Minimi • Lateral process of the tuberosity of the calcaneus
Flexor digitorum brevis
Flexor Digitorum Brevis • Medial process of the tuberosity of the calcaneus
INSERTION
Abductor hallucis
Abductor Hallucis • Medial side of the base of the proximal phalanx of the
Abductor digiti minimi
great toe
Abductor Digiti Minimi • Lateral aspect of the base of the proximal phalanx of
the fifth toe
•
FIGURE 10-10
Abductor hallucis, abductor digiti m i nimi, and flexor
digitorum brevis anatomical attachment sites. (Reprinted with per
Flexor Digitorum Brevis • The muscle splits into four tendons. Each tendon splits
mission from Hendrickson T. Massage for Orthopedic Conditions. Baltimore, MD: Lippincott Williams & Wilkins; 2003.)
at the base of the proximal phalanx to allow passage of the corresponding tendon of the flexor digitorum lon gus, and then reunites, splits again, and attaches to both sides of the middle phalanx of the lateral four toes
' One interesting study showed that only one-fifth of 22 peo
ACTION
ple studied had the attachment to the medial side of the first
Abductor Hallucis • Flexion and/or abduction of the proximal phalanx of
the great toe
phalanx for the abductor hallucis. The others had the attachment either directly or indirectly to the plantar sur face. This means that, in these people, the action is prima rily as a flexor.
Abductor Digiti Minimi • Abducts and assists flexion of the proximal phalanx of
the fifth toe
Flexor Digitorum Brevis • Flexes the middle phalanx of the four lateral toes
TRIGGER POINTS AND REFERRAL ZONES The trigger points for these muscles typically occur within the muscle bellies. A strong referral area usually occurs to the medial heel, with spillover down the medial plantar surface of the foot for the abductor hallucis.
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For the abductor digiti minimi, a strong referral area often occurs at the plantar surface of the fifth metatarsal, with a bit of spillover toward the tarsals on the lateral plan tar surface of the foot. A strong referral usually occurs to the center of the ball of the foot, with spillover surrounding it for the flexor digi torum brevis (Figs. 1 0- 1 1 to 1 0- 1 3 ) .
TRIGGER POINT ACTIVATION The major complaint of clients with trigger points in this area is typically that the sole of the foot is very sore and that everything this person has tried has made the foot more sore. These clients will report having fallen arches and that they limp a bit. Also, when at rest, they often experience a deep, aching pain. Wearing shoes that are too tight in the toe area can cause constriction that may overload the muscles in the foot and
• FIGURE 10- 1 1 Abductor hallucis trigger points and referral zones. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
activate trigger points. Any banging, bruising, or other trauma to this area could also activate trigger points here. Having Morton foot structure can cause the development of trigger points along with having to keep the foot immobilized.
STRESSORS AND PERPETUATING FACTORS • Stress fractures of the ankle or foot, which are frac
tures caused by overuse or other trauma, such as a blow to the foot or ankle, that causes a fracture to one or more of the bones in this area • Having to wear a cast on the foot • Wearing shoes that are too tight • Pes planus, also known as flat feet; a condition in which
the foot lacks the three arches: the medial and lateral longitudinal arches, as well as the transverse arch • Any trauma to the foot
PRECAUTIONS
• FIGURE 10-12 Abductor digiti minimi trigger points and referral zones. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
• With any suspected fracture, encourage the client to
have it evaluated by a physician • Some clients may be ticklish on the plantar surface of
the feet
MASSAGE THERAPY CONSIDERATIONS • The foot i s a potential source o f bacteria and fungus. It
may be wise to use a witch hazel pad to cleanse the foot before working with it and to use latex gloves when working with the feet of clients who have foot fungus or warts
• FIGURE 10- 13 Flexor digitorum brevis trigger points and referral zones. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
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Quadratus Plantae, Lumbricals, and Interossei: Vipers' Nest These are some of the deep intrinsic foot muscles located on the plantar surface (Fig. 1 0- 1 4 ).
ORIGIN
Hallucis longus
Quadratus Plantae • •
Medial head: medial side of the calcaneus Lateral head: lateral side of the calcaneus and the long plantar ligament
Lumbricals
Flexor hallucis brevis
Lumbricals • Flexor digitorum longus tendon in the midplantar
region
Flexor digitorum longus
Interossei • Base of the three most lateral metatarsals
INSERTION Quadratus Plantae • At an acute angle to the lateral margin of the flexor
digitorum longus tendon, just before it splits into four
Lumbricals • Medial base of the proximal phalanx of the lateral four
• FIGURE 10-14 Quadratus plantae and lumbricals anatomical attach ment sites. (Reprinted with permission from Hendrickson T. Massage for Orthopedic Conditions. Baltimore, MD: Lippi ncott Williams &
Wilkins; 2003.)
toes
Interossei • Medial base of the proximal phalanx of the lateral
three toes
ACTION Quadratus Plantae •
Assists flexion of the lateral four toes
referral zone to the plantar surface of the entire heel, with a bit of spillover surrounding it. The trigger points in the plantar interossei and the lumbricals often refer strongly into the metatarsals on the plantar surface of the foot. Some spillover from the strong referral area into the tarsal area commonly occurs as well (Fig. 1 0- 1 5 ) .
Lumbricals • Flexion of the proximal phalanges of the lateral four
toes
Interossei
TRIGGER POINT ACTIVATION Clients with trigger points in this region often report pain and possibly numbness in the foot, along with a feeling of it being swollen. They also will most likely experience limita
• A bduction of the second toe away from its main axis
tion of walking due to. the pain. Such clients may have tried
• A bduction of the third and the fourth toes away from
new shoes and/or orthotics devices and found that they did
the second toe or main ray • Flexion of the proximal phalanges of the lateral four
toes • Weak assisting of extension of the two distal phalanges
of the second, third, and fourth toes
TRIGGER POI NTS AND REFERRAL ZONES
not help. They might remark that they have plantar fascii tis. Plantar fasciitis is a painful condition that includes inflammation to the plantar fascia due to injury. Often, this type of injury is due to long standing hyperpronation. You will need to decide whether the client has plantar fasciitis or trigger points in this region. The client may have both conditions.
The trigger points for all three muscles normally occur
To test for plantar fasciitis, have the client lying supine.
within the muscle bellies. Quadratus plantae has an extreme
Cup the heel into one palm while pressing the toes into
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here. Having Morton foot structure can cause the develop ment of trigger points, along with having to keep the foot immobilized. This is the same as with the other muscles of the feet.
STRESSORS AND PERPE TUATING FAC TORS • Walking in soft sand barefoot • Walking or running on uneven or sloped surfaces • Soaking the feet in cold water or wearing wet socks • Having impaired mobility of the joints of the foot • Morton foot structure • Wearing shoes with inflexible soles that limit move
ment • Systemic conditions such as gout
•
FIGURE 10-15
PRECAU TIONS Quadratus plantae trigger points and referral zones.
(Repri nted with permission from Medi Clip, Lippi ncott Williams & Wilkins.)
extreme dorsiflexion, being sure to put most pressure on the great toe. If the plantar fascia pops out and appears corru gated a bit, this test was positive. Wearing shoes that are too tight in the toe area can cause
• With any suspected fracture, b e sure t o have i t evalu
ated by a physician • Some clients may be ticklish on the plantar surface of
the feet
MASSAGE THERAPY CONSIDERATIONS • The foot i s a potential source o f bacteria and fungus. It
may be wise to use a witch hazel pad to cleanse the foot
constriction that may overload the muscles in the foot and
before working with it and to use latex gloves when
activate trigger points. Any banging, bruising, fracture, or
working with the feet of clients who have foot fungus
other trauma to this area could also activate trigger points
or warts
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/
M U S C L E S A N D N E U RO M U S C U L A R T H E R A P Y RO U T I N E S B Y BO D Y R E G IO N
Adductor Hallucis, Flexor Hallucis Brevis, and Flexor Digiti Minimi Brevis: Vipers' Nest Adductor hallucis, flexor hallucis brevis, and flexor digiti mimini brevis are deep intrinsic foot muscles located on the
Adductor hallucis (transverse head)
plantar surface that provide action of the great toe and the fifth toe (Fig. 1 0- 1 6 ) .
Adductor hallucis (oblique head)
ORIGIN Adductor Hal/uds •
tarsals, attaching onto the bases of metatarsal numbers
2 to 4 and the tendon of peroneus longus •
Flexor hallucis brevis
Oblique head: slants obliquely across the first four meta
Transverse head: the plantar metatarsophalangeal and metatarsal ligaments of toe numbers 3 to 5
Opponens digiti minimi Flexor digiti minimi
Flexor Hal/uds Brevis • The adjacent surfaces of the cuboid and lateral cunei
form bones • The tendon of tibialis posterior
Flexor Digiti Minimi Brevis • The base of the fifth metatarsal
• FIGURE 10-16 Adductor hall ucis, flexor hall ucis brevis and flexor dig itorum minimi brevis anatomical attachment sites. (Reprinted with
INSERTION
permission from Hendrickson T. Massage for Orthopedic Conditions.
Adductor Hal/uds
Baltimore, MD: Lippincott Williams & Wilkins; 2003.)
•
Oblique head: the lateral aspect of the base of the prox imal phalanx of the great toe
•
Transverse head: the lateral aspect of the base of the proximal phalanx of the great toe, blending with the oblique head
Flexor Digiti Minimi Brevis • Flexes the proximal phalanx of the fifth toe at the
metatarsal phalangeal joint
TRIGGER POINTS AND REFERRAL ZONES
Flexor Hal/uds Brevis • The medial and lateral aspects of the base of the proxi
mal phalanx of the great toe • Occasionally, an additional slip of tendon may attach
to the proximal phalanx of toe number 2
Trigger points in these muscles typically occur within their muscle bellies. The referrals from trigger points in the adduc tor hallucis often produce a very strong referral around both heads of this muscle, with a bit of spillover surrounding the strong referral. The referrals from trigger points in the flexor hallucis
Flexor Digiti Minimi Brevis • The lateral side of the base of the proximal phalanx of
the fifth toe
brevis commonly produce very strong referrals to the meta tarsal of the great toe, wrapping medially from the plantar surface to the dorsal surface there. Much spillover may occur
ACTION
to both the plantar and dorsal aspects of the great and the
Adductor Hal/ucis
second toes.
• Adducts the great toe, drawing it toward toe number
2
• Assists flexion of the proximal phalanx of the great
toe
Flexor Hal/uds Brevis • Flexes the proximal phalanx of the great toe at the
metatarsalphalangeal joint • Assists abduction of the proximal phalanx and adduc
tion of the great toe toward toe number 2
Trigger points and referral patterns for the flexor digiti minimi brevis have not been established. According to Travell and Simons, the referrals from trigger points here appear to be similar to those of the abductor digiti minimi muscle (Figs. 1 0- 1 7 and 1 0- 1 8).
TRIGGER POINT ACTIVATION Clients with trigger points in this area often report pain and possibly numbness in the foot, along with a feeling of it
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(
• FIGURE 10-17 Adductor hallucis trigger points and referral zones.
• FIGURE 10-18 Flexor hallucis brevis trigger points and referral zones.
( Reprinted with permission from Medi Clip, Lippincott Williams &
(Reprinted with permission from Medi Clip, Lippincott Williams &
Wilkins.)
Wilkins.)
being swollen. They will most likely experience limitation
•
of walking due to the pain. Such clients may have tried new
• Wearing shoes with inflexible soles that limit move
shoes and/or orthotics devices and found that they have not helped. Wearing shoes that are too tight in the toe area can cause constriction that may overload the muscles in the foot and activate trigger points. Any banging, bruising, fracture, or other trauma to this area could also activate trigger points here. Having Morton foot structure can cause the develop ment of trigger points, along with having to keep the foot immobilized.
STRESSORS AND PERPETUATING FACTORS • Walking in soft sand barefoot
Morton foot structure ment
• Systemic conditions such as gout
PRECAUTIONS • With any suspected fracture, b e sure t o have i t evalu
ated by a physician • Some clients may be ticklish on the plantar surface of
the feet
MASSAGE THERAPY CONSIDERATIONS • The foot i s a potential source o f bacteria and fungus. It
may be wise to use a witch hazel pad to cleanse the foot
• Walking or running on uneven or sloped surfaces
before working with it and to use latex gloves when
• Soaking the feet in cold water or wearing wet socks
working with the feet of clients who have foot fungus
• Having impaired mobility of the joints of the foot
or warts
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MUS C L ES A N D NEU RO MUS CU L A R T H E R A P Y ROU T I N ES B Y BO D Y R E G IO N
lATERAL lEG AREA The lateral leg area consists of the muscles that attach to the fibula on the lateral surface of the leg.
Peroneal Group: Peroneus Longus, Peroneus Brevis, and Peroneus Tertius-Weak Ankle Muscles
=====================================-.--
The peroneal group of muscles strongly impacts the ankle, especially if there has been a significant sprain to the area. According to Travell and Simons, these muscles, like most lower limb muscles, frequently function to control rather than produce movement. Peroneus longus forms a stirrup, along with tibialis ante rior, to allow movements of inversion and eversion (Figs.
---_.------
Peroneus Brevis • Deep to peroneus longus, this muscle attaches to the
distal two-thirds of the lateral surface of the fibula
Peroneus Tertius • The distal one-half to two-thirds of the anterior mar
gin of the fibula
1 0- 1 9 and 1 0-20 ) .
I NSERTION
ORIGIN
Peroneus Longus • The tendon spirals to the po terior aspect of the lower
Peroneus Longus • Superficial to the majority of peroneus brevis, this
muscle attaches to the head of the fibula
one-third of the fibula along with the tendon of per oneus brevis
• The upper two-thirds of the lateral surface of the fibula
ero n eu s longus
IIttf1ft---f-- P
Peroneus ---'"+-1F-+ l o n gus te n do n
Lateral view • FIGURE 10-19 Peroneus longus anatomical attachment sites.
• FIGURE 10-20 Peroneus longus anatomical attachment sites.
(Reprinted with permission from Oatis CA. Kinesiology. Baltimore, MD:
(Reprinted with permission from Anatomical Chart Company,
Lippincott Williams & Wilkins; 2004.)
Lippincott Williams & Wilki ns.)
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• This tendon crosses behind the tuberosity of the base
'of the fifth metatarsal to the plantar surface of the foot crossing obliquely • The ventral and lateral aspects of the base of the first
metatarsal and the medial cuneiform
Peroneus Brevis • The tendon spirals to the posterior aspect of the lower
one-third of the fibula, along with the tendon of per oneus longus • The dorsal aspect of the tuberosity of the base of the
fifth metatarsal
Peroneus Tertius • The dorsal aspect of the tuberoSity of the base of the
(� � .. '.
.,
.
, ! !ii
• FIGURE 10-21 Peroneals trigger points and referral zones. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
fifth metatarsal • The base of the fourth metatarsal
ACTION Peroneus Longus and Brevis • Evert and abduct (pronate) foot • Assist plantar flexion of the ankle
Peroneus Tertius • Assists foot eversion • Assists dorsiflexion of the ankle
TRIGGER POINTS AND REFERRAL ZONES Trigger points usually occur in peroneus longus at the very superior aspect of the muscle belly. In peroneus brevis, they usually occur in the muscle belly at its midpoint. These muscles have the same referral zone, which strongly sur rounds the lateral malleolus, with spillover above at the lower fibula area and beyond to the lateral dorsal metatarsal area. Some spillover may occur just distal to the actual trig ger point in the peroneus longus as well. The trigger points in peroneus tertius most commonly occur in the muscle belly, with a severe referral zone at the anterior ankle and proximal dorsum of the foot. Spillover may occur to the distal dorsum of the foot and across the lateral ankle to the entire heel of the foot ( Fig. 1 0-2 1 ) .
TRIGGER POINT ACTIVATION
ligaments in this condition are the lateral talofibular liga ment and the lateral calcanealfibular ligament. Clients with trigger points in these muscles may say that they often sprain their ankle. Ankle sprains are injuries to ligaments in the ankle, and possibly the tendons crossing the ankle to the foot, involving them being overstretched and/or torn due to the ankle being forcefully turned while in use. This trauma to the joint causes pain and disability, depending on the degree of injury to the ligaments. There will be pain, tenderness, swelling, discoloration to the area, and limitation of motion. In such clients, the ankle will tend to be quite unstable. According to Travell and Simons, these clients are likely to have foot drop if the deep peroneal nerve is entrapped. A client with trigger points here may have a history of ankle fracture, along with on-going heel and ankle pain. This person is also likely to have Morton foot structure, accord ing to Travell and Simons. Taking a fall with a twist and inversion of the ankle can overload the peroneus longus and brevis muscles, activating trigger points there. Weakness induced by prolonged immo bilization of the ankle can also activate trigger points in all three muscles. Active trigger points in the anterior section of gluteus minimus, which refers strongly to the lateral aspect of the
Although weakness in any of these three muscles can con
lower leg, may induce satellite trigger points in the peroneus
tribute to having weak ankles and ankle sprains, a trigger
longus and brevis muscles.
point typically causes pain and tenderness in the ankle behind and over the lateral malleolus, especially after an inversion sprain of the ankle. Inversion sprain of the ankle is an ankle sprain in which the foot and the ankle roll later ally, drastically inverting the foot at the ankle and damaging ligaments on the lateral ankle. The most often damaged
STRESSORS AND PERPETUATING FACTORS • Inversion sprain to the ankle • Weakness due to prolonged immobility from wearing a
cast because of a fracture • Morton foot structure
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• Leg length inequality, causing the shorter limb to carry
more weight and thus stressing the peroneals • Poor arches, causing taut and pos ibly fibrous bands in
longus and brevis • Overloading these muscles, causing lateral compart
ment shin splints • Chronic tension and active trigger points in tibialis
anterior and/or tibialis posterior, overloading the pero neals and perpetuating trigger points there • Wearing high heels • Having flat feet and unsupported arches • Wearing long socks with a tight elastic top • Sleeping with the foot in plantar flexion for prolonged
periods • Compressing the peroneal nerve by sitting with one
leg crossed over the other
PRECAUTIONS • B e sure t o observe the client walking from behind,
looking for excessive pronation of the foot • Look for Morton foot structure • Clients who sit cross-legged for prolonged periods
may compress the common peroneal nerve against the underlying knee
MASSAGE THERAPY CON SI DERATIONS • A side-lying position i s the best way to access these
muscles • Be sure to ask about a history of ankle injuries, as these
contribute to weakness and muscular imbalances • Tension in peroneus longus often coincides with a
weak tibialis posterior and an exaggerated pronated gait
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POSTERIOR LEG AND ANKLE AREA In the posterior leg and ankle area, we will first consider the more superfic ial muscles impacting both the knee and the ankle and then move into the deeper muscles that impact the ankle and the toes. Gastrocnemius: Calf Cramp Muscle The gastrocnem ius is the most superficial muscle in the posterior lower leg area and makes up what we call the calf (Fig. 1 0-22) .
ORIGIN •
Each of the two heads attach to the corresponding posterior condyle of the femur, medially and laterally
INSERTION •
Both heads come together, attaching by way of the Achilles tendon
Gastrocnemius �1.WII.� \\\\lllll to
the calcaneus
ACTION •
Plantar flexion of the foot at the ankle
•
Assists flexion of the knee
TRIGGER POINTS AND REFERRAL ZONES According to Travell and Simons, there are four distinct trigger points that occur with the muscle bellies, two medi ally and two laterally. The first is in the medial head at its midpoint, with a strong referral to the center of the plantar surface of the foot with some spillover surrounding it. There is also spillover from the lower posterior thigh area to the Achilles tendon at the calcaneus. The second trigger point is found in the lateral head at its midpoint, with a strong referral around the actual trigger point and some spillover around the strong referral . The third trigger point is in the medial head, just below the musculotendinous junction. It has a strong referral sur rounding the actual trigger point with some spillover sur rounding the strong referral. The fourth trigger point is found in the lateral head, just below the musculotendinous j unction. It also has a strong referral that surrounds the actual trigger point and some spillover surrounding the strong referral . Both latent and active trigger points here can cause calf cramps, along with pain in the back of the knee and the lower leg (Fig. 1 0-23 ) .
• FIGURE 10-22 Gastrocnemius anatomical attachment sites. (Reprinted with permission from Oatis CA. Kinesiology. Baltimore, MD: Lippi ncott Williams & Wilkins; 2004.)
TRIGGER POI NT ACTIVATION Trigger points in this region are commonly activated by climbing steep slopes and maybe climbing over rocks. Often, cyclists set the seat too low and activate trigger points when riding their bikes, overloading this muscle.
• FIGURE 10-23 Gastrocnemius trigger points and referral zones. (Reprinted with permission from Medi Clip, Lippi ncott Williams & Wilki ns.)
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Another trigger point activator is having the ankle immo bilized for long periods of time. Walking or running on slanted surfaces can activate trigger points, along with standing in one position while leaning forward for prolonged periods.
STRESSORS AND PERPETUATiNG FACTO.RS • Wearing a walking cast • Running or walking at the beach or on a banked surface • Standing to lecture at a microphone on a lectern or
working at a kitchen sink • Allowing this muscle to get chilled • Riding a bicycle with the seat set too low • Any situation that shortens this muscle for long periods of
time (both knee and plantar flexion) ; wearing high heels, driving in a car for long distances, sleeping positions, etc
PRECAUTIONS • Always check for varicosities before engaging muscles
of the leg
MASSAGE THERAPY CONSIDERATIONS • This muscle i s commonly tight due t o standing for long
periods. When having to stand for long periods, a cli ent can help prevent trigger points here by stabilizing his or her body when leaning forward by leaning against gravity • Nocturnal cramps and muscle spasms are common
with this muscle when it is held in plantar flexion too long. Muscle spasms and cramps are involuntary con tractions of skeletal muscle. Spasms are considered low-grade and long-lasting, whereas cramps are consid ered short-lived and very acute • Some anatomists identify this muscle , along with
soleus, as the triceps surae group • Teaching the client tense and relax techniques is ben
eficial as a self-care exercise • Pincer compression to the muscle bellies and stretches
are effective techniques
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Soleus: Jogger's Heel With the gastrocnemius being the most superficial, the soleus is the second layer of muscle in this area. Soleus is the workhorse for the leg. Also, this muscle has an unusual attachment site of the tendinous arch for nerves and vessels (Fig. 1 0-24 ) .
ORIGIN • Posterior surface of the head of the fibula
Popliteus muscle
• Proximal one-third of the posterior surface of the fib
ula • Soleal line on the upper posterior tibia and the tendi
nous arch that forms the roof of the soleus canal • Middle one-third of the medial tibia
INSERTION • Calcaneus by way of the Achilles tendon
Gastrocnemius muscle (cut)
ACTION • Plantar flexion of the foot at the ankle
TRIGGER POI NTS AND REFERRAL ZONES
Achilles tendon (calcaneal tendon)
Four distinct trigger points, along with one rare one, are
Peroneus brevis
commonly found here. The first is the most common and is in the muscle belly at its distal end near the musculotendi nous junction medially. It has a strong referral to the entire heel and up the Achilles tendon. Some spillover occurs sur rounding this strong referral. Runners often complain of this type of heel pain. The second trigger point is found just distal to the mus culotendinous junction at the head of the fibula. There is a
•
FIGURE 10-24 Soleus anatomical attachment sites. (Reprinted with permission from Hendrickson T. Massage for Orthopedic Conditions. Baltimore, MD: Lippincott Williams & Wilkins; 2003.)
strong referral to the medial middle calf area, with quite a large spillover site surrounding it. The third trigger point is generally found in the lower lateral muscle belly, interestingly showing up as a strong referral to the sacroiliac joint on the same side. There may be a bit of spillover surrounding the strong referral. This
difficult, especially going uphill or up and down stairs (Fig. 1 0-25 and 1 0.26 ) .
TRIGGER POINT ACTIVATION
trigger point, along with the second one, is likely to inter
Activation of trigger points here is most commonly caused
fere with the soleus musculovenous pump, causing pain in
by overloading the muscle. Other causes include an unex
the calf and foot, along with edema of the foot and the
pected, vigorous lengthening contraction, having sustained
ankle.
pressure against the soleus, and prolonged chilling when
A rare trigger point occurs here near the Achilles ten
this muscle is fatigued.
don. This trigger point strongly refers to the mandible and
Some cases of Achilles tendonitis may be due to shorten
maxilla on the same side. Some spillover may occur around
ing of the soleus and gastrocnemius muscles caused by trig
the strong referral here as well.
ger points in both muscles, with chronically increased ten
Trigger points here characteristically restrict dorsiflexion
sion on the Achilles tendon. Achilles tendonitis is a painful
and possibly cause low back pain, as this person will lean
injury of the Achilles tendon that includes inflammation,
forward to lift something and have to do it improperly. This
usually at or near the tenoperiosteal or musculotendinous
person will most likely describe walking as painful and
junction.
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• FIGURE 10-25 Soleus trigger points and referral zones. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilki ns.)
•
FIGURE 10-26 Soleus trigger points and referral zones. (Reprinted with permission from Simons DG, Travell JG, Simons LS. The Lower Extremities.
Any of these trigger points may develop as satellites to primary trigger points in the posterior portion of gluteus
Philadelphia, PA: Lippincott Williams & Wilkins; 1 993:430; Fig. 22.2. Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 2.)
minimus, which often refer into the calf region.
STRESSORS AND PERPETUATING FACTORS • Keeping the muscle in a shortened position-chronic
• If the pain progressively worsens, there may be medial
tibial stress syndrome here. Other names for this con
overuse-as when wearing high heels or sitting in a
dition include soleus syndrome, periostalgia,
chair that is too high so that only toes touch the floor
tibial stress syndrome
• Stress overload, such as slipping off of a stair • Wearing long socks with a tight elastic top, maintain
or
medial
• Deep vein thrombosis could mimic an acute myofascial
syndrome such as compartment syndrome
ing pressure on the muscle • lee skating, skiing, or roller blading without having
adequate ankle support • Leg length inequality, which may activate and perpet
uate trigger points in the short limb
PRECAUTIONS • Always check for varicosities before engaging this muscle
MASSAGE THERAPY CONSIDERATIONS • Pincer compression is a n effective technique for allevi
ating ischemia in this muscle • Using slight dorsiflexion will elevate the gastrocne
mius off the soleus for better engagement • Resting the client's prone foot on the therapist's abdo
• If the pain is persistent and the athlete cannot run
men while using both thumbs to muscle strip from
through the pain, stress fractures in the tibia may be
distal to proximal allows for a bunching of the gastroc
present; refer the client to a physician for evaluation
nemius fibers and good soleus accessibility
L E G W I T H P O S T E R I O R K N E E , A N K L E , A N D F O OT
C H A P T E R 10
305
F l exor Lon g u s G ro u p The flexor longus group of muscles is made up of the flexor digitorum longus and flexor hallucis longus muscles. These muscles are two of the deeper muscles in this area of the leg.
Flexor Digitorum Longus and Flexor Hallucis Longus: Claw Toe Muscles Flexor digitorum longus and flexor hallucis longus make up the long flexor muscles that move the toes (Figs. 1 0-27 to
1 0-29 ) .
ORIGI N Flexor Oigitorum Longus •
Posterior surface of the middle half of the tibia, begin ning distally to the soleus attachment Flexor digitorum longus
Flexor Hallucis Longus •
Inferior two-thirds of the posterior shaft of the fibula
I NSERTION Flexor Oigitorum Longus •
The tendon passes behind the medial malleolus, then splits into four attachments at the base of the distal phalanx of the lateral four toes on the plantar sur face
•
(Reprinted with permission from Oatis CA. Kinesiology. Baltimore, MD: Lippi ncott Williams & Wilkins; 2004.)
Flexor Hallucis Longus •
FIGURE 10-27 Flexor digitorum longus anatomical attachment sites.
The tendon passes behind the medial malleolus to attach to the base of the distal phalanx of the great toe on the plantar surface
Soleus ----��
ACTION
Gastrocnemius --�; tendon
Flexor Oigitorum Longus
Calcaneal ----'i��----'JI�..\ tendon
•
Flexes the four lateral toes at the distal interphalangeal joints
•
Assists plantar flexion of the foot at the ankle
Flexor halluc is longus Flexor
Flexor Hallucis Longus •
Flexes the great toe at the distal interphalangeal joint
•
Assists plantar flexion of the foot at the ankle
Tibialis posterior tendon Tibialis
TRIGGER POINTS AND REFERRAL ZONES In both muscles, the trigger point typically occurs within the muscle belly; it usually occurs quite proximal in the
Tuberosity of navicular
Calcaneus Quadratus plantae Fibularis (peroneus) longus Fibularis (peroneus) brevis Flexor digitorum longus tendon Slip from flexor hallucis longus
i!=---- Flexor hallucis longus tendon
flexor digitorum longus while being at the halfway point in
If''ffi�*"---- Lumbricals
flexor hallucis longus. Strong referral typically occurs into the plantar surface of the lateral four metatarsals from the trigger point in flexor digitorum longus. Some spillover commonly occurs sur rounding the strong referral and extending into the lateral four toes. A line of spillover may occur, extending from the actual trigger point to below the medial malleolus.
•
FIGURE 10-28 Flexor digitorum longus anatomical attachment sites. (Reprinted with permission from Moore KL, Dalley AF. Clinical Oriented Anatomy. 4th ed. Baltimore, MD: Lippi ncott Williams & Wilkins; 1999.)
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• FIGURE 10-29 Flexor hallucis longus anatomical attachment sites.
•
FIGURE 10-30 Flexor dig itorum longus trigger points and referral
(Reprinted with permission from Oatis CA. Kinesiology. Baltimore, MD:
zones. (Reprinted with permission from Medi Clip, Lippincott Williams
Lippi ncott Williams & Wilkins; 2004.)
& Wilki ns.)
From the trigger point in flexor hallucis longus, a very strong referral often occurs into the plantar surface of the great toe and its metatarsal. These referrals cause people to complain of having sore feet and toes on the plantar surface. Often, these people have had custom orthotics made for them to reduce stress on their feet (Figs. 1 0-30 and 1 0-3 1 ) .
TRIGGER POINT ACTIVATION Running on uneven ground or on slanted surfaces can acti vate trigger points in both muscles. Overloading these mus cles mechanically can also activate trigger points here.
STRESSORS AND PERPETUATING FACTORS • Running on a sloped track or road •
Having Morton foot structure or other deviation that produces hyperpronation or an unstable foot
•
Wearing badly worn shoes, especially runners, that then create an unstable gait
• Wearing an inflexible shoe that prevents normal exten
sion of the metatarsalphalangeal joints during ambula tion • Running or walking on sand, especially when barefoot • Having extremely high arches or supinated feet
•
FIGURE 10-3 1 Flexor hallucis longus trigger points and referral zones. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
C H A P T E R 10
PRECAUTIONS .' Work thoroughly with gastrocnemius and soleus before
L E G W I T H P O S T E R I O R K N E E , A N K L E , A N D F O OT
307
MASSAGE THERAPY CONSIDERATIONS •
Claw toe deformities may result from overactivity of
getting into these deeply placed muscles
the long flexor muscles of the toes. Claw toe is a condi
•
Be sure to avoid any varicosities found in the leg
tion in which the metatarsal phalangeal joints of the
•
According to Travel and Simons, referrals from trigger
four lesser toes are markedly extended and the proxi
points here may be mistaken for tarsal tunnel syn
mal and distal interphalangeal joints are fixed in flex ion, producing a claw curvature
drome. Tarsal tunnel syndrome is a neuropathy of the distal portion of the tibial nerve at the ankle due to
•
cult to access directly. Using a thumb or a finger to
chronic pressure on the nerve at the point it passes through the tarsal tunnel. With this condition, there is
hook into the medial posterior shaft of the tibia will
typically pain and numbness of the sole of the foot and
directly engage flexor digitorum longus
weakness of plantar flexion of the toes •
These muscles, along with tibialis posterior, are diffi
•
Using this same technique posterior and medial to the
According to Travell and Simons, spontaneous rupture
medial malleolus may directly engage the tendons of
of the flexor hallucis longus tendon can occur during
both muscles
overload without evidence of previous disease or injury
•
These are two of the three "TDH" tendons: tibialis poste rior, flexor digitorum longus, and flexor hallucis longus
3 08
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M U S C L E S A N D N E U R O M U S C U LA R T H E RA P Y R O U T I N E S B Y B O DY R E G I O N
Tibialis Posterior: Runner's Nemesis Tibialis posterior is the most deeply located muscle in the calf and therefore the most difficult to impact therapeuti
ACTION
cally. Looking at all of its attachments on the plantar surface of the tarsals and metatarsals, one can see that this is a sta
•
Assists plantar flexion of the foot at the ankle
A trigger point will most likely be found in the extreme
ORIGIN
proximal muscle belly. The referral zone is quite extensive
•
Interosseous membrane
•
Medial surface of the posterior fibula
•
Lateral portion of the posterior body of the tibia
here. There will be very strong referral to the entire Achilles tendon, with quite a bit of spillover to the entire heel and plantar surface of the foot. There may be spillover extending from the actual trigger point down to the Achilles tendon as
I NSERTION The tendon passes medially behind the medial malleo lus to split into several tendons •
Ankle inversion
TRIGGER POINTS AND REFERRAL ZONES
bilizer for our arches (Fig. 1 0- 3 2 ) .
•
•
Plantar surface of the navicular, calcaneus, each cunei form, medial cuboid, and the bases of the second, third,
well. A person with trigger points in this area will most likely complain of having Achilles tendonitis, along with pain in the foot and the heel (Fig. 1 0-3 3 ) .
and fourth metatarsals
Popliteus muscle
Peroneus longus II f rlIJI Tibialis posterior --t--IIoILllD
Flexor digitorum -"'--JeTtIl longus
Flexor hallucis longus
Peroneus brevis
•
FIGURE 10-32 Tibialis posterior anatomical attachment sites.
•
FIGURE 10-33 Tibialis posterior trigger points and referral zones.
(Reprinted with permission from Hendrickson T. Massage for Orthopedic
(Reprinted with permission from Medi Clip, Lippincott Williams &
Conditions. Baltimore, MD: Lippincott Williams & Wilkins; 2003.)
Wilkins.)
C HAPTER 1 0
L E G W I T H P O S T E R I O R K N E E , A N K L E , A N D F O OT
• Wearing badly worn shoes encourages eversion and
TRIGGER POINT ACTIVATION
rocking of the foot
Mostly, trigger points in this muscle are activated by over loading of the muscle during activity that involves hyper pronation or eversion.
•
.
STRESSORS AND PERPETUATING FACTORS
• B e aware o f any varicosities i n the lower leg area before
working with this very deep muscle
• Having hyperuricemia, with or without signs and
symptoms of gout. Hyperuricemia is abnormal amount of uric acid in the blood Having polymyalgia rheumatica. Polymyalgia rheumat ica is a poorly understood condition almost always found in patients over 50 years of age and four times more
MASSAGE THERAPY CONSI DERATi oNS • It i s common for there t o b e shin splinting from this
muscle •
inflammatory arthritis, absence of signs of muscle dis ease such as atrophy or weakness, and prompt and dra matic response to low doses of corticosteroid therapy • Running on uneven surfaces by poorly conditioned
athletes or novice runners • Excessive pronation will severely strain the distal por
It is possible for this muscle's tendon to develop teno synovitis
frequently in women. It is characterized by pain in the muscles of the shoulder and pelvic girdle, absence of
tion of this muscle
Hypermobile flat foot conditions weaken tibialis posterior
PRECAUTIONS .
•
309
•
The main function of this muscle-inversion-is to prevent excessive pronation of the foot during mid stance of the walking cycle and to evenly distribute body weight among the heads of the metatarsals
• Muscle stripping the deep posterior compartment will
affect tibialis posterior along with flexor digitorum lon gus and flexor hallucis longus • Resisted inversion exercises using a power band are
effective strengthening measures
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POSTERIOR KNEE AREA The posterior knee is an endangerment area with two muscles running through it, the popliteus and the plantaris. Deep to these muscles are various vessels that should not be occluded.
Popliteus: Bent-Knee Troublemaker The popliteus muscle fills in the space proximal to the soleal line up to the joint capsule at the back of the knee and is one of the very few muscles that actually attach to ligaments (Fig.
1 0-34) .
ORIGIN • Lateral femoral condyle • Capsule of the knee joint • Lateral meniscus •
Arcuate popliteal ligament
I NSERTION • Upper medial posterior tibia proximal t o the soleal
line
ACTION • Initiates knee flexion b y laterally rotating the femur on
the tibia •
Unlocks an extended knee at the beginning of weight bearing by laterally rotating the thigh on the fixed tibia
TRIGGER POI NTS AND REFERRAL ZON ES A trigger point may occur within the belly of the muscle, with a strong referral to the middle of the posterior knee. There may be spillover surrounding the strong referral as well. A person with this trigger point will most likely complain
• FIGURE 10-34 Popliteus anatomical attachment sites. (Repri nted with permission from Anatomical Chart Company, Lippi ncott Williams & Wilkins.)
of pain behind the knee, especially when going either upstairs or downstairs (Fig.
1 0-35 ) .
TRIGGER POINT ACTIVATION This trigger point is easily activated by running while twist ing and sliding. This type of movement specifically over 16) shows an associa
loads this muscle. A study by Brod/ (p I5. tion
between
an
excessively
pronated
foot
during
weight-bearing activities and aggravation of popliteus ten donitis.
STRESSORS AND PERPETUATING FACTORS • Playing sports such as football, soccer, running, or ski
ing downhill • Any trauma or strain that tears the posterior cruciate
ligament of the knee
• FIGURE 10-35 Popliteus trigger points and referral zones. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
C H A P T E R 10
•
L E G W I T H POST E R I O R K N E E, A N K L E, A N D FOOT
phlebitis or lymphatic blockage. For the last two con
Knee hyperextension, especially during exercise such
ditions, have the client evaluated by a doctor
· as using a rowing machine •
Excessive pronation
PRECAUTIONS
31 1
MASSAGE THERAPY CONSIDERATIONS •
Muscle stripping the posterior medial aspect o f the
•
This i s a n endangerment site
tibia will affect the insertion. This technique is the
•
The popliteal artery is superficial to the popliteus muscle
same as muscle stripping tibialis posterior; just con
•
Be sure to rule out a Baker's cyst by referring the client
tinue the stroke more superiorly until behind the
to a doctor for evaluation. A Baker's cyst is a fluid
medial condyle of the tibia, but use less pressure
•
filled extension of the synovial membrane at the knee
•
protruding into the popliteal fossa
•
Do not work the posterior knee area if there are any signs of inflammation or if there is a suspicion of
Be sure to be very gentle when working in this area The direction of the muscle fibers is more transverse than those of plantaris
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Plantaris: Jogger's Heel Plantaris is a very small muscle with a very long, frail tendon.
ORIGIN •
Lateral epicondyle o f the femur and distal linea aspera
INSERTION •
Calcaneus
ACTION •
Plantar flexion
•
Ankle inversion
•
Weakly assists flexion of the knee
TRIGGER POI NTS AND REFERRAL ZON ES Often a trigger point will occur in the muscle belly and cause spillover from the point of the trigger point down to the middle of the posterior calf. A person with trigger points in this muscle often complains of vague pain in the posterior calf area (Fig. 1 0-36 ) .
TRIGGER POI NT ACTIVATION Sudden overloading of this muscle can activate trigger points, as can excessive pronation, weak arches, or overly developed arches.
STRESSORS AND PERPETUATING FACTORS •
•
Slipping on a wet surface and trying to maintain one's
•
FIGURE 10-36 Pla ntaris trigger points and referral zones. (Reprinted
balance
with permission from Simons DG,Travell JG, Simons LS. The Lower
Maintaining this muscle in a shortened position for
Extremities. Philadelphia, PA: Lippincott Williams & Wilkins; 1993:430; Fig.
long periods •
Wearing long socks with tight elastic tops
•
Morton foot structure
•
Flat feet
or
22.3. Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 2.)
•
muscle
high-arched feet
PRECAUTIONS •
This i s a n endangerment site
•
Do not work the posterior knee area if any signs of
MASSAGE THERAPY CONSIDERATIONS •
Plantaris i s actually a very weak plantar flexor; 9 5 % of plantar flexion is initiated by gastrocnemius and soleus
inflammation are present or if there is suspicion of phlebitis or lymphatic blockage. For the last two con
•
d itions, be sure to have the client evaluated by a
•
physician
The popliteal artery is superficial to the popliteus
Plantaris is superficial to popliteus Plantaris fiber direction is more oblique to the axis of the leg than that of popli teus
C H A P T E R 10
L E G W I T H P O S T E R I O R K N E E , A N K L E , A N D F O OT
Leg with Posterior Knee, An kle, a n d Foot Neuromusc u l a r Thera py Routine Note that the video icon indicates routines that are featured i n online video cli ps,on the book's companion Web site.
FOOT
e
Have the client lie supine with the bolster under the knees. Sit on a stool at the foot of the table. 1.
Warm the foot usi ng petrissage and ankle mobilization movements.
2.
Apply flexion, extension, inversion, and eversion stretches to the ankle (Routine 1 0-1 ).
Note: Apply lubrication now. 3.
Use thumb stripping and circular fingertip friction to the dor sal aspect of the foot. Work between the metatarsals and around the malleoli. Apply dorsiflexion to achieve better con tact between the metatarsals while working between them (Routine 1 0-2).
4.
ROUTINE 10-1
Use deep palm and thumb stripping across the retinaculum of the ankle with the foot in plantar flexion. You may also use active mobilization of the ankle into plantar flexion,then dor siflexion,while gliding across this structure.
• ROUTINE 10-2
313
314
5.
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Use deep thumb stripping and/or the knuckles with a loose fist over the plantar fascia (Routine 1 0-3). Move in both an upward and downward direction. Also, thumb strip between the metatarsals on the plantar surface, then use transverse friction and sustained compression to any tender areas.
6.
Work the entire calcaneus using transverse friction and direct pressure using a thumb and/or knuckles.
7.
Apply friction to the tendinous insertions of the peroneals, tibialis anterior, and tibialis posterior (Routine 1 0-4). (Tertius and brevis at the base of the 5th metatarsal on the dorsal surface, longus and tibialis anterior at the base of the 1 st met atarsal, and the medial cu neiform on the plantar surface, tibialis posterior on the tarsals and metatarsal bases of toe numbers 2 through 4 on the plantar surface.)
ANTERIOR COMPARTMENT Tibialis Anterior a nd Extensor Digitorum longus
�
ROUTINE 10-3
Stand at the side of the table,facing the head. Medially rotate the leg and press in toward the tibia. 1.
Use palmar compression and petrissage to warm the bellies of these muscles.
Note: Lubricate now. 2.
Use muscle stripping from distal to proximal working from midline to lateral (tibialis anterior, then extensor digitorum longus, and then the peroneals). Use thumbs or knuckle varia tions.You can also apply an active stretch into plantar flexion while lengthening from the insertion toward the origin. ROUTINE 10-4
3.
Use transverse and longitudinal friction along with trigger point pressure on any tight bands of tissue and/or trigger points found.
4.
Complete with slow, deep effleurage using knuckles or the heel of a hand.
C H A P T E R 10
L E G WITH POSTE R I O R K N E E, A N KLE, A N D FOOT
LATERAL COMPARTMENT Peroneals
�
The client is in a side-lyi ng position. Stand at the side of the table.
1 . A deep engagement of the peroneals can be performed with the client in the side-lying position, with the i nferior knee flexed and the superior leg straight with a bolster under the straight thigh and leg (Routine 1 0-5).
2. Use transverse friction and longitudinal friction to any tight
bands found there (Routine 1 0-6).
3. Friction the peroneal tendons posterior (longus and brevis) and anterior (tertius) to the lateral malleolus, the base of the 5th metatarsal, and the plantar su rface of the foot in the prox imity of the tarsals and the bases of the metatarsals.
ROUTINE 10-5
ROUTINE 10-6
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M U S C LES A N D N E U ROMUSCULAR T H E RAPY ROUTI N E S B Y BODY R E G I O N
4. Complete with a deep, broad effleurage. You may also use
active dorsi/plantar flexion, using movement to assist the release of any tight tissue (Routine 1 0-7).
POSTERIOR COMPARTMENT Have the client lie prone with a bolster under the ankles. Stand at the side of the table facing the client's head.
Gastrocnemius and Achilles Tendon
e
1 . Warm a nd loosen the posterior leg using compression, petris
sage, and fi ber spreading movements.
Note: Lubricate now. 2. Use broad effleurage, and then m uscle strip the Achilles ten
don, gastrocnemius, a nd soleus. Be thorough with the warm ing of these large muscles.
3. Work the Achilles tendon using circular friction. Then, with the
client's knee flexed, use transverse friction and pincer com
• ROUTINE 10-7
pression from the calcaneus to the musculotendinous junc tion of gastrocnemius. This may be done with the Ach il les tendon relaxed or stretched from this position.
4. With the dorsum of the foot supported on the bolster, placing the ankle into plantar flexion, begin specific work on the Achilles tendon. This pOSition slackens the tendon, a llowing you to work on its anterior side.
S. Using one finger of one hand to displace the tendon medial ly,
friction the a nterior surface with one fingertip of the other hand. Repeat the process after displacing the tendon laterally (Routine ' 0-8). Note: use the very tip of the finger to work here. It is very important that you have no fingernail length at all.
•
ROUTINE 10-8
C H A P T E R 10
L E G W I T H P O S T E R I O R K N E E , A N K L E , A N D F O OT
6. Now isolate the gastrocnemius with two-handed pincer com
pr�ssion, and then use transverse friction and sustained pres sure to any tight bands found, along with trigger point pres sure to trigger points (Routine 1 0-9).
7. With the client's leg flexed to almost a 90-degree position, isolate the attachments at the medial and lateral epicondyles of the femur with thumb pressure and gentle transverse fric tion. Use trigger point pressure, if necessary. The lateral attach ment will be medial to the biceps femoris tendon. The medial attachment will be lateral to the semimembranosus and semi tendinosus tendons (Routine 1 0-1 0).
•
ROUTINE 10-9
ROUTINE 10-10
317
318
Soleus
PA R T I I
M U S C L E S A N D N E U RO M U S C U L A R TH E RAPY ROUTI N E S BY B O D Y R E G I O N
e
Stand at the side of the table. 1 . Work the soleus with muscle stripping by displacing the belly
of gastrocnemius laterally to access the med ial border of soleus, and then medially to access the lateral border. You can do a variation of this with both sides at the same time by flex ing the client's knee and placing the plantar surface of the foot into your a bdomen while thumb stripping from insertion to origin u p under both heads of the gastrocnemius onto the soleus (Routine 1 0- 1 1 ).
2. Now use transverse friction to tight bands and trigger point pressure to any trigger point found.
3. Complete with deep effleurage using the forearm from inser tion to origin.
DEEP POSTERIOR COMPARTMENT Tibialis Posterior, Flexor Digitorum longus, and Flexor Hallucis longus
ROUTINE 10-1 1
�
1 . With the client's knee flexed and leg supported on a pillow or you r knee, a pply m u scle stri pping to the middle posterior aspect of the tibia as well as under the lateral gastrocnemius to the space between the fi bula and the tibia. This will influ ence muscle attachments on the i nterosseous membrane (Routine 1 0- 1 2).
2. Displacing the gastrocnemius laterally to access the tibialis posterior (on the posterior tibia a nd fibula as wel l as the inter osseous membrane) and the flexor digitorum longus (on the u p per three-fourths of the posterior tibia), you can use muscle stripping techniq ues along with friction and trigger point release to those areas.
3 . Displacing the gastrocnemius medially to access the flexor h a l lucis longus (on the lower one-ha lf of the posterior fi bu la), you can do the same as step 2. Note: as you move proximally, at the medial/posterior aspect of the condyle of the tibia, the insertion of popliteus will be affected. Use less pressure there, as it may be quite tender.
ROUTINE 10-12
C H A P T E R 10
Plantaris
L E G W I T H P O S T E R I O R K N E E, A N K L E , A N D FOOT
e
1 . With the knee flexed and supported on your leg, isolate the
plantaris with gentle transverse friction. This muscle will be superficial and its fiber direction at a 3�-degree angle to the leg, from the lateral epicondyle of the fem u r to below the medial aspect of the crease of the knee (Routine 1 0- 1 3).
2. Use trigger point pressure as necessary. Be gentle. Note: use caution in this area because of the superficial nerves, arteries, and veins located at the posterior knee; remember that this is an endangerment site.
Popliteus
•
ROUTINE 10-13
•
ROUTINE 10-14
e
1 . Using the thumbs, apply effleurage with a l ight pressure and
a broad sweep. The popliteus runs at a n angle greater than 30 degrees, from the lateral condyle of the fem u r to the u pper medial shaft of the tibia (Routine 1 0- 1 4).
2. Apply friction from the insertion to the origin.
3 . Use trigger point pressure as necessary. Note: use caution here due to this being an endangerment site.
FINISHING THE LEG 1 . Use deep effleurage with the forearm or the hands from
inferior to superior.
2. Stretching techniques may now be a pp l i ed in the form of plantar and dorsi flexion at the a nkle.
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M U SCLES A N D N E U RO M U SC U LA R T H E RAPY ROUTINES BY BODY R E G I O N
Case Study 1 0- 1 •
Peter: A C l ient with Pa i n Behind H i s Knee
Background
that first time. They discovered that Peter had been hyperex
Peter was referred to a neuromuscular therapist by his regular
tending his knees with each rowing stroke.
massage therapist. He had been experiencing pain behind his
The therapist had worked specifically on Peter's popliteus
right knee for 6 months, and it was getting worse, not better,
and plantaris muscles, finding both to be quite sore on pa lpa
even though he had been receiving reg u l a r, weekly massage.
tion. She was quite pleased that she had done so on the dis covery of the hyperextension issue.The therapist also focused on the gastrocnemius and soleus muscles to be sure they
Treatment The neuro m u sc u l a r therapist fi rst a s ked Peter if he could remember when the pain fi rst bega n and what he had been doing. Peter a nswered that he remembered just waking up with it feeling odd and then it actually hurting that same day after his morning exercise. When questioned about his regu lar exercise, Peter began to get anxious stating that he would rather it be worked on than tal ki n g a bout it.The neuromuscu lar therapist suggested that he get on the ta ble and that they could continue with the talk as she warmed u p his hips, thig hs, and legs. During the ta l k while Peter was on the ta ble, he remem bered that h i s workout that day beg a n with his rowing machine and that he used that machine every other day. The therapist further asked h i m to show her how he moved his legs when on the rowing machine after he got off the ta ble
loosened up nicely. Even though the other leg had no pain, it was also worked with to maintai n balance. The treatment of the plantaris and popliteus muscles con tin ued on a weekly basis for 5 weeks successfu l ly. Peter changed the position of the seat on his rowing machine so he would no longer hyperextend his knees.
Critical Thinking Questions 1 . Why would a constant, slight hyperextension of the knee d u ring exercise every other day cause pain in the popli teus and plantaris muscles? 2. Why was it i m portant to the neuromuscular therapist to ask so many questions about the client's activity? 3. Why did not Peter's regular massage therapist find these sore muscles?
.'
Case Study 1 0-2 •
Lisa: A R u n ner with Anterior Leg Pa i n Bi latera l ly
Background
the therapist to work with the deeper layers of muscle. It was
Lisa was referred for neuromuscular therapy by her doctor
determined in the second session that tibialis posterior was
after being seen for anterior leg pain. The doctor determined
the cu I prit.
that it was due to muscular soreness because Lisa was a run ner who racked u p 5 m iles/day.
The therapist worked successfu l ly with Lisa weekly for another 1 2 sessions while Lisa iced her legs daily at home by placing each leg i nto a tal l bucket fil led with ice and water for
Treatment
a 20-minute period of time. Lisa also began a more thorough
After listening to Lisa's story and reading over her health his
stretching program for her legs.
tory notes, the neuromuscular therapist bega n an i n itial ses sion working on Lisa's legs. Lisa had told the therapist that she
Critical Thinking Questions
felt the pain a bout 1 0 m i n utes after she stopped running.
1 . Why did the therapist check out a l l three leg compart
Although finding tibialis a nterior q uite tight and sore, it was not the pain Lisa was experiencing daily. The therapist tu rned Lisa to a side-lying position to work with the peroneals. Again, these were sore, but not the pain Lisa was describing. Lisa was now i n a prone position for the posterior leg compartment to be worked on. Both gastrocne mius and soleus were sore, but loosened sufficiently to allow
ments looking for the cause of anterior pain? 2. Why would it take many sessions to get tibialis posterior to let go of its trigger points and inflammation? 3. Why did not the therapist suggest a simple cold pack for Lisa to use rather than a bucket of ice water for this condition? 4. Why was specific stretching i mportant?
C H A P T E R 10
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321
REVIEW QUESTIONS
Short Answer Questions 1 . Name the three peroneal muscles.
2. Which of the above three muscles has an action that is different from the other two? Why ?
3 . Which direction does the ankle roll over i n a n inver sion sprain ?
4. Which ligaments are most often damaged during an inversion sprain ?
5. Describe a phasic muscle. Multiple Choice Questions
6. Which is a two-joint muscle of the posterior leg? A. Soleus B.
Tibialis posterior
C. Gastrocnemius D. Flexor hallucis longus
7. The two muscles whose bellies are at the posterior knee
1 0. Which muscle located i n the posterior leg i s the most difficult to impact therapeutically? A. Soleus B.
Flexor hallucis longus
C. Gastrocnemius D. Tibialis posterior True/False 1 1 . Claw toe deformities may result from overactivity of
the long flexor muscles of the toes.
1 2. An ankle sprain results when muscles are injured dur ing an incident when the ankle rolls over.
1 3 . Bunions are also known as hallux valgus. 1 4. Hammer toe is an identical condition to Claw toe. 1 5 . A stress fracture is usually due to overuse or other traumas. Matching
are the
a. Pes planus
d. Plantar fasciitis
A. Semimembranosus and semitendinosus
b. Articular dysfunction
e. Baker's cyst
B.
c. Achilles tendonitis
f. Tarsal tunnel syndrome
Soleus and gastrocnemius
C. Tibialis posterior and gastrocnemius D.
Plantaris and popliteus
B. Referred pain to the big toe is commonly caused by
the A. Tibialis anterior B.
Peroneus longus
C. Gastrocnemius D. Extensor digitorum longus
9. The two muscles that form a stirrup to stabilize the ankle and arches of the foot are the A. Tibialis posterior and tibialis anterior
1 6. A fluid-filled pouch within the synovial membrane pro truding into the popliteal fossa.
1 7 . Neuropathy of the distal tibial nerve in the ankle area causing pain and numbness of the foot. l B . A foot without arches, also known as a flat foot.
1 9. An inflammatory injury of certain tissues on the plantar surface of the foot.
20. An inflammatory injury of a certain structure in the posterior leg.
B. Tibialis anterior and peroneus longus C. Tibialis anterior and soleus D. Tibialis posterior and peroneus longus
REFEREN CES 1 . Basmaj ian J V, Deluca q . Muscles Alive. 5 th ed. Baltimore, MO: Will iams & Wilkins; 1 98 5 :3 5 3 , 3 54 .
2. Brody OM. Running injuries. Clin Symp. 1 980:3 2 : 1 -3 6 .
THIS PAGE INTENTIONALLY LEFT BLANK
TRIGGER POINT AND REFERRAL GUIDE This chapter is presented as a quick guide for those students
•
Semispinalis capitis
and therapists who practice this work to be able to use when
•
Splenius cervicis
they have a client on the table and lack the time to re-read
•
Suboccipital group
the significant chapter or chapters that describe where the trigger points and associated referral zones are. The following lists of areas and muscles are meant to be an
FRONTAL AREA
easy guide to use when tracking down the areas holding the
•
actual trigger points that are impacting the body in such a way
•
Frontalis
•
Semispinalis capitis
that the client is feeling pain and other sensations distally.
Sternocleidomastoid (both heads)
The lists below are headed by the name of each area where the pain or other sensation may be present. The list of muscles below each heading are a compilation of different authors' ideas of what muscles or groups are responsible for sensation in those areas identified in the headings. With the muscles listed this way, it is the author's hope that the following will aid students and therapists in deter mining which muscles to address and in which order to address them.
DOME OF THE HEAD AREA: VERTEX •
Sternocleidomastoid (sternal head)
•
Splenius capitis
TEMPORAL AREA
EYE AND EYEBROW AREA •
Sternocleidomastoid (sternal head)
•
Corrugator supercilii
•
Temporalis
•
Splenius cervicis
•
Masseter (superficial head)
•
Occipitalis
•
Suboccipital group
•
Trapezius (upper)
SINUS AREA •
Lateral pterygoid
•
Temporalis Sternocleidomastoid
•
Trapezius (upper)
•
•
Sternocleidomastoid (sternal head)
•
Masseter
Temporalis
•
Medial pterygoid
•
323
324
PART II
MUSCLES AND NEUROMUSCULAR THERAPY ROUTINES BY BODY REGION
• EAR AND TEMPOROMANDIBULAR JOINT AREA •
Lateral pterygoid
•
Masseter (deep head)
•
Sternocleidomastoid (clavicular head)
•
Medial pterygoid
•
Longus capitis
•
Anterior suboccipitals
•
Infraspinatus
lATERAL NECK AREA •
Levator scapulae
CHEEK AND JAW AREA •
Sternocleidomastoid (sternal head)
ANTERIOR SHOULDER AND CHEST AREA
•
Masseter (superficial head)
•
Scalenes
•
Lateral pterygoid
•
Pectoralis major
•
Trapezius (upper)
•
Subclavius
•
Digastric (posterior head)
•
Pectoralis minor
•
Infraspinatus
•
Supraspinatus
• TEETH •
Temporalis
•
Masseter (superficial head)
•
Digastric (anterior head)
BACK OF THE HEAD AREA •
Trapezius (upper)
•
Sternocleidomastoid (both heads)
•
Semispinalis capitis
•
Semispinalis cervicis
•
Suboccipital group
•
Occipitalis
•
Digastric (posterior head)
•
Temporalis
•
Splenius cervicis
ANTERIOR NECK AND THROAT AREA •
Sternocleidomastoid (sternal head)
•
Medial pterygoid
•
Longus capitis
•
Longus colli
•
Anterior suboccipitals
•
Trapezius (upper)
•
Digastric (posterior head)
POSTERIOR NECK AREA
•
Anterior deltoid
•
Teres major
•
Subscapularis
•
Coracobrachialis
•
Biceps brachii
•
Brachialis
•
Latissimus dorsi
ABDOMEN •
Rectus abdominis
•
Obliquus externus abdominis
•
Lateral walls of both obliques and transversus abdominis
•
Iliocostalis thoracis
•
Multifidi
•
Quadratus lumborum
•
Pyramidalis
POSTERIOR SHOULDER AND UPPER BACK AREA •
Scalenes
•
Levator scapulae
•
Splenius cervicis
•
Deltoid (posterior head)
•
Trapezius (middle and lower)
•
Rhomboids
•
Serratus anterior
Trapezius (upper and lower)
•
Erector spinae
•
Levator scapula
•
Multifidi
•
Splenius cervicis
•
Rotatores
•
Longus colli
•
Supraspinatus
•
CHAPTER 11
/ TRIGGER POINT AND REFERRAL GUIDE
•
Quadratus lumborum
'. Teres major
•
Iliocostalis lumborum
•
Infraspinatus
•
Teres minor
•
Longissimus thoracis
•
Subscapularis
•
Piriformis
•
Serratus posterior superior
•
Gluteus minimus
•
Latissimus dorsi
•
Semitendinosus
•
Triceps brachii
•
Semimembranosus
•
Biceps brachii
•
Obturator internus
lATERAL SHOULDER AREA •
Deltoid (middle or acromial head)
•
Supraspinatus
•
Infraspinatus
•
Teres major
•
Scalenes
•
Teres minor
•
Subscapularis
MIDBACK AREA •
Erector spinae
•
Quadratus lumborum
•
Multifidus
PElVIC AREA (IN TERNAL SENSATIONS) •
Adductor magnus
•
Obturator internus
•
Obturator externus
•
Lateral walls of both obliques and transversus abdominis
GROIN AREA •
Pectineus
•
Adductor magnus
•
Rectus abdominis
•
Internal and external obliques
•
Obturator internus
•
Iliopsoas
•
Rotatores
•
Serratus anterior
•
Serratus posterior inferior
•
Rectus abdominis
ANTERIOR UPPER ARM AREA
•
Intercostals
•
Scalenes
•
Latissimus dorsi
•
Supraspinatus
•
Psoas
•
Infraspinatus
•
Deltoid (anterior head)
•
Pectoralis major
Piriformis
•
Subclavius
•
Gluteus medius
•
Pectoralis minor
•
Psoas
•
Biceps brachii
•
Erector spinae
•
Brachialis
•
Multifidus
•
Triceps brachii
•
Rotatores
•
Anconeus
•
Quadratus lumborum
•
Serratus posterior superior
•
Gluteus maximus
•
Serratus anterior
•
Rectus abdominis
•
Soleus
lOW BACK LUMBAR AND SACRUM AREAS •
BUT TOCK AREA
325
POSTERIOR UPPER ARM AREA •
Scalenes
•
Supraspinatus
•
Gluteus maximus
•
Infraspinatus
•
Gluteus medius
•
Serratus posterior superior
326
PART II
/
MUSCLES AND NEUROMUSCULAR THERAPY ROUTINES BY BODY REGION
•
Subscapularis
•
Scalenes
•
Teres major
•
Triceps brachii (medial head)
•
Teres minor
•
Latissimus dorsi
•
Latissimus dorsi
•
Pectoralis major
•
Posterior deltoid
•
Pectoralis minor
•
Triceps brachii
•
Serratus posterior superior
•
Anconeus
•
Supraspinatus
•
Coracobrachialis
•
Infraspinatus
LATERAL ELBOW AREA
HAND AND FINGER AREA: NUMBNESS
•
Extensors (all)
•
Scalenes
•
Brachioradialis
•
Serratus posterior superior
•
Supinator
•
Teres minor
•
Anconeus
•
Pectoralis minor
•
Subclavius
•
Triceps brachii
•
Scalenes
•
Brachialis
•
Supraspinatus
•
Supinator
•
Extensors (all)
•
Flexor carpi ulnaris
•
Flexor digitorum
•
Pronator teres
MEDIAL ElBOW AREA •
Flexors (all)
•
Pronator teres
•
Serratus anterior
•
Pectoralis minor
POSTERIOR FOREARM AREA •
Triceps brachii (long and lateral heads)
•
Anconeus
•
Scalenes
•
Subscapularis
•
Extensors (all)
•
Brachioradialis
•
Coracobrachialis
•
Infraspinatus
•
Latissimus dorsi
•
Teres major
•
Supraspinatus
HAND AND FINGER AREA: PAIN •
Subscapularis
•
Extensors (all)
•
Flexors (all)
•
Scalenes
•
Serratus posterior superior
•
Latissimus dorsi
•
Triceps brachii
•
Brachialis
•
Coracobrachialis
•
Pectoralis minor
•
Subclavius
•
Brachioradialis
•
Supinator
•
Infraspinatus
•
Serratus anterior
AN TERIOR FOREARM AREA AN TERIOR THIGH AREA
•
Flexors (all)
•
Pronator teres
•
Adductor longus
•
Serratus anterior
•
Pectineus
•
Subclavius
•
Gracilis
•
Biceps brachii
•
Iliacus
•
Brachialis
•
Psoas major
CHAPTER 11
• .•
Vastus intermedius Rectus femoris
•
Sartorius
•
Rectus abdominis
•
Deep lateral hip rotators
•
Gluteus minimus
POSTERIOR THIGH AREA •
Gluteus maximus
•
Gluteus medius
•
Gluteus minimus
•
Quadratus lumborum
•
Semitendinosus
•
Semimembranosus
•
Biceps femoris
•
Piriformis
•
Deep lateral hip rotators
•
Adductor magnus
LATERAL THIGH AREA •
Tensor fascia latae
•
Gluteus minimus
ANTERIOR KNEE AREA •
Rectus femoris
•
Vastus medialis
•
Adductor longus
POSTERIOR KNEE AREA •
Quadratus lumborum
•
Gastrocnemius
•
Soleus
•
Semimembranosus
•
Plantaris
•
Popliteus
•
Gluteus medius
•
Gluteus minimus
MEDIAL KNEE AREA
/ TRIGGER POINT AND REFERRAL GUIDE
ANTERIOR LEG AREA •
Tibialis anterior
•
Tibialis posterior
•
Adductor longus
POSTERIOR LEG AREA •
Soleus
•
Gastrocnemius
•
Gluteus maximus
•
Gluteus medius
•
Gluteus minimus
•
Piriformis
•
Deep lateral hip rotators
•
Quadratus lumborum
•
Flexor digitorum longus
•
Flexor hallucis longus
•
Semimembranosus
•
Tibialis posterior
•
Plantaris
LATERAL LEG AREA •
Gastrocnemius
•
Gluteus minimus
•
Peroneals (all)
•
Vastus lateralis
ANTERIOR ANKLE AREA •
Tibialis anterior
•
Extensor digitorum longus
•
Peroneus tertius
POSTERIOR ANKLE AREA •
Soleus
•
Tibialis posterior
LATERAL ANKLE AREA •
Peroneals (all)
•
Deep lateral hip rotators (all)
•
Vastus medialis
•
Semimembranosus
•
Tibialis anterior
•
Adductor longus
•
Extensor digitorum longus
•
Adductor magnus
•
Extensor hallucis longus
DORSUM OF THE FOOT AREA
327
328
PART II
/
MUSCLES AND NEUROMUSCULAR THERAPY ROUTINES BY BODY REGION
ARCH AN D PLANTAR FOOT AREA •
Gastrocnemius
•
Flexor digitorum longus
•
Flexor digitorum brevis
•
Adductor hallucis
•
Dorsal and plantar interossei
•
Soleus
•
Tibialis posterior
•
Clicking and pain in the TMJ
•
Bruxism and/or malocclusion in and effort to hold the jaw in its proper place
•
area •
Thoracic Kyphosis
HEEl AREA Soleus
•
Tibialis posterior
•
Abductor hallucis
LEG AND FOOT NUMBNESS •
Gluteus minimus
•
Piriformis
•
Soleus
•
Peroneus longus
•
Extensor digitorum longus
•
Abductor hallucis
•
Adductor hallucis
POSTURAL FINDINGS These are lists of postural symptoms and signs found with
Abnormal fascial accumulation in the lower cervi cals and upper thoracics
•
Depressed sternum and locked ribs inhibiting 3-D breathing
•
Elevation and depression in the thoracic cage
•
Paradoxical breathing patterns
•
Poor diaphragmatic function-possibly cellular degeneration
•
Hyperventilation resulting from poor diaphragmatic function
• •
Gasping or wheezing while speaking Frequent yawning, sighing , or attempting to catch one's breath
•
Elevation of the first rib: tendency toward thoracic outlet syndrome
• •
Dowager's hump Internal rotation of the humerus and scapular abduc tion with elevation
•
Hands anterior to the thigh and palms face posteri orly
certain conditions. The list of conditions is meant to be a sampling only, not all-inclusive.
Cervical hyperextension is perpetuated because of the "righting reflex"
•
•
The anterior fascial of the chest pulls into the hyoid
•
Inclination toward rotatar cuff tears, bursitis, and tendonitis
Forward-Head Posture •
•
vicular and sternoclavicular joints (V-shaped clavicles)
Hyperextension of the atlanta-occipital joint; impingement of the occipital nerves
Clavicular angulation, compression of the acromiocla
•
Restricted elongation of the longitudinal axis of the body
•
Chin-poking posture
•
Stretch strain of the interspinous and supraspinous
•
Anxiety states, panic attacks
ligaments
•
Fascial binding of the esophagus and the vagus nerve
• •
• •
•
•
at the diaphragm
Radiculopathy in the cervical region Increased cervical curve squeezes discs and risks her
•
Stomach issues, reflux disease
niation
•
Fascial restriction of the aorta, vena cava, and main lymphatic ducts
Cervical misalignment creates the possibility of arthritis Loss of range of motion increases the possibility of
•
fusion
•
Visceral prolapse or altered organ position Exaggerated spinal curves narrowing the intervertebral foramen; could cause spinal stenosis
Forward-head posture creates a powerful fascial downward pull on the mandible
•
Fascial pull on the dural tube and spinal nerve roots
The mandible is pulled posteriorly and superiorly, forc
•
'Migration of disc material toward the spinal cord
ing the temporomandibular joint (TMJ) forward
•
Memory loss
CHAPTER 11
Anterior Pelvic Tilt (a pelvis in too much flexion) . •
•
Coccyx elevates posteriorly
•
Excessive lumbar lordosis
•
Distended abdominal contents
•
Weakened lower abdominals
•
Compressive loading on lower body
•
Hyperextended or locked knees
•
Flattening of the medial longitudinal arch of the foot
•
Indentation or groove in the iliotibial band
•
Possible internal femoral rotation
•
Tendency toward forward-head posture
•
Downward pull on the pectoral and cardiac fascia
Pelvic rotation causes LS to rotate toward the low
•
T he lumbar vertebrae above LS compensate by laterally flexing (rotoscoliosis)
•
Disc compression at the level of L4-LS and LS-S 1
•
Functional scoliosis
•
Pronated foot is more obvious on the low hip side
•
Knee pain with an increased Q-angle
Pronation Strain •
Excessive lumbar lordosis
•
Dropped arches
•
Foot abduction
•
Bowed Achilles tendons
•
Tibial rotation
•
Femoral rotation
•
Increased Q-angle
most obvious finding
•
Achilles tendonitis
Hips appear uneven and the client tends to lean
•
Possible heel spurs
toward the high hip
•
Possible plantar fasciitis
The posterior superior iliac spine is higher on the
•
Hallux valgus and bunions
high hip side
•
Foot calluses
•
Possible shearing of the pubic symphysis
•
Hammer toes
•
The leg on the high hip will appear shorter when
•
Chondromalacia
lying supine and longer when standing
•
Pes anserine and trochanteric bursitis
Tightness in the lumbar erectors on the high hip
•
Problems with the sacroiliac joint
side
•
Morton foot structure
•
Various muscle strains
Lateral Pelvic Tilt •
•
•
•
The body weight sways to the high hip; this is the
329
hip side (rotoscoliosis)
Pubis drops anteriorly
•
TRIGGER POINT AND REFERRAL GUIDE
•
Sacroiliac joint jamming on the high hip side
•
The ilium rotates anteriorly on the high hip side
•
The femur internally rotates on the high hip side
•
The femur abducts on the low hip side
•
Forearm Strain Lateral humeral epicondylitis (tennis elbow)
Iliotibial shearing with rotation and restriction on
•
Medial humeral epicondylitis (golfer's elbow)
adduction
•
Carpal tunnel syndrome
•
Trochanteric bursitis on the low hip side
•
Extensor retinaculum gluing
•
Narrowing of the greater sciatic notch with possible
•
Flexor retinaculum and antebrachial fascial gluing
•
sciatic nerve impingement
THIS PAGE INTENTIONALLY LEFT BLANK
APPENDIX A
ANSWERS TO CHAPTER REVIEW QUESTIONS
CHAPTER 1
Short Answer Questions
9. B 10. B
1. A comprehensive and advanced system of soft tissue
2.
manipulation that specializes in working with chronic
True/False
myofascial pain and pain syndromes.
11. T
•
Identify and isolate tissue irregularities
12. F
•
Restore local tissue circulation and reduce ischemia
13. T
•
Reduce hypertonicity and spasm
14. T
•
Reduce soft tissue pain
15. F
•
Reduce and eliminate noxious or excessive nerve sti mulation Normalize the reflex activity of the neuromuscular
16. e
system
17. b
•
Reduce and eliminate trigger points
18. a
•
Restore normal range of motion to affected muscles
19. c
•
Release related adhesions or fascial binding
•
Lengthen chronically shortened fascia and other
•
soft tissues •
Identify and reduce or eliminate the perpetuating factors continuing to aggravate the trigger points and chronic pain patterns
3.
Matching
20. d CHAPTER 2
Short Answer Questions
1. A plate ending where a branch of the axon of a motor neuron makes synaptic contact with a striated muscle fiber.
•
History, evaluation, and assessment
•
Soft tissue assessment and treatment
•
Trigger point therapy
•
Myofascial release and muscle lengthening
•
Postural stress analysis
•
T herapeutic stretching
•
Identification and reduction of perpetuating factors
visceral disease, arthritis, joint dysfunction, and emo
•
Client management and follow-up
tional distress. Virtually any stress will aggravate a trig
4. Any three of the following: myofascial release, deep effleurage, muscle stripping, or deep transverse friction. 5. Central nervous system and musculoskeletal system
2. A class of drugs that lowers the level of cholesterol in the blood by reducing the production of cholesterol by the liver. 3. Trigger points are activated directly by acute overload, overwork fatigue, direct impact trauma, and radiculop athy and indirectly by other existing trigger points,
ger point, and, therefore, its referral pattern. 4. A scientific principle that is uniformly true for a whole class of natural physiological occurrences. 5. Any of the following: Law of Facilitation, Davis' Law,
Multiple Choice Questions
Hilton's Law, Arndt-Schultz Law, Law of Unilaterality,
6. B
Law of Symmetry, Law of Intensity, Law of Radiation,
7. D
Law of Generalization, Wolff's Law, and righting
8. A
reflexes 331
APPENDIX A / ANSWERS TO CHAPTER REVIEW QUESTIONS
332
Multiple Choice Questions
6. 0
14. T 15. F
7. C 8. A
Matching
9. C
16. a
10. 0
17. g 18. d
True/False
19. c
11. F
20. e
12. F 13. T
CHAPTER 4
14. F
Short Answer Questions
15. F
1. Using wrist movements repeatedly might put the ten dons running through the carpal tunnel under pres
Matching
sure, resulting in pain and possibly carpal tunnel syn
16. a
drome; repetitive movements at the wrist in general
17. g
may cause a repetitive strain injury or tendonitis.
18. j
2. T he therapist runs the risk of developing thoracic out
19. k
let syndrome or trigger points due to chronically short
20. e
ened pectoralis major. 3. By using a squeeze ball
CHAPTER 3
Short Answer Questions
1. Range of motion; passive structures such as joints, bur sas, and ligaments; muscle injuries 2. Scoliosis 3. Paradoxical breathing patterns, gasping/wheezing/ yawning and having to catch one's breath, 3-D breath ing inhibited 4. Taut bands with exquisite spots of tenderness at a nod
4. Using proper body mechanics means working smarter not harder and helps increase the longevity of a thera pist's career by not having injuries. 5. Level of pain, level of tolerance for receiving the work, alleviation of trigger points, muscle flexibility, range of motion, ease of movement and energy, and home care Multiple Choice Questions
ule, which the client will recognize, compromised
6. C
range of motion with painful stretch limitation, local
7. B
twitch response, and referral sensation changes upon
8. A
compression of a tender nodule
9. A
5. All predisposing factors, mis-lifting, poor posture,
10. C
chronically shortened muscles, repetitive movement, and abuse of the checkrein function
True/False
11. T Multiple Choice Questions
12. F
6. A
13. T
7. C
14. T
8. C
15. F
9. B 10. C True/False
Matching
16. a 17. d
1 1. T
18. c
12. T
19. b
13. F
20. e
APPENDIX A
CHAPTER 5
Short Answer Questions
1. Because of the extreme whipping of the head and neck causing the muscles to overstretch and powerfully
ANSWERS TO CHAPTER REVIEW QUESTIONS
Multiple Choice Questions
6. C 7. A 8. 0
shorten, the neck musculature goes into spasm, caus
9. C
ing proprioception issues (the head/neck relationship
10. B
and orientation in the field of gravity) and dizziness (vertigo). 2. There are chronically contracted muscles in the neck, causing a constant lateral flexion of the neck. 3. Frontalis 4. Overly tense muscles that act upon the jaw due to bruxism and/or malocclusion issues
True/False
1 1. T 12. F 13. T 14. F 15. T
5. Pain at the angle of the jaw, dizziness, visual blurring, and decreased vision Multiple Choice Questions
Matching
16. a 17. b
6. B
18. e
7. 0
19. h
8. A
20. i
9. C 10. A
CHAPTER 7
Short Answer Questions True/False
1 1. F
1. The wrist and fingers 2. The main ray
12. F
3. Anconeus
13. T
4. The thenar eminence
14. T
5. Transcarpal ligament
15. T Multiple Choice Questions Matching
6. 0
16. e
7. B
17. g
8. A
18. b
9. C
19. i
10. B
20. d True/False CHAPTER 6
11. T
Short Answer Questions
12. T
1. This will help release the tendinous attachments of
13. F
rotatores, multifidi, semispinalis, spinalis, serratus pos
14. F
terior superior, rhomboids, middle trapezius, lower tra
15. F
pezius, latissimus dorsi, splenius capitis, and splenius cervicis.
Matching
2. Teres major, latissimus dorsi, and pectoralis major
16. c
3. Rhomboids major and minor, pectoralis minor, and
17. e
levator scapula
18. f
4. Teres major and latissimus dorsi
19. g
5. Upper trapezius
20. a
333
334
APPENDIX A / ANSWERS TO CHAPTER REVIEW QUESTIONS
CHAPTER 8
Short Answer Questions
1. Three 2. Longissimus, latissimus dorsi, iliocostalis lumborum, quadratus lumborum, internal obliques, and external obliques 3. Same as above
4. The quadriceps group is a much larger and heavier group of muscles than the hamstrings are. The quadri ceps group becomes chronically shortened due to us sitting most of the time, keeping the upper fibers in constant contraction. 5. Anterior pelvic tilt
4. Quadratus lumborum 5. Quadratus lumborum and gluteus minimus
Multiple Choice Questions
6. D Multiple Choice Questions
7. A
6. B
8. C
7. A
9. B
8. B
10. C
9. C 10. D
True/False
11. T True/False
12. F
11. T
13. F
12. T
14. F
13. F
15. F
14. F 15. F
Matching
16. f Matching
17. d
16. c
18. e
17. e
19. h
18. g
20. c
19. f 20. b
CHAPTER 1 0
Short Answer Questions CHAPTER 9
Short Answer Questions
1. Sciatica is caused by nerve root compression of the nerve. Piriformis syndrome is due to the piriformis
1. Peroneus longus, peroneus brevis, and peroneus tertius (also known as fibularis longus, fibularis brevis, and fibularis tertius, respectively) 2. Peroneus tertius. Because of its location on the ante
entrapping the nerve within its fiber or pressing it
rior surface of the tibia, it dorsiflexes the ankle,
into the greater sciatic notch. With sciatica, one feels
whereas the longus and brevis plantarflex at the ankle.
radiculopathy at a distance; with piriformis syndrome,
3. Laterally placing the foot into inversion
one feels referrals from trigger points at a distance.
4. Anterior talofibular ligament and the calcaneofibular
2. Adductor magnus, the vertical portion, is synergistic in that action due to its orientation and attachments at the ischial tuberosity and the adductor tubercle of
ligament 5. Also known as fast-twitch muscles, these are muscles with large motor units that activate on demand for
the femur. It also performs hip extension along with
rapid or powerful motion in the short term. They
the hamstrings.
respond quickly and fatigue quickly. They can weaken
3. Helps stabilize the knee joint
without shortening.
APPENDIX A / ANSWERS TO CHAPTER REVIEW QUESTIONS
Multiple Choice Questions
13. T
6.' C
14. F
7. D
15. T
8. A
Matching
9. B
16.
e
10. D
17. f
True/False
19. d
11. T
20.
18.
12. T
a
c
335
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GLOSSARY Achilles tendonitis: a painful injury of the Achilles tendon that includes inflammation, usually at or near the tenoperiosteal or musculotendinous junction
becomes callused there; the big toe becomes laterally deviated, and this lateral deviation is also known as hallux valgus.
Carpal tunnel syndrome: a condition that presents with pain in
Active trigger point: a trigger point that causes clinical pain
the wrist and hand and numbness of the thumb, index, middle,
complaints; it is always tender, prevents the muscle from
and ring fingers with atrophy and weakness of the thenar mus
fully lengthening, causes muscular weakness, refers sensa
cles due to compression of the median nerve in the wrist.
tion that is obvious to the client, and causes sensation to the referral zone.
Acute: of recent onset Adhesions: tissue that has become fibrous and holds together soft tissue parts that are normally separated
Chondromalacia (pateUofemoral syndrome): a pathological soften ing of the patellar cartilage from an overuse syndrome; the patella may begin to move out of the groove of the femoral condyles, grinding across a condyle with each movement of the knee.
Chronic: of long standing
Adhesive capsulitis or frozen shoulder: inflammation of the ante
Claw toe: a condition in which the metatarsal phalangeal joints of
rior and inferior glenohumeral joint capsule, which shortens
the four lesser toes are markedly extended and the proximal and
and thickens
Anesthetize: to induce loss of sensation Ankle sprain: injury to ligaments in the ankle, and possibly the tendons crossing the ankle to the foot, involving them being overstretched and/or torn due to the ankle being forcefully turned while in use. This trauma to the joint causes pain and disability depending on the degree of injury to the ligaments. There will be pain, tenderness, swelling, discoloration to the area, and limitation of motion.
Anomalous: exceptional or abnormal; deviating from the normal rule
Anterior pelvic tilt: a condition in which there is a hyperlordotic curve and the pelvis has tilted forward, causing the pubis to be
distal interphalangeal joints are fixed in flexion, producing a claw curvature. If only a mallet toe, then only the distal inter phalangeal joint is flexed. True claw toe deformity is often asso ciated with cavus foot deformity and neuromuscular conditions. The claw toe deformity tends to create a more severe functional disability than the hammer toe. This condition usually devel ops because of muscle imbalance initiated by compensatory mechanisms.
Concentric strain: a condition in which a muscle is chronically shortened due to overuse or postural dysfunction; its opposing muscle will most likely be eccentrically strained, or over stretched.
Congenital: existing prior to or at birth
low and the ischial tuberosities to be high; there is too much
Cryotherapy: the therapeutic use of cold
flexion at the pelvis
Dupuytren contracture: contracture of the palmer aponeuroses
Aponeurotic tissue: tissue from an aponeuroses; a fibrous sheet of connective tissue that serves to attach muscle to bone or other tissues
Articular dysfunction: a condition of either hypermobility or
causing the ring and little fingers to bend into the palm and not be extended
Dysesthesia: abnormal sensations on the skin, such as numbing, tingling, prickling, burning, or cutting pain
hypomobility of the foot that can seriously disturb foot mechan
Dyspnea: shortness of breath normally due to vigorous activity
ics and produce imbalances that may cause pain in many loca
Eagle syndrome: an elongated styloid process of the temporal bone
tions of the body.
Baker's cyst: a fluid-filled extension of the synovial membrane at the knee protruding into the popliteal fossa
Bicipital tendonitis: inflammation of the long head tendon of biceps brachii
Bilateral: affecting or related to two sides of the body Biomechanics: the study of the forces exerted by soft tissue (muscle) and gravity on the skeletal system
Bruxism: clenching the jaw and grinding the teeth, especially dur ing sleep
Bunion: a condition in which the joint capsule becomes stretched at the metatarsalphalangeal joint of the hallux and then
that punctures the sternocleidomastoid muscle and may cause dizziness and pain.
Electromyographic test (EMG): a test to record graphically the contraction of a muscle using electric stimulation.
Enigmatic: puzzling Entrapment of either the ulnar or the median nerve: a pressing on either nerve within soft tissue causing radicular symptoms
Entrapment of the brachial plexus: an endangerment site that lies between anterior and medial scalenes and can become entrapped if the scalene muscles are chronically shortened.
Entrapped supraorbital nerve: pressure on the supraorbital nerve caused by a tight frontalis muscle
337
338
GLOSSARY
Epicondylitis: inAammation of either epicondyle of the humerus and surrounding tissues
Hypoxia: deficiency of oxygen Iliotibial band (ITB) syndrome: a condition involving the con
Etiology: the cause of disease
tinual rubbing of the iliotibial band over the lateral femoral
Femoral triangle: also known as Scarpa's triangle, an endanger
epicondyle combined with the repeated flexion and extension
ment site on the anterior, proximal thigh bounded by the inguinal ligament superiorly, by the sartorius laterally, and by the adductor longus medially. There are structures within this triangle that should not be pressed upon, including the femoral artery, vein, and nerve, primarily.
Forward-head posture (protracted head syndrome): poor posture that includes the head being forward in relation to the coronal plane
Fusiform muscle: a muscle that is spindle-shaped, with tapering at both ends
Gastrectomy: surgical removal of part of or the entire stomach Glaucoma: disease of the eye characterized by increase in intraocu lar pressure, which atrophies the optic nerve, causing blind ness
Groin strains (pulls): pain from tearing and inAammation of an adductor muscle near its origin at the pubic bone
Growing pains: an imprecise term indicating ill-defined pain in the musculoskeletal system of young persons. There is no evi dence that the pain is actually related to rapid growth.
Hammer toe: persistent Aexion at the interphalangeal joint of the great toe, and/or persistent flexion of the proximal interphalan geal joint with extension of the distal interphalangeal joint of one of the four lesser toes. This condition usually develops
of the knee during running, causing the area to become inflamed; one of the leading causes of lateral knee pain, espe cially in runners; also known as iliotibial tract friction syn drome and iliotibial band friction syndrome.
Impingement syndrome: a condition in which a lack of space between the coracoacromial arch and the proximal humerus leads to soft tissue being compressed (pinched) there.
Inert tissue: tissue remaining in a sluggish state until acted upon by an outside force
Informed consent: competent and voluntary permission for a pro cedure, test, or medication; consent given on the basis of under standing the nature, risks, and alternatives of the procedure or test
Inversion sprain of the ankle: an ankle sprain in which the foot and the ankle roll laterally, drastically inverting the foot at the ankle and damaging ligaments on the lateral ankle. The most often damaged ligaments in this condition are the lateral tal ofibular ligament and the lateral calcanealfibular ligament.
Ipsilateral: affecting or related to the same side of the body Ischemia: local and temporary deficiency of blood supply Isometric contraction: a contraction in which a muscle increases its tension without shortening
Jump sign: a general pain response of a client in the form of winc
because of muscle imbalance initiated by compensatory mecha
ing, crying out, or withdrawing in response to pressure applied
nisms.
to a trigger point
Hamstring strains (pulls): chronic overstretching of the ham strings because of an imbalance between the quadriceps and hamstring groups, causing tearing if used strenuously or stretched further
Headaches: pain inside the head, including tension headaches, migraines, dome headaches, etc.
Heberden's nodes: often identified with osteoarthritis. The node is an enlargement of soft tissue, sometimes partly bony, on the dorsal surface of either side of the terminal phalanx at the distal interphalangeal joint.
Hunter's canal: a triangular space lying beneath the sartorius and between the adductor longus and vastus medialis. It extends from the femoral triangle to the popliteal space allowing for nervous and blood vessels to run through it.
Hypercontraction: a condition in which the contractile elements in muscle fiber contract beyond the normal.
Hyperkyphosis: an increase in the normal posterior curve of the spinal column
Hypertonicity: excess muscular tonus Hypertrophy: increase in a muscle's size without an increase in the number of cells
Hyperuricemia: ahnonnal amount of uric acid in the blood Hypoesthesia: dulled sensitivity to touch Hypothenar eminence: the fleshy mound of muscle tissue that covers the fifth metacarpal distal to the medial carpals
Juxtaposition: a position that is adjacent or side by side Key trigger point: a trigger point responsible for activating one or more satellite trigger points
Knee-buckling episodes: hypercontraction of the adductor magnus, causing a closure of Hunter's canal, which can result in knee buckling when the thigh and adductor muscles are contracted.
Kyphosis: the normal, forward curvature of the spine; if excessive, it can represent a pathological condition
Lamina groove: the flattened part of the vertebral arch, which extends between the vertebral spinous processes and the trans verse processes
Latent trigger point: an inactive trigger point; it will be tender and refer sensation only upon palpation
Lateral pelvic tilt: a muscular imbalance in the pelvic girdle, resulting in one hip being high and the other low
Local twitch response: a transient contraction of a group of tense muscle fibers that traverse a trigger point in response to stimula tion of the trigger point
Lumbago: a nonspecific term for dull, aching pain in the lumbar region
Main ray: referring to the middle finger or toe Malocclusion: malposition and imperfect contact of the mandibu lar and maxillary teeth
Medulla oblongata: an enlarged portion of the spinal cord above the foramen magnum; the lower portion of the brain stem
GLOSSARY
Motor endplate: a plate ending where a branch of the axon or a motor neuron makes synaptic contact with a striated muscle fiber
Muscle energy technique: a form of proprioceptive neuromuscular
339
Pes planus: a condition in which the foot lacks the three arches: the medial and lateral longitudinal arches, as well as the trans verse arch; also known as flat feet
facilitation designed to promote or hasten the response of the
Phasic muscle: a muscle with large motor units that activate on
neuromuscular mechanism to lengthen the muscle in question
demand for rapid, powerful, short-term motion; responds quickly
through stimulation of the proprioceptors
and fatigues quickly, and usually weakens without shortening;
Muscle spasms and cramps: involuntary contractions of skeletal muscle. Spasms are considered low-grade and long-lasting, whereas cramps are considered short-lived and very acute.
Musculotendinous junction: where a muscle and tendon join together
Myotatic unit: a group of agonist and antagonist muscles that function together as one unit due to sharing spinal reflex responses
Neuralgia: severe pain occurring along a nerve Neuropathy: disease of the nerves
similar to sciatica but that is due to nerve and vascular entrap ment by the piriformis at the greater sciatic foramen, or due
to
referrals from trigger points in the piriformis, or due to dysfunc tion of the sacroiliac joint
Plantar fasciitis: a painful condition that includes inflammation to the plantar fascia due to injury. Often, this type of injury is due to long-standing hyperpronation.
Pneumothorax: a collection of air or gas in the pleural cavity Polymyalgia rheumatica: a poorly understood condition that most
Noxious: harmful or painful
often occurs in patients older than 50 years and that is four
Occlusal imbalance: an uneven bite causing the muscles of the jaw
times more frequent in women. It is characterized by pain in the muscles of the shoulder and pelvic girdle, absence of inflam
to be in disharmony
Orthopedic assessment: the assessment of disorders involving the locomotor structures of the body, especially the skeleton, joints, muscles, fascia, and other supporting structures such as liga
matory arthritis, absence of signs of muscle disease such as atro phy or weakness, and prompt and dramatic response to low doses of corticosteroid therapy.
Posterior pelvic tilt: a condition in which the pelvis has too much
ments and cartilage
Orthopedic testing: various tests developed to help in the assess ment of disorders and injuries of the locomotor structures of the
extension and is tilted backward
Postural and biomechanical dysfunction: abnormal function of the body due to poor posture and poor biomechanics
body
Osgood--Schlatter disease: a condition attributed to adolescent growth spurts in which the bones, specifically the tibia, grow faster than muscles and tendons
Pyothorax: pus in the pleural cavity Radiculopathy: any diseased condition of roots of spinal nerves; the sensation caused by such disease
Overuse syndrome: a condition in which a part of the body is injured by repeated overuse or exerting too much strain on that body part; includes a large group of conditions that result from using the body in a repetitious way causing injury; also known as repetitive strain injury
Paradoxical breathing patterns: an imbalance in osseous structures above the core (determined by the integrity of the fascial planes of the body) that causes the osseous and myofascial structures to begin to pull down unevenly on the respiratory diaphragm, affecting the thoracic inlet and causing serious implications for
the pr9per functioning of our breathing apparatus
Perpetuating factor: something that prolongs the existence of a condition, such as neck pain due
also known as a fast-twitch muscle
Piriformis syndrome: a condition that presents with symptoms
to
improper workstation
set-up causing neck strain daily; also, a chronic condition or disease that a person must learn to manage and work with, such as an athlete with diabetes or a person with post-polio syn drome
Pes anserine: the area on the anterior, medial tibia just inferior to the tibial tuberosity. This area is raised somewhat and is the attachment site of the sartorius, gracilis, and semitendinosus. The words "pes anserine" mean "goose foot," and this area is so
Range of motion: the amount of movement of a joint Reference or referral zone: sensory and motor phenomena such as pain, itching, and thermal sensation caused by a trigger point while occurring at a distance from the trigger point
Rotator cuff tendinitis: inflammation of the supraspinatus tendon and, in some cases, of the infraspinatus, teres minor, and sub scapularis tendons
Rotoscoliosis: a condition in which one or more vertebra rotate to one side
Sarcomere: the portion of striated muscle fibrils between two Z-disks Sarcoplasmic reticulum: a network of fine tubules filled with fluid present in muscle tissue
Satellite trigger points: a central trigger point induced by the activity of a key trigger point
Sciatica: pain from the sciatic nerve from nerve compression at its root, where it emerges from the vertebral column
Scoliosis: abnormal lateral and rotational curvature of the spinal column
Shin splints: a leg condition involving some combination of an
named due to the three tendons inserting in a pattern that
injury to tibialis anterior or tibialis posterior and a possible
looks like a webbed goose foot.
hairline fracture to the tibia and that is usually due to overuse
Pes cavus: a condition impacting the structure of the foot in which there is an abnormal hollowness or concavity of the sole of the foot
and/or misalignment of the ankle (often hyperpronation)
Small hemipelvis: a condition in which one side of the pelvis is smaller than the other
340
GLOSSARY
Stiff neck: tight cervical muscles that cause pain and/or stiffness Stress factor: any stress-inducing condition that aggravates a trig ger point and its referral pattern, leading to pain
Stress fractures of the foot/ankle: fractures caused by overuse or other trauma, such as a blow to the foot or ankle, that causes a fracture to one or more of the bones in foot or ankle
Subdeltoid bursitis: inflammation of the subdeltoid bursa Subluxation: a partial dislocation of a joint Synergistic muscles: muscles that work together to perform spe cific movement
Tarsal tunnel syndrome: neuropathy of the distal portion of the tibial nerve at the ankle due to chronic pressure on the nerve at the point it passes through the tarsal tunnel, typically accompa nied by pain and numbness of the sole of the foot and weakness of plantar flexion of the toes
Temporomandibular joint dysfunction (TMJ syndrome): symp toms of pain and discomfort in the temporomandibular joint
T horacic outlet syndrome: a complex condition caused by condi tions in which nerves or vessels are compressed in the neck or axilla; also known as thoracic outlet compression syndrome
Tinnitus: a subjective ringing or buzzing sound in the ear Torticollis: stiff neck associated with tight muscles on one side of the neck that usually cause chronic lateral flexion and twisting of the head
Trigger finger/trigger thumb: a state in which flexion or extension of a digit is arrested temporarily but finally is completed with a jerk; usually found when a sheathed tendon is within an inflamed sheath
Trigger point referral: the sensation felt at a distance from a trig ger point
Trigger point: an area of hypersensitivity that when compressed creates referral sensitivity at a distance from that area
Trochanteric bursitis: inflammation of the bursa related to the greater trochanter of the femur
usually caused by a combination of poor posture along with
Unilateral: affecting or related
tight muscles and malocclusion
Upper and/or mid trapezius strain: caused by a forward head pos
Tendinous inscriptions: fibrous bands that appear in rectus abdominis, interrupting the muscle fibers three to four times along their length. These give the muscle more strength to keep the abdominal contents from pushing forward.
T henar eminence: the fleshy mound of muscle tissue that covers the first metacarpal distal to the base of the thumb
T horacic kyphosis: derived from Greek, meaning humpback or hunchback; an exaggeration or angulation of the normal poste rior curve of the spine
to
one side of the body only
ture with rounded shoulders and possibly a collapsed chest
Varicosities: multiple varicose or dilated veins present Whiplash injury: an injury to the cervical vertebrae and adjacent soft tissues produced by a sudden jerking of the head either backward, forward, or to the side with respect to the vertebral column
Z-disk: a thin, dark disk that transversely crosses through and bisects the clear zone of a striated muscle fiber
INDEX Note: Page numbers followed by "f" indicate figures; those followed by "t" indicate tables.
Adductor hallucis,flexor hallueis brevis,and
A Abdominal muscles,215. See also Lower torso and abdomen region,muscles of Abductor digiti minimi,198 action, 198 anatomical attachment sites for,198 inserrion,198 massage therapy considerations,198 origin, 198 precautions while working on, 198 stressors and perpetuating factors, 198 trigger point activation in,198 trigger points and referral zones for,198 Abductor hallucis,abductor digiti minimi,and flexor digitorum brevis, 292-293 action,292 anatomical attachment sites, 292f inserrion,292 massage therapy considerations, 293 origin,292 precautions while working on,293 stressors and perpetuating factors, 293 trigger point activation in,293 trigger points and referral zones for, 292-293, 293f Accurate muscle testing, 29 Acetylcholine (ACh), as neurotransmitter, 15 Achilles tendonitis, 285,303,337 Action potential,13-14 Active testing, 29-30 Active trigger point, 11,16,337 Acute,3,337 Acute pain,activation of brain area in, 16 Adductor and opponens pollicis,192-193 action,192 anatomical attachment sites for,192f insertion,192 massage therapy considerations, 193 origin,192 precautions while working on,193 stressors and perpetuating factors, 193 trigger point activation in, 192-193 trigger points and referral zones for, 192, 193f Adductor brevis and longus,267 action,267 inserrion, 267 massage therapy considerations, 267 origin, 267 precautions while working on,267 stressors and perpetuating factors, 267 trigger point activation in,267 trigger points and referral zones for,267
flexor digiti mimini brevis, 296-297
Aponeurotic tissue, 163, 186, 337 Arm, wrist, and hand, neuromuscular therapy routine,199
action,296 anatomical attachment sites, 296f
anconeus,207
insertion,296
biceps brachii, 199-200
massage therapy considerations,297
brachialis, 201-202
origin, 296
brachioradialis,203-204
precautions while working on, 297
case studies on, 212
stressors and perpetuating factors, 297
coracobrachialis, 200-201
trigger point activation in, 296-297
extensors, 206-207
trigger points and referral zones for, 296
flexors and pronator teres, 208-209 hanel, 209
Adductor magnus, 268-269
supinator, 204-205
action,268
triceps brachii, 210-211
anatomical attachment sites,268f
Arm,wrist,and hand region, muscles of,
inserrion,268
163-164
massage therapy considerations, 269
forearm
origin,268
anconeus, 181-182
precautions while working on, 268-269 stressors and perpetuating factors, 268
brachioradialis,171-172
trigger point activation in,268
extensor carpi radialis brevis, 177 extensor carpi radialis longus,175-176
trigger points and referral zones for, 268,269f
extensor carpi ulnaris, 180
Adductor muscles, 264-269 adductor brevis and longus,267
extensor eligitorum, 178-179
adductor magnus, 268-269
flexor carpi radialis, 183-184
gracilis,264-265
flexor carpi ulnaris,185-186
neuromuscular therapy routine, 278-281
flexors digitorum superficial is and profundus,187-188
pectineus,266
palmaris longus, 189-190
Adenosine triphosphatase (ATP),role in muscle
pronator teres,191
contraction, 13
supinator,173-174
Adhesions, 215, 220,337
upper arm (brachium)
Adhesive capsulitis or frozen shoulder,103,337
biceps brachii,164-165
Anconeus,181-182
brachialis, 167-168
action,181 anatomical attachment sites for, 181f
coracobrachialis,166
inserrion, 181
triceps brachii,169-170 wrist and hand
massage therapy considerations, 182 neuromuscular therapy routine, 207
abductor digiti minimi,198
origin, 181
adductor and opponens poll ieis, 192-193
precautions while working on, 182
extensor indieis, 195
stressors and perpetuating factors,181-182
flexor pollicis longus,194
trigger point activation in, 181 trigger points and referral zones for, 181, 181f
interossei and lumbricals, 196-197 Arndt-Schultz law,18
Anesthetize,227
Arrhythmia trigger point, 229
Ankle sprain,285, 286,299, 337
Articular dysfunction, 285, 291,337
Anomalous, 337 Anterior pelvic tilt,32-34,215, 217,245,256, comparing ASIS
versus
PSIS for,33f
and postural findings,32, 34 Anterior suboccipitals,neuromuscular therapy routine,94-95 Anterior superior iliac spine (ASIS), 32,33f, 34,34f
B Backnobbers, 52
329,337
Back pain cryptic,deep,upper back pain ( see Serratus posterior superior) low back pain, 216 in pregnancy, 227 scalene muscles and,68
341
3 42
INDEX
Baker's cyst, 2 8 5 , 311, 3 3 7
massage therapy considerations, 1 2 2
C I ient assessment, 2 3
Barrier release concept, 48--49
health information form, 2 4 , 25-27f
neuromuscular therapy routine, 1 5 3
Biceps brachii, 164-165
interviewing the client, 24, 28
origin, 121
action, 164
for cause of pain, 28
precautions while working on, 122
anatomical attachment sites for, 1 64
for previous treatment, 28
stressors and perpetuating factors, 1 2 2 trigger point activation i n , 1 2 2
orthopedic testing, 28-29 (see also
insertion, 164 Illassage therapy considerations, 1 65
trigger points ami referral zones for, 12 1 ,
Orthopedic testing)
neuromuscular therapy routine, 199-200
postural assessment, 31-36
origin, 164
range of motion assessment, 29-31
12 l f Diaphragm, 2 30-2 3 1
precautions while working on, 1 65
palpation, use of, 3 6-38
action, 2 3 0
stressors and perpetuating factors, 1 65
perpetuating factor, 39--40
anatomical attachment sites, 2 30f
trigger point activation in, 1 6 5
chemicals, 4 1
trigger points and referral zones for, 164, 165f
d isease, 41
massage therapy considerations, 2 31
exercise, 41
neuromuscular therapy routine, 242
Bicipital tendon itis, 10 3 , 1 63 , 1 65 , 3 37
nutrition, 40--41
origin, 2 3 0
Bi lateral, 61, 3 37
overuse syndromes, 40
precautions while working on, 231
Biomechanics, 40, 3 3 7
postural dysfunction, 41
stressors and perpetuating factors, 2 31
B()dy Mechanics for Manual Therapists, A Functional A/J/Jroach to Self-Care, 5 5
psychoemotional d istress, 41
trigger point activation in, 2 3 1
sleep/rest habits, 40
trigger [1oints a n d referral mnes for, 2 3 0-231,
Biceps femoris. See Hamstrings
insertion, 2 30
2 3 0f
trauma, 41
Body mechanics, f o r massage therapists, 5 5-56
predisposing factors, 38-39
Brachialis, 167-168
Digastric, 74. See also Head and neck, muscles of
action, 167
foot hyperpronation, 3 9
action, 74
anatomical ,machment sites for, 167f
leg length discrepancy, 3 8
insertion, 74
insertion, 167
short humerus, 3 8- 3 9
massage therapy considerations, 74
massage therapy considerations, 168
small hemipelvis, 3 9
origin, 74 precautions while working on, 74
neuromuscular therapy routine, 201-202
Client-therapist communication, 7-8
origin, 167
Concentric strain, 3 , 4, 3 3 7
stressors and perpetuating factors, 74
precautions while working on, 1 68
Congen ital, 1 6 3 , 1 89, 3 37
trigger point activation, 74
stressors and perpetuating factors, J 67
Contraction knot, in trigger point, 12, 12f
trigger point activation in, 1 67
Contrast therapy, 5 1 -52
Direct strokes, 47--48
trigger points and referral zones for, 1 67, 168f
Coracobrachialis, 1 66
Dorsal interosse i, 290-291
trigger points and referral zones, 74, 74f
action, 1 66
action, 290
action, J 71
anatomical attachment sites for, 1 66f
anatomical attachment sites, 290f
anatomical attachment sites for, 171f
insertion, 1 66
insertion, 290
insertion, 171
massage therapy considerations, 166
massage thera[1Y considerations, 291
massage therapy considerations, 1 72
neuromuscular therapy routine, 200-201
origin, 290
neuromuscular therapy routine, 203-204
origin, 166
precautions while working on, 29 1
origin, 171
precautions while working on, 166
stressors and perpetuating factors, 29 1
precautions while working on, 172
stressors and perpetuating factors, 166
trigger point activation in, 291
stressors and perpetuating factors, 1 72
trigger point activation in, 166
trigger [1oint activation in, 1 71
trigger points and referral zones for, 166, 166f
Brachiorad ialis muscle, 17 1 -172
trigger [1oints and referral zones for, 1 71, l 72f
Corrugator superc i l i i , 78. See also Head and neck, muscles of
Brachium, 164. See also Arm, wrist, and hand
action, 78
region, muscles of
trigger points and referral zones for, 291, 291f Dupuytren contracture, 163, 189, 3 3 7 Dysesthesia, 61, 6 9 , 3 37 Dyspnea, 215, 231, 3 37
Briefcase elbow, 174
anatomical attachment sites for, 78f
E
Bruxism, 2 3 , 36, 61, 74, 8 3 , 3 37
insertion, 78
Eagle syndrome, 6 1 , 74, 3 37
massage therapy considerations, 78
Effleurage, 46
c
origin, 78
Electric moist heating pads, 50
precautions while working on, 78
Electromyographic tcst (EMG), 1 6 3 , 3 3 7
Calcium, role in Illuscle contraction, 1 3
stressors and perpetuating factors, 78
Calf cramp muscle. See Gastrocnemius
trigger point activation, 78
Endorphins, 3
trigger points and referral zones, 78
Entrapment of brachial plexus, 6 1 , 3 3 7
Bunion, 2 8 5 , 286, 3 3 7
Carpal tunnel syndrome, 4 5 , 56, 1 63 , 1 8 3 , 3 37 Central nervous system, interactions with trigger point, 17f
Cross fiber friction, 48, 48f Cryotherapy, 45, 50-51, 3 3 7
o f anconeus, 181
scalenes and, 69 Entrapment of ulnar or median nerve, 1 63 , 183, 3 37
Chapter review questions, answers to, 3 31-3 3 5
ice massage, 5 1 , 5 l f
Chem ica Is, a s stress factor, 41
ice pack or cold compress, 51, 51 f
Entrapped surraorb ital nerve, 61, 77, 3 37
immersion in cold water, 5 1 , 52f
Epicondylitis, 163 , 1 67, 3 38
Chondroma lacia (patellofemoral syndrome), 2 4 5 , 262, 3 37 Chron ic, 3 37
Cyriax movement. See Cross tiber friction
Ergonomics of Workstation Design, 54 Extensor carpi rad ialis brevis, 177
Circular friction, 47
D
Claw toe, 285, 307, 3 3 7
Davis' law, 18
anatomical attachment sites for, 177f
Claw toe muscles. See Flexor longus group, of
Deep transverse friction. See Cross fiber friction
insertion, 177
muscles
action, 177
Deltoid muscle, 1 21-1 2 2
massage therapy considerations, 177
action, 1 21
origin, 177
assessment of (see Client assessment)
anatomical attachment sites for, 121 f
precautions while working on, 1 77
reassessment of, 5 5
insertion, 1 21
stressors and perpetuating factors, 1 77
Client
INDE X
trigger point activation in, 177
Extensor longus group muscles, 288-289
trigger points and referral zones for, 177f Exte'nsor carpi radialis longus, 175-176
Flexor poll icis longus, 194
action, 288
action, 194
anatomical attachment sites, 288f
anatomical attachment sites f or, 194
action, 175
insertion, 288
insertion, 194
anatomical attachment sites for, 175f
massage therapy considerations, 289
massage therapy considerations. 194
insertion, 175
origin, 288
origin, 194
massage therapy considerations, 176
precautions while working on, 289
precautions while working on, 1 94
origin. 175
stressors and perpetuating factors, 289
stressors and perpetuating factors, 194
precautions while working on, 176
trigger point activation in, 289
trigger point activation in, 194
stressors and perpetuating factors, 176
trigger points and referral zones for, 288, 289f
trigger point activation in, 175
Extensors, neuromuscular therapy routine,
176f
trigger points and referral zones for, 194 Flexors and pronator teres, neuromuscular therapy routine, 208-209
206-207
trigger points and referral zones for, 175,
External and internal obliques, 219-220
Flexors digitorum superficial is and profundus, 187-188
action, 219
Extensor carpi ulnaris, 180
343
anatomical attachment sites, 219f
action, 187
anatomical attachment sites for, 180, 180f
insertion, 2 1 9
anatomical attachment sites for, I 87f, 188f
insertion, 180
massage therapy considerations, 220
insertion, 187
massage therapy considerations, 180
origin, 219
massage therapy considerations, 188
origin, 180
precautions while working on, 220
origin, 187
precautions while working on, 180
stressors and perpetuating factors, 220
precautions while working on, 188
stressors and perpetuating factors, 180
trigger point activation in, 220
stressors and perpetuating factors, 187
trigger point activation in, 180
trigger points amI referral zones for, 219-220,
trigger point activation in, 187
action, 180
Extensor digitorum, 178-179
trigger points and referral zones for, 187, 188f
220f
trigger points and referral zones for, 180, 180f
Foot hyperpronation, 3 9
action, 178
F
anatomical attachment sites for, 178f
Forearm strain, 3 2 9
insertion, 178
Facilitated Stretching, 54 Fast-twitch muscle. See Phasic muscle
massage therapy considerations, 179
Fatigue, in muscles with active trigger
Forward or protracted head posture, 36, 61, 6 3
origin, 178
Foot roller, 5 3
points, 1 3
Forward-head posture, 3 28, 3 38 Frontalis, 77. See also Head and neck, muscles of action, 77
precautions while working on, 179
Femoral triangle, 24 5 , 3 3 8
stressors and perpetuating factors, 178
Flat palpation, 3 7 , 37f
insertion, 77
trigger point activat ion in, 178
Flexor carpi radialis, 183-184
massage therapy considerations, 77
trigger points and referral zones for, 178, 179f Extensor d igitorum brevis and extensor hallucis
action, 183
origin, 77
anatomical attachment sites for, 183f
precautions, 77
insertion, 183
stressors and perpetuating factors, 77
massage therapy considerations, 184
trigger point activation, 77
action, 290
origin, 1 83
trigger points and referral zones, 77, 77f
anatomical attachment sites, 290f
precautions while working on, 1 84
insertion, 290
stressors and perpetuating factors, 184
massage therapy considerations, 291
trigger point activation in, 1 83
G
origin, 290
trigger points and referral zones for, 183 , 184f
Gastrectomy, 215, 2 31, 3 38
brevis, 290-291
precautions while working on, 291
Flexor carpi ulnaris, 185-186
Fusiform muscle, 1 6 3 , 189, 3 3 8
Gastrocnemius, 301-302
stressors and perpetuating factors, 291
action, 185
action, 301
trigger point activation in, 291
anatomical attachment sites for, 185f
anatomical attachment sites, 3 0 I f
trigger points and referral zones for, 291,
i nsenion, 185
insertion, 30 I
massage therapy considerations, 186
massage therapy considerations, 302
291f Extensor digitorum longus. See Extensor longus group muscles Extensor group muscle
origin, 185
origin, 301
precautions while work ing on, 186
precautions while working on, 302
stressors and perpetuating factors, 186
stressors and perpetuating factors, 3 0 2
anconeus, 181-182
trigger point activation in, 185
trigger point activation in , 301-302
extensor carpi radialis brevis, 177
trigger points and referral zones for, 185, 186f
trigger points and referral zones for,
extensor carpi radialis longus, 175-176 extensor carpi ulnaris, 180 extensor digi torum, 178-179 Extensor hallucis longus. See Extensor longus group muscles Extensor indicis, 195 action, 195
Flexor d igitorum longus. See Flexor longus group, of muscles Flexor hallucis longus. See Flexor longus group, of muscles Flexor longus group, of muscles, 305-307 action, 3 0 5 anatomical attachment sites, 3 0 5 f, 306f
301, 3 0 l f Gemellus inferior. See Short hip rotators Gemellus superior. See Short hip rotators General adapmtion syndrome, 19 Geniohyoid, 7 3 . See also Head and neck, muscles of action, 7 3
anatomical attachment sites for, 195
insertion, 30 5
insertion, 7 3
insertion, 195
massage therapy considerations, 307
massage therapy considerations, 7 3
massage therapy considerations, 195
origin, 305
origin, 7 3
origin, 195
precautions while working on, 307
precautions while working o n , 7 3
precautions while working on, 195
stressors and perpetuating factors, 306
stressors and perpetuating factors, 7 3
stressors and perpetuating factors, 195
trigger point activation in, 306
trigger point activation, 7 3
trigger point activation in, 195
trigger points and referral zones for, 305-306,
trigger points and referral zones for, 195
306f
trigger points and referral zones, 7 3 Glaucoma, 61, 3 3 8
3 44
IND E X
Gluteus maximus, 246-247 action, 246 anaromical anachmenr sites, 246f inserrion, 246
Headaches, 6 1 , 3 3 8 by posterior suboccipital muscles, 62 Head and neck, muscles of anterior cervical muscles, 66
anterior thigh, 274 hip flexor tendons at origin, 276 knee, 274 quadriceps bellies, 275
massage therapy considerations, 247
anterior subocc ipitals muscles, 70
quadriceps tendons, 275
neu romuscular therapy routine, 270
longus capitis and longus colli , 7 1
sartorius, 275
origin, 246
scalenes, 68-69
stretches, 277
precautions while working on, 247
sternocleidomasroid, 66-67
stressors and perpetuating facrors, 247
suprahyoid muscles, 72-74
nigger point activation in, 247 nigger points and referral zones for, 246-247, 247f Gl uteus medius, 248-249
head and face muscles, 75
gluteus medius, 2 70-2 7 1
frontalis, 7 7
gluteus minimus, 2 7 1
masseter, 80-8 1
lateral thigh
occipitalis, 75-76
anatomical anachment sites, 248f
pterygoid muscles, 82-83
inserrion, 248
temporalis, 79
neuromuscular therapy routine, 270-2 7 1 origin, 248 precautions while working on, 249
gluteus maximus, 270
corrugaror superc i l i i , 78
aerion, 248
massage therapy considerations, 249
tensor fasc ia lawe, 275 case studies o n , 28 2
posterior cervical region levaror scapulae, 64-65 posterior suboccipital muscles, 62-63 Head and neck, neuromuscular therapy routine, 84
stretches, 278 tensor fascia latae ,md iliotibial band, 277 medial thigh adductors, 278-281 stretches, 281 piriformis, 2 7 1 -272 posterior thigh
stressors and perpetuating factors, 248
case studies on, 98-99
hamstrings, 2 7 3
trigger point activation in, 248
prone routines, 84
stretches, 2 7 3-274
trigger poinrs and referral zones for, 248, 249f Gl uteus mini mus, 250-2 5 1
levaror scapula, 85-86
sacrotuberous l igament and hip, 272-273
middle trapezius/rhomboid area, 87-89
short lateral hip rotators, 272
action, 2 50
posterior cervical muscles, 86-87
anaromical attachment sites, 2 50f
upper trapezius, 84
insertion, 250
supine routines, 89
Home care assignments, 5 3 , 5 3f and client compliance, 5 5 development o f proper postures, 54
massage therapy considerations, 2 5 1
lateral pterygoid, 96-97
self-trigger point release, 54-55
neuromuscular therapy routine, 2 7 1
levator scapula, 92
stretching, 54
origin, 2 50
masseter, 95-96
precautions while working on, 2 5 1
medial pterygoid, 96
Humerus, short, 38-39
snessors and perpetuating factors, 2 5 1
posterior cervical muscles, 89-90
Hunter's canal, 245, 3 3 8
nigger roint activation in, 2 50-2 5 1
scalenes, 9 3-94
Hypercontraction, 1 0 3 , 1 1 8, 3 38
trigger points and referral zones for, 2 50, 2 50f
sternocleidomasroid, 92
Hyperkyphosis, 103 , 3 38 Hypertonicity, 3 , 6, 3 38
work station rearrangement, 5 3-54
Golfer's elbow, 1 84, 1 86, 1 88, 1 90
subocc ipitals, 9 1
Goniometer, 3 2
suprahyoid and infrahyoid muscles, 97
Hypertrophy, I I , 18 , 3 38
Gracilis, 264-265
suprahyoids, anrerior suboccipitals, longus
Hyperuricemia, 285, 309, 3 3 8
action, 264
capitis, longus colli , 94-95
Hypoesthesia, 6 1 , 68, 3 3 8
anaromical anachment sites, 264f
Health information form, 24, 2 5-27f
Hypothenar eminence, 1 6 3 , 1 98, 3 38
insertion, 264
Heberden's nodes, 1 63 , 1 96 , 3 3 8
Hypoxia, 4 5 , 3 3 8
massage therapy considerations, 265
Hemipelvis, small, 3 9 , 1 06
origin, 264
Hidden prankster. See I l iopsoas
precautions while working on, 265
H ilton 's law, 1 8
Icing roller tool, 5 3
stressors and perpetuating facrors, 265
Hip, thigh, and anterior knee region, muscles
I l iocostal is muscle, 1 28- 1 29
trigger point activation in, 264 trigger points and referral zones for, 264, 265f Groin snains (pulls), 245, 2 58, 3 38 Growing pains, 245, 2 5 5 , 3 38
of, 246 anterior thigh, 2 5 7
insertion, 1 28
sartorius, 2 5 8
massage therapy considerations, 1 29
tensor fascia larae, 2 5 7
origin, 1 28
i l iotibial band, 2 6 3
Hallux valgus, 286 Hammer roes, 285, 288, 3 3 8. See also Extensor longus group muscles Hamsnings, 2 5 5-256 action, 2 5 5 insertion, 2 5 5
anatomical attachment sites for, 1 28f
quadriceps, 259-262
lateral thigh, 2 6 3
H
action, 1 28
medial thigh adductor brevis and longus, 267 adductor magnus, 268-269 gracilis, 264-265 pectineus, 266 posterior hip, 246
precautions while working on, 1 28- 1 29 stressors and perpetuating factors, 1 28 trigger point activation in, 1 28 trigger points and referral zones for, 1 28, 1 29f I liopsoas muscle, 226-227 action, 226 anatomical attachment sites, 226f
massage therapy considerations, 2 5 6
gluteus maximus, 246-247
insertion, 226
neuromuscular therapy routine, 2 7 3
gluteus medius, 248-249
massage therapy considerations, 227
origin, 2 5 5
gluteus minimus, 2 50-2 5 1
neuromuscular therapy routine, 240-242
precautions while working o n , 2 5 6
piriformis, 2 5 2
origin, 226
stressors and perpetuating factors, 2 5 6
short lateral hip rotators, 2 53 - 25 4
precautions while working on, 227
trigger point activation i n , 2 5 5 trigger points and referral zones for, 2 5 5 Hamsning strains (pulls), 2 4 5 , 256, 3 38 Hand, neuromuscular therapy routine, 209
posterior thigh, 25 5 hamstring muscles, 2 5 5-256 H ip, thigh, and anterior knee region, neuromuscular therapy routine, 270
stressors an d perpetuating factors, 227 trigger point activation in, 227 trigger points an d referral zones for, 226-227, 227f
IND E X
I l iotibial band, 263 a'1atomical attachment sites, 263f clinical significance, 263 massage therapy considerations, 263 precautions while working on, 263
Lateral pelvic t i l t , 34, 34f, 103, 106, 2 1 5 , 329, 3 3 8 a n d postural findings, 3 4 Lateral pterygoid, 8 3 . See also Head a n d neck, muscles of
I l iotibial hand (lTB) syndrome, 245, 263 , 3 3 8
action, 83
I mpingement syndrome, 103, 3 38
anatomical attachment sites for, 83, 83f
Industrial Ergonomics, 54
insertion, 83
345
flexor digitorum longus and flexor hallucis longus muscles, 305-307 gastrocnemius, 301-302 soleus, 303-304 tibialis posterior, 308-309 Leg with posterior knee, ankle, and foot region, neuromuscular therapy routine, 313 anterior compartment tibialis anterior and extensor digitorum
Inert tissue, 23, 29, 3 3 8
massage therapy considerations, 83
I nformed consent, 2 3 , 3 38
neuromuscular therapy routine, 96-97
Infraspinatus muscle, 111-112
origin, 83
case studies on, 320 deep posterior compartmem
longus, 314
action, I I I
precautions while working on, 83
anatomical attachment sites for, I I I f
stressors and perpetuating factors, 8 3
plamaris, 319
insertion, I I I
trigger point activation, 83
popl iteus, 319
massage therapy considerations, 112
trigger points and referral zones, 83, 83f
tibialis posterior, flexor digitorum longus,
neuromuscular therapy routine, 149-150
Latissimus dorsi muscle, 115-116
origin, I I I
action, 115
and flexor hallucis longus, 318 finishing leg, 319
precautions while working on, 112
anatomical attachment si tes for, 1 15f
foot, 313-314
stressors and perpetuating factors, I I I
insertion, 115
lateral compartment
trigger point activation in, I I I
massage therapy considerations, 116
trigger points and referral zones for, I I I , 112f
neuromuscular therapy routine, 150- 1 51
Intercostal muscles, 228-229
origin, 1 1 5
peroneals, 315-316 posterior compartment gastrocnemius and achilles tendon, 3 I 6-317
action, 228
precautions while working on, 116
anatomical attachment sites, 228f
stressors and perpetuating factors, 1 1 5-116
Lengthening techniques, for concentric strain, 4
insertio,1, 228
trigger point activation in, 1 1 5
Levator scapulae. See also Head and neck,
massage therapy considerations, 229
trigger points and referral zones for,
origin, 228
L 15 , 116f
soleus, 318
muscles of action, 64
precautions while working on, 229
Law of bone transformation. See Wolff's law
stressors and perpetuating factors, 229
Law of fac i l itation, 1 8
insertion, 64
symptoms in client, 229
Laws of physiology, 17-18
massage therapy considerations, 65
trigger point activation in , 229
Arndt-Schultz law, 18
trigger points and referral zones for,
Davis' law, 18
228, 228f
defi n i tion of, 18
anatomical attachment sites for, 64f
neuromuscular therapy routines, 85-86, 9 2 , 147 origin, 64
H ilton 's law, 18
precautions while working on, 65
action, 196
law of facilitation, 18
stressors and perpetuating factors, 6 5
anatomical attachment sites for, 197f
Pfluger's laws
trigger point activation, 6 5
I nterossei and lumbricals muscle, 196-197
trigger points and referral zones, 64-6 5 , 64f
insertion, 196
law of generalization, 19
massage therapy considerations, 197
law of intensity, 1 8
origin, 196
law of radiation, 1 9
"Little helper". See Anconeus
precautions while working on, 197
law of symmetry, 18
Local twitch response, 4 5 , 3 38
law of unilaterality, 18
Longissimus muscle, 126-127
stressors and perpetuating factors, 197
Lief, Stanley, 4-5
trigger point activation in, 196
righting reflexes, 19
action, 1 26
trigger points and referral zones for, 1 96, 197f
Wolff's law, 19
anatomical attachment sites for, 126f
Interviewing client, during assessment process, 24, 28 cause of, cl ient's pain, 28 previous treatment, understanding of, 28 Inversion sprain of ankle, 285, 299, 3 3 8 Ipsi lateral, 61, 75, 338 Ischemia, 3, 6, 338 I sometric contraction, 2 3 , 30, 338
J
j ogger's heel. See Plantaris; Soleus j ump sign, 45, 49, 338 j uxtaposition, 3 3 8
K Key trigger point, I I , 16-17, 338 Kneading, 47 Knee-buckl ing episodes, 245, 269, 338 Kyphosis, 103 , 338
L Lamina groove, 61, 86, 338 Latent trigger point, I I , 16, 3 3 8
Leg length d iscrepancy, 38
insertion, 126
Leg with posterior knee, ankle, and foot region,
massage therapy considerations, 127
muscles of, 286 anterior leg area (shin)
origin, 126 precautions while working on, 127
extensor longus group, 288-289
stressors and perpetuating factors, 126
tibialis anterior, 286-287
trigger point activation in, 126
dorsal foor area
trigger points and referral zones for, 126, 127f
dorsal interossei, 290-291
Longitudinal friction, 48, 48f
extensor d igitorum brevis and extensor
Longus capitis and longus colli , 71. See also
hallucis brevis, 290-291 lateral foot area peroneal group, 298-300 plantar foot area, 292 abductor hallucis, abductor digiti minimi, and flexor digitorum brevis, 292-293 adductor halluc is, flexor hallucis brevis, and flexor digiti mimini brevis, 296-297 quadratus plantae, lumbricals, and interossei , 294-295 posterior knee area, 310
Head and neck, muscles of action, 71 insertion, 71 massage therapy considerations, 71 neuromuscular therapy routine, 94-95 origin, 71 precautions w h i le working on, 71 stressors and perpetuating factors, 71 trigger point activation, 71 trigger points and referral zones, 7 I Low back pain
plantaris, 312
i l iopsoas and, 226-227
popliteus, 310-311
quadratus lumborum and (see Quadratus
posterior leg and ankle area, 30 I
lumborum)
346
INDEX
precautions while working on, 82
Lower l i m b length inequality. See Leg length Lower torso and abdomen region, muscles of, 2 1 5
Medulla oblongata, I I , 1 9, 3 3 8
iliopsoas, 226-227
Middle trapezius/rhomboid area, neuromuscular
intercostals, 228-229
transverse abdominis, 2 2 1 -222
Molded foam rollers, 5 2- 5 3
trigger point and referral guide, 3 23 - 3 29 working of, procedure for, 4 Neuropathy, 3 3 9 and trigger points, 1 5
Morton foot structure, an d load on gluteus
therapy routine, 2 3 2
medius, 248 Motor endplates, I I , 1 4, 3 3 9
diaphragm, 242
external and internal obliques, transverse
pressure bars, 7, 7f Thumby, 7
longus colli Moist heating pad, application of, 50, 50f
2 3 3 -2 3 5
lubricant, 6-7
Military neck, 66. See also Longus capitis and
rectus abdominis and pyramidalis, 223-225
erector spinae and transversospinalis groups,
tools, 52-53 tools required for
therapy routines, 87-89
serratus posterior inferior, 2 1 8
case studies on, 243
and precautions, 8
trigger points and referral zones, 82, 82f
external and internal obliques, 2 1 9-220
Lower torso and abdomen region, neuromuscular
physiology; Trigger points)
trigger point activation, 82
diaphragm, 2 30-2 3 1
quadratus lumborum, 2 1 6-2 1 7
physiology of, 1 1 - 1 9 (see also Laws of
stressors and perpetuating factors, 82
discrepancy
and management of trigger points, 1 4- 1 5
Neurotransmitters, 1 5 Nociceptors, sensitization of, 1 6 Noxious, 3 3 9
Motor neuron, 1 3 , 1 4 Motor units, 1 3- 1 4, 1 5f
points, 6 N u isance residual backache. See Serratus posterior inferior
M u ltifidus, 1 3 1 - 1 3 2 action, 1 3 1
abdominis, and intercostals, 2 3 8 general torso work, 2 3 8
anatomical attachment sites for, 1 3 1 f
Nutrition, as stress factor, 40-4 1
il iolumbar ligament, 2 3 6
insertion, 1 3 1
o
il iopsoas, 240-242
massage therapy considerations, 1 3 2
Obliquus capitis inferior. See Posterior
lower chest and abdomen, 2 3 8
origin, 1 3 1
lower, posterior torso, 2 3 2-23 3
precautions while working on, 1 3 2
quadratus lumborum, 2 3 6- 2 3 7
stressors and perpetuating factors, 1 3 1
rectus abdominis a n d pyramidalis, 2 3 9-240
trigger point activation in, 1 3 1
Obturator extern us. See Short hip rotators
trigger points and referral zones for, 1 3 1 , 1 32f
Obturator internus. See Short hip rotators
sacroil iac l igaments/sacrum, 2 3 5 stretches, 2 3 7
Muscle energy technique, 4 5 , 5 2, 3 3 9
Luhrication, t o reduce friction t o skin, 6
Muscle guarding, 1 9
Lu mbago, 245, 248, 3 3 8
Muscle pain, 1 6
muscle (see Gluteus medius)
M
suboccipital muscles Obliquus capitis superior. See Posterior suboccipital muscles
Occipitalis, 7 5 . See also Head and neck, muscles of action, 75
Muscle spasms and cramps, 285, 3 0 2 , 3 3 9
insertion, 7 5
Muscles , Testing and Function with Posture and
massage therapy considerations, 7 6 origin, 7 5
Pain, 29
Main ray, 1 63 , 1 78, 3 3 8
precautions while working on, 7 6
Muscle, structure and contractile mechanism of, 13
Maissiat's band. See Iliotibial band Malocclusion, 2 3 , 36, 3 3 8
M usculotendonus j unction, 1 6 3 , 1 66
Manual muscle testing. See Orthopedic testing
Mylohyoid, 7 2 . See also Head and neck, muscles
Ma Roller, 5 3
of
Massage therapists
action, 72
stressors and perpetuating factors, 7 6 trigger point activation, 75-76 trigger points and referral zones, 75, 75f Occlusal imbalance, 6 1 , 3 3 9 Optimal therapy zone (OTZ), 3 7
body mechanics for, 5 5-56
insertion, 72
Orthopedic assessment, 2 3 , 3 39
home care assignments to c l ient, providing of,
massage therapy considerations, 72
Orthopedic testing, 2 3 , 28-29, 3 3 9
origin, 72
5 3- 5 5
postural assessment, 3 1 - 3 2
and referral network, 5 3
precautions while working on, 72
anterior pelvic t ilt , 3 2, 3 3f, 3 4
and treatment techniques (see Treatment
stressors and perpetuating factors, 72
forward head posture, 3 6 , 3 6 f
techniques) trigger point and referral guide for, 3 2 3- 3 2 9 Massage tools, 52-53
anatomical attachment sites for, 80
lateral pelvic tilt, 3 4 , 3 4 f
trigger points and referral zones, 72
postural d istortion o f pelvis, 3 2 , 3 3 f shoulder asymmetry, 3 4 , 3 5f
Myofascial Pain and Dysfunction; The Trigger
Masseter, 8 0. See also Head and neck, muscles of action, 80
trigger point activation, 7 2
thoracic kyphosis, 3 5-36, 3 5f
Point Manual, S , 1 2
vertically ill person, 3 1 , 3 2 f
Myotatic unit, 1 0 3 , 1 1 7 , 3 3 9
range o f motion assessment, 2 9 , 3 0 t
insertion, 80
N
massage therapy considerations, 8 1
Neuralgia, 1 0 3 , 104, 3 3 9
passive testing, 29
neuromuscular therapy routine, 95-96
Neuromuscular j u nction, I S , 1 5f
resistive testing, 30-3 1
origin, 80
Neuromuscular therapy, 3-4, 4f
active testing, 29-30
precautions while working on, 8 1
application of, in health care setting, 3
stressors and perpetuating factors, 8 1
and client, relationship
trigger point activation, 8 1 trigger points and referral zones, 80-8 1 , 8 1 f Medial pterygoid, 82. See also Head and neck, muscles of
c lient-therapist communication, 7-8 dependency, participation, and support, 7
Osgood Schlatter disease, 245, 262, 3 3 9 Overload strain, and serratus posterior inferior, 218 Overuse syndrome, 40, 3 3 9
components of, 4
p
contraindications to, 3-4
Painful weak grip. See Brachiorad ialis muscle;
action, 82
goals and therapeutic intent of, 6
anatomical attachment sites for, 82f
history of, 4-6
Extensor group muscle Palmaris longus muscle, 1 89- 1 90
insertion, 82
knowledge and tools required for, 6
action, 1 89
massage therapy considerations, 82
knowledge required for
anatomical attachment sites for, 1 89f
neuromuscular therapy routine, 96
analysis and kinesiology, 6
massage therapy considerations, 1 90
origin, 82
anatomy, 6
origin, 1 89
IN D E X
precautions while working on, 1 90 srressors and perpetuating factors, 1 90
Phasic muscle, 285, 287, 3 3 9 . See also Tibialis
347
whole body dysfunction, postural findings in,
anterior
3 1 -32
trigger point activation in, 189
Pincer palpation, 37, 3 7 f
Postural dysfunction, 4 1
trigger points and referral zones f or, 189
Pincer technique, 4 8
Pregnancy, back pain i n . See I l iopsoas muscle
Pi riformis, 2 5 2
Pressure bars, 7, 7f
Palpation, 36-37 and assessing for trigger points, 37-38
action, 2 5 2
Pronation strain, 3 29
flat palpation, 37, 3 7f
insertion, 2 5 2
Pronator teres, 1 9 1
pincer palpation, 37, 37f
massage therapy considerations, 2 5 2
action, 1 9 1
snapping palpation, 3 7-38, 38f
neuromuscular therapy routine, 2 7 1 -272
anatomical attachment sites for, 1 9 1 f
Paradox ical breathing patterns, 2 3 , 35, 3 39
origin, 2 5 2
insertion, 1 9 1
Passi ve testing, 29
precautions while working o n , 2 5 2
massage therapy considerations, 1 9 1
Pectineus, 266
stressors and perpetuating factors, 2 5 2
origin, 1 9 1
action, 266
trigger point activation i n , 2 5 2
precautions while working on, 1 9 1
insertion, 266
trigger points and referral zones for, 2 5 2 , 2 52f
stressors and perpetuating factors, 1 9 1
massage therapy considerations, 266
Piriformis syndrome, 245, 2 5 2 , 3 39
trigger point activation in, 1 9 1
origin, 266
Plantar fasciitis, 285, 294, 3 3 9
trigger points and referral zones for,
precautions while working on, 266
Plantaris, 3 1 2
191, 19lf
stressors and perpetuating factors, 266
action, 3 J 2
Pseudo sciatica. See G luteus m i n imus
trigger point activation in, 266
insertion, 3 1 2
Pseudovisceral pain. See External and internal
trigger points and referral zones for, 266, 266f
massage therapy considerations, 3 1 2
Pectoralis major, 1 3 7- 1 39
obliques; Transverse abdominis
neuromuscular therapy routine, 3 1 9
Psoas major. See I l iopsoas
action, 1 3 7
origin, 3 1 2
Psoas minor. See I l iopsoas
anatomical attachment sites for, 1 38f
precautions while working on, 3 1 2
Psoas m i nor syndrome, 227
insertion, 1 3 7
stressors and perpetuating factors, 3 1 2
Psychoemotional d istress, 4 1
massag� therapy considerations, 1 39
trigger point activation in, 3 1 2
Pterygoid muscles, 8 2. See al.,o I-lead and neck,
neuromuscular therapy routine, 1 5 5- 1 56
trigger points and referral zones for, 3 1 2
origin, 1 3 7
Pneumothorax, 2 1 5 , 229, 3 3 9
precautions while working on, 1 39
Polymyalgia rheumatica, 285-286, 309, 3 3 9
stressors and perpetuating factors, 1 38- 1 39
Popliteus muscle, 3 1 0-3 1 1
muscles of lateral pterygoid, 8 3 medial pterygoid, 82 Pyothorax, 2 1 5 , 229, 3 3 9
thickly layered insertion of, 1 3 7f
action, 3 1 0
trigger point activation in, 1 38
anatomical attachment sites, 3 1 0f
trigger points and referral zones for, 1 3 7- 1 38,
insertion, 3 1 0
Quadratus femoris. See Short hip rotators
massage therapy considerations, 3 1 1
Quadratus lumborum, 2 1 6-2 1 7
! J8f Pectoralis minor, 1 40- 1 4 1
Q
neuromuscular therapy routine, 3 1 9
action, 2 1 6
action, 1 40
origin, 3 1 0
anatomical attachment sites, 2 1 6f
anatomical attachment sites for, 1 40f
precautions while working on, 3 1 1
insertion, 2 1 6
insertion, 1 40
stressors and perpetuating factors, 3 1 0- 3 1 1
and low hack pain, 2 1 6
massage therapy considerations, 1 4 1
trigger point activation in, 3 1 0
massage therapy considerations, 2 1 7
neuromuscular therapy routine, 1 56
trigger points and referral zones for, 3 1 0
origin, 1 40 precautions while working on, 1 4 1
Posterior cervical muscles, neuromuscular therapy routine, 86-87, 89-90
neuromuscular therapy routine, 2 3 6-2 3 7 origin, 2 1 6 precautions while working on, 2 1 7
stressors and perpetuating factors, 1 40
Posterior pelvic tilt, 245, 3 39
stressors and perpetuating factors, 2 1 7
trigger point activation in, 1 40
Posterior subocc ipital muscles, 6 2. See also Head
trigger point activation in, 2 1 7
trigger points and referral zones for, 1 40, 1 40f Peroneal group, of muscles, 298-300 action, 299
and neck, muscles of action, 62 anatomical attachment sites for, 62f
trigger points and referral zones for, 2 1 6, 2 1 6f, 2 1 7f Quadratus plantae, lumbricals, and interossei ,
anatomical attachment sites, 298f
insertion, 62
insertion, 298-299
massage therapy considerations, 63
action, 294
294-295
massage therapy considerations, 300
origin, 62
anatomical attachment sites, 294f
origin, 298
precautions while working on, 63
insertion, 294
precautions while working on, 300
stressors and perpetuating factors, 63
massage therapy considerations, 295
stressors and perpetuating factors, 299-300
trigger point activation, 63
origin, 294
trigger point activation in, 299 trigger points and referral zones for, 299, 299f Peroneals, neuromuscular therapy routine, 3 1 5-3 1 6 Peroneus brevis. See Peroneal group, o f muscles
trigger points and referral zones, 62-63, 63f Posterior superior iliac spine ( PSIS) 32, 3 3f, ' 34, 34f Postural and biomechanical dysfunction, 3 39 Postural assessment, 3 1 - 3 2
precautions while working on, 295 stressors and perpetuating factors, 295 trigger point activation in, 294-295 trigger points and referral zones for, 294 Quadriceps, 259-262
Peroneus longus. See Peroneal group, of muscles
anterior pelvic tilt, 3 2 , 3 3f, 3 4
action, 25 9
Peroneus tertius. See Peroneal group, of muscles
forward head posture, 3 6 , 36f
anatomical attachment sites, 260f
Perpetuating factor, 2 3 , 3 3 9
lateral pelvic tilt, 34, 34f
insertion, 2 5 9
Pes anserine, 245, 2 5 5 , 3 3 9
overstretched muscle, 3 1
massage therapy considerations, 262
Pes cavus, 285, 3 39
postural d istortion of pelvis, 3 2 , 3 3 f
origin, 2 5 9
Pes planus, 285, 293, 3 3 9
shortened muscles and, 3 1
precautions while working o n , 2 6 2
Petrissage, 4 7
shoulder asymmetry, 34, 3 5f
stressors and perpetuating factors, 262
use o f opposing thumbs for, 47, 47f Pfluger's laws, 1 8- 1 9
thoracic kyphosis, 3 5-36, 3 5f
trigger point activation in, 2 59, 262
vertically ill person, 3 1 , 3 2f
trigger points and referral zones for, 2 59, 261 f
348
INDEX
Rotoscoliosis, 23, 3 4 , 2 1 5 , 2 1 7 , 3 3 9
R Radiculopathy, 1 1 , 1 7, 3 39 Range of motion, 3, 4, 1 3 , 29, 3 3 9 assessment, 29-3 1 for fundamental movements, 30t Reassessment of client, 5 5 Rece/Jtor Tonus Techniques , 5 Rectus abdominis and pyramidalis, 223-225 action, 223 anatomical attachment sites, 223f insertion, 223 massage therapy considerations, 225 neuromuscular therapy routine, 239-240 origin, 2 2 3 precautions w h i l e working o n , 2 2 5 stressors and perpetuating factors, 224 trigger point activation in, 224 trigger points and referral zones for, 224, 224f, 225f Rectus capitis anterior and rectus capitis lateral is. See aLso Head and neck, muscles of action, 70 insertion, 70 massage therapy considerations, 70 origin, 70 precautions while working on, 70 stressors and perpetuating factors, 70 trigger point activation, 70 trigger points and referral zones, 70 Rectus capitis posterior major. See Posterior suboccipital muscles Rectus capitis posterior minor. See Posterior suboccipital muscles Rectus femoris ( two-jointed puzzler). See Quadriceps Reference or referral zone, 3 3 9 Reference/referral zone, 1 1 , 1 7 Referral network, importance of, 5 3 Referred pain, 4 Resistive testing, 3 0-3 1 Rhomboid major and minor, 1 1 9- 1 20 action, 1 1 9 anatomical attachment sites for, 1 1 9f insertion, 1 1 9 massage therapy considerations, 1 20 neuromuscular therapy routine, 1 48-149 origin, 1 1 9 precautions while working on, 1 20 stressors and perpetuating factors, 1 1 9 trigger point activation in, 1 1 9 trigger points and referral zones for, 1 1 9, 1 1 9f Rhomboid muscles, 1 1 9- 1 20 Righting reflexes, 1 9 Rotator cuff, muscle of. See Infraspinatus muscle; Subscapularis muscle; Supraspinatus muscle; Teres minor muscle Rotator cuff tendinitis, 1 03 , 3 3 9 Rotatores, 1 33 - 1 34 action, 1 3 3 anatomical attachment sites for, 1 33 f insertion, 1 3 3 massage therapy considerations, 1 34 origin, 1 3 3 stressors and perpetuating factors, 1 34 trigger point activation in, 1 33 trigger points and referral zones for, 1 3 3 , 1 34f
"Rowing motion", 1 3
trigger point activation in, 2 1 8 trigger points and referral zones for, 2 1 8, 2 1 8f Serratus posterior superior muscle, 1 2 3
s
action, 1 23
Sarcomere, 3 3 9 in skeletal muscles, 1 3
anatomical attachment sites for, 1 23 , 1 23f insertion, 1 2 3
Sarcoplasmic reticulum, 3 3 9
massage therapy considerations, 1 2 3
Sartorius, 2 58
neuromuscular therapy routine, 148- 1 49
action, 2 5 8
origin, 1 23
anatomical attachment sites, 2 58f
precautions while working on, 1 23
insertion, 258
stressors and perpetuating factors, 1 23
massage therapy considerations, 25 8
trigger point activation in, 1 23
neuromuscular therapy routine, 2 7 5
trigger points and referral zones for, 1 2 3 , 1 23 f
origin, 258
Shin splints, 286, 287, 339
precautions wh ile working o n , 25 8
Short hip rotators, 2 5 3-254
stressors an d perpetuating factors, 2 58
action, 2 5 3
trigger point activation in, 25 8
anatomical attachment sites, 2 5 3f
trigger points an d referral zones for, 2 5 8, 258f
insertion, 2 5 3 massage therapy considerations, 254
Satellite trigger point, 1 1 , 1 6- 1 7 , 339
origin, 2 5 3
Scalene minimus, 68
precautions while working o n , 2 5 4
Scalene muscle, 68. See also Head and neck,
stressors and perpetuating factors, 2 5 4
muscles of action, 68 insertion, 68 massage therapy considerations, 69
trigger point activation i n , 2 5 4 trigger points and referral zones for, 2 5 4 , 2 54f Shoulder asymmetry, 34-35 comparing acromions for, 3 5f
neuromuscular therapy routine, 93-94
"Shoulder joint pain" muscle. See I nfraspinatus
origin, 68
Simons, David, S , 1 2
precautions while working on, 69
"Six pack abs", 2 2 3
stressors and perpetuating factors, 68
Skeletal muscle
trigger point activation, 68
endplates in, 1 5
trigger points and referral zones, 68, 69f
structure and contractile mechanism of, 1 3 ,
Scarpa's triangle. See Femoral triangle Sciatica, 245, 2 5 2 , 3 39 Scoliosis, 3 4 , 3 5 , 103, 2 1 5 , 2 1 7, 3 3 9
1 4f trigger points in, 4, I I Skin rolling, 46, 46f
Semimembranosus. See Hamstrings
Small hemipelvis, 1 03 , 3 39
Semispinalis muscle, 1 30
"Smoker's muscle". See Serratus anterior
action, 1 30
Snapping palpation, 37-38, 38f
anatomical attachment sites for, 1 30f
Soft tissue therapy. See N euromuscular �herapy
insertion, 1 3 0
Soleus, 303-304
massage therapy considerations, 1 30
action, 303
origin, 1 30
anatomical attachment sites, 303f
precautions while working on, 1 30
insertion, 303
stressors and perpetuating factors, 1 3 0
massage therapy considerations, 304
trigger point activation in, 1 3 0
neuromuscular therapy routine, 3 1 8
trigger points a n d referral zones for, 1 30
origin, 303
Semitendinosus. See Hamstrings
precautions while working on, 304
Serratus anterior muscle, 1 1 8
stressors and perpetuating factors, 304
action, 1 1 8
trigger point activation in, 303-304
anatomical attachment sites for, 1 1 8
trigger points and referral zones for, 303 , 304f
insertion, 1 1 8
Sore foot muscles. See Abductor halluc is,
massage therapy considerations, 1 1 8
abductor digiti minimi, and flexor
neuromuscular therapy routine, 1 5 2-1 5 3
d igitorum brevis
origin, 1 1 8
Spinalis muscle, 1 2 4- 1 2 5
precautions while working on, 1 1 8
action, 1 24
stressors and perpetuating factors, 1 1 8
anatomical attachment sites for, 1 24f
trigger point activation in, 1 1 8
insertion, 1 24
trigger points and referral zones for, 1 1 8, 1 1 8f Serratus posterior inferior muscle, 2 1 8
massage therapy considerations, 1 2 5 origin, 1 24
action, 2 1 8
precautions while working on, 1 2 5
anatomical attachment sites, 2 1 8f
stressors and perpetuating factors, 1 24
insertion, 2 1 8
trigger point activation in
massage therapy considerations, 2 1 8 origin, 2 1 8 precautions while working on, 2 1 8 stressors and perpetuating factors, 2 1 8
trigger points and referral zones for, 1 24 Splenius cervicis and splenius capitis muscles, 107-108 action, 1 07
INDEX
anatomical attachment sites for, 1 07f
trigger point activation in, 1 44
neuromuscular therapy routine, 1 5 2
insertion, 1 0 7 '11assage therapy considerations, 1 08
trigger points and referral zones for, 1 44, 1 44f
origin, 1 1 7
Supinator, 1 73- 1 74
349
precautions while working on, 1 1 7 stressors and perpetuating factors, 1 1 7
neuromuscular therapy routine, 1 48- 1 49
action, 1 73
origin, 1 07
anatomical attachment sites for, 1 7 3f
trigger point activation in, 1 1 7
precautions while working on, 1 08
insertion, 1 7 3
trigger points and referral zones for, 1 1 7 , 1 1 7f
stressors and perpetuating factors, 1 08
massage therapy considerations, 1 74
trigger point activation in, 1 07-108
neuromuscular therapy routine, 204-205
action, 1 1 3
trigger points and referral zones for, 107, 1 08f
origin, 1 7 3
anatomical attachment sites for, l 1 3 f
Teres minor muscle, 1 1 3- 1 1 4
precautions while working on, 1 74
insertion, 1 1 3
action, 1 3 5
stressors and perpetuating factors, 1 74
massage therapy considerations, 1 1 4
anatomical attachment sites for, 1 36f
trigger point activation in, 1 74
neuromuscular therapy routine, 1 50
insertion, 1 3 5
trigger points and referral zones for, 1 73 - 1 74,
origin, 1 1 3
Sternalis, 1 3 5- 1 36
1 73 f
massage therapy considerations, 1 36 neuromuscular therapy routine, 1 5 5
Suprahyoid muscles, n. See also Head and neck, muscles of
origin, 1 3 5
precautions while working on, 1 1 4 stressors and perpetuating factors, 1 1 3 trigger point activation in, 1 1 3 trigger points and referral zones for, 1 1 3 , 1 1 3f
precautions while working on, 1 36
anatomical attachment sites for, nf
stressors and perpetuating factors, 1 36
d igastric, 74
Thenar eminence, 1 63 , 1 9 2 , 340
trigger point activation in, 1 3 5-1 36
geniohyoid, 73
Theracanes, 5 2
trigger points and referral zones for, l3 5 , 1 36f
infrahyoid muscles and, n
The Trigger Point Manual , 6
mylohyoid, n
The Whartons' Stretch Book: Active-Isolated
Sternocleitlomastoid, 66. See also Head and
neuromuscular therapy routine, 94-95 , 97
neck, muscles of action, 66
Supraspinatus muscle, 1 09- 1 1 0
insertion, 66
action, 1 09
massage therapy considerations, 67
anatomical attachment sites for, 1 09f
neuromuscular therapy routine, 92
insertion, 1 09
Stretching, 5 4 Thoracic kyphosis, 2 3 , 35-36, 3 5f, 3 28, 340 Thoracic outlet syndrome, 45, 56, 1 0 3 , 1 63 , 1 8 5 , 340 Thoracolumbar paraspinals, 1 24 deep paraspinal muscles, 1 30
origin, 66
massage therapy considerations, 1 1 0
precautions while working on, 67
neuromuscular therapy routine, 1 46
stressors and perpetuating factors, 67
origin, 109
rotatores, 1 33- 1 34
trigger point activation, 67
precautions while working on, 1 1 0
semispinalis, 1 30
trigger points and referral zones, 66-67
stressors and perpetuating factors, 1 1 0
multifidus, 1 3 1- 1 32
superficial muscles, 1 24
for clavicular head, 67f
trigger point activation in, 1 09
il iocostalis, 1 28- 1 29
for sternal head, 66f
trigger points and referral zones for, 1 09, 109f
longissimus, 1 26-1 2 7
Stiff fingers. See Extensor indicis Stiff neck, 6 1 , 64, 340. See also Levator scapulae
Synergistic muscles, 1 63 , 1 66, 340
spinalis, 1 24- 1 2 5 Three-step satellite trigger point system, case
"Stitch in the side muscle". See Serratus anterior
T
Stress factor, 340
Tarsal tunnel syndrome, 286, 307, 340
Thumb stripping, 47, 47f
Stress fractures of foot/ankle, 286, 293, 340
TBar pressure bar, 7, 7f
Thumby, 7 , 52
Stretching, 54
Temporal is, 79. See also Head and neck, muscles
Tibialis anterior, 286-287
Stretching, 54
study on, 1 7
of
action, 286 insertion, 286
Stretching Anatomy, 54
action, 79
Stretch to Win, 54
insertion, 79
massage therapy considerations, 287
Subclavius muscle, 1 42 - 1 43
massage therapy considerations, 79
origin, 286
action, 1 42
origin, 79
precautions while working on, 287
anatomical attachment sites for, 1 42f
precautions while working on, 79
stressors and perpetuating factors, 287
insertion, 142
stressors and perpetuating factors, 79
trigger point activation in, 286-287
massage therapy considerations, 1 42
trigger points and referral zones, 79, 79f
trigger points and referral zones for, 286, 287f
neuromuscular therapy routine, 1 56
Temporomandibular joint dysfunction (TMJ
origin, 1 4 2
syndrome ) , 6 1 , 7 5 , 79-8 1 , 83, 340
Tibialis posterior, 308-309 action, 308
precautions while working o n , 1 4 2
Tendinous inscriptions, 2 1 5 , 2 2 3 , 340
anatomical attachment sites, 308f
stressors anti perpetuating factors, 1 4 2
Tennis elbow, 1 73 . See also Supinator
insertion, 308
trigger point activation i n , 1 4 2
Tensor fascia latae, 2 5 7
massage therapy considerations, 309
action, 2 5 7
origin, 308
Subdeltoid bursitis, 1 03 , 340
insertion, 2 5 7
precautions while working on, 309
Subluxation, 1 03 , 1 3 2 , 340
massage therapy considerations, 2 5 7
stressors and perpetuating factors, 309
Suboccipitals, neuromuscular therapy routine,
neuromuscular therapy routine, 2 7 5
trigger point activation in, 309
trigger points and referral zones for, 1 42 , 1 43 f
91
origin, 2 5 7
trigger points and referral zones for, 308, 308f
precautions while working o n , 2 5 7
Tinnitus, 6 1 , 340
action, 1 44
stressors and perpetuating factors, 2 5 7
Torticollis, 64, 1 03 , 340
anatomical attachment sites for, 1 44f
trigger point activation i n , 2 5 7
Transverse abdominis, 2 2 1 -222
insertion, 1 44
trigger points and referral zones for, 2 5 7 , 2 5 7f
Subscapularis muscle, 1 44
massage therapy considerations, 1 44
Teres major muscle, 1 1 7
action, 2 2 1 anatomical attachment sites, 2 2 l f
neuromuscular therapy routine, 1 5 7- 1 58
action, 1 1 7
insertion, 2 2 1
origin, 1 44
anatomical attachment sites for, 1 1 7f
massage therapy considerations, 222
precautions while working on, 1 44
insertion, 1 1 7
origin, 2 2 1
stressors and perpetuating factors, 1 44
massage therapy considerations, 1 1 7
precautions while working on, 2 2 2
350
INDEX
Transverse abdominis (continued)
active, 1 2, 1 6
throacolumbar paraspinals, 1 24- 1 34
stressors and perpetuating factors, 222
anatomy of, 1 2 , 1 2f
trapezius, 1 04-106
trigger point activation i n , 2 2 1
characteristics of, 1 2- 1 3
trigger points
interaction with nervous system, 1 6- 1 7 , 1 7f
Upper torso, neuromuscular therapy routine, 1 45
"Transverse carpal ligament", 1 89
key and satellite, 1 6- 1 7, 1 6f
case study on, 1 59
Tnlpczius muscle, 1 04- 1 06
latent, 1 6
deltoid, 1 53
action, 1 04
motor endplates and, 1 4- 1 5
infraspinatus, 1 49- 1 50
anatomical attachment sites for, 1 04f
motor units and, 1 3- 1 4
latissimus dorsi , 1 50- 1 5 1 levator scapulae, 1 47
insertion, 1 04
and muscle pain, 1 6
massage therapy considerations, 1 06
muscle structure and function and, 1 3
middle and lower trapezius, 1 48-149
origin, 1 04
neuromuscular j unction and, 1 5
pectoral is major and i nsertions of teres major
precautions while work ing on, 1 06
i n pectoralis muscle, and length of treatment,
and latissimus dorsi , 1 5 5 - 1 5 6 pectoralis m inor, 1 56
16
stressors and perpetuating factors, 1 06
rhomboids, 1 48- 1 49
trigger point activation i n, 1 06
research, h istory of, 1 2
trigger points and referral zones for, 104, 1 0 5 f
sources of, and referrals, 1 7
serratus anterior, 1 52- 1 53
Travel l , Janet, S
i n trapezius muscle, 1 04
serratus posterior superior, 1 48- 1 49
Treatment techniques, 45-46
treatment of, 48-49
d i rect strokes, 47 cross liber friction, 48, 48f
moist heat and cryotherapy, 50-52
pincer tcchniquc, 48
stretching involved muscles, 52
gu ide! i nes f or
sternalis, 1 5 5
muscles, 49-50
longitudinal friction, 48, 48f thumh stripping, 4 7 , 4 7f
SIT tendons, 1 54 splenius capitis and cervicis, 1 48- 1 49
active range of motion of involved
subclavius, 1 56 subscapularis, 1 5 7-1 58
Trigger point therapy, 4 , Sf
supraspinatus, 1 46
Trochanteric bursitis, 2 1 5 , 2 1 6, 245, 2 5 7 , 340
teres major, 1 5 2
direct contact, 46
teres m inor, 1 50
proper di rection of pressure, 46
U
use of appropriate pressure, 46
Uni lateral, 6 1 , 62, 340
warming strokes, 46 c i rcular friction, 47 effleurage, 46 petrissage, 47 skin rolling, 46, 46f
upper and middle trapezius, 1 4 5- 1 46
Upper and/or midtrapezius strain, 1 0 3 , 340
upper paraspinals, 1 48- 1 49 Upper trapezius, neuromuscular therapy routine,
Upper paraspinals, neuromuscular therapy routine, 1 48- 1 49 Upper torso, muscles of, 1 0 3 anterior shoulder/chest area
84
V Varicosities, 2 1 5 , 23 1
pectoralis major, 1 3 7- 1 3 9
Vastus intermedius (frustrator). See Quadriceps
action, 1 69
pectoralis minor, 1 40- 1 4 1
Vastus lateralis (stuck patella muscle). See
anatomical attachment sites for, 1 69f
sternalis, 1 3 5- 1 3 6
insertion, 1 69
subclavius, 1 42- 1 43
Triceps brac h i i , 1 69- 1 70
massage therapy considerations, 1 70 neuromuscular therapy routine, 2 1 0-2 1 1
Quadriceps Vastus medialis (buckling knee muscle ) . See
subscapularis, 1 44 posterior shoulder/upper back area
Quadriceps Visceral d iseases, and abdominal trigger points,
origin, 1 69
deltoid, 1 2 1- 1 2 2
prec
infraspinatus, 1 1 1 - 1 1 2
stressors and perpetuating factors, 1 69- 1 70
latissimus dorsi, 1 1 5- 1 1 6
w
trigger point activation in, 1 69
rhomboid major and minor, 1 1 9- 1 20
Warming strokes, 46-47
trigger points and referral zones for, 1 69, 1 70f
serratus anterior, 1 1 8
Weeder's thumb. See Adductor and opponens
Trigger finger/trigger thumb, 1 63 , 1 84 , 340
serratus posterior superior, 1 23
Trigger point complex, 1 2, I lf
splenius capitis and splenius cervicis,
Trigger point pressure, 48-49
1 07- 1 08
220, 2 2 1
pollicis Whiplash injury, 6 1 , 63, 340 Wolff's law, 1 9
Trigger point referral, 3, 4, 340
supraspinatus, 1 09- 1 1 0
Trigger points, 3, 4, 1 1 - 1 2 , 340
teres major, 1 1 7
Z
teres minor, 1 1 3 - 1 1 4
Z-disk , 340
activation of, 1 7
