trigger point therapy slides

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05/01/23 2

WelcomeTrigger point therapy & soft tissue release for sports and massage therapists

With Katie Emmett & Kate Mcnally


3@Physiocouk #manchesterphysio facebook.com/physiocouk

Who are we?Katie’s LinkedIn: www.linkedin.com/katieemmett Twitter: @KatiePhysiocouk

Kate’s LinkedIn: www.linkedin.com/katemcnally Twitter: @KateMcPhysiocouk

http://www.linkedin.com/katieemmett

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Let’s connectWebsite: www.physio.co.uk

Twitter: @physiocouk

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Aims of today


Learn the theory of a trigger point Learn the theory of trigger point therapy Practice the trigger point technique to muscle groups Use other soft tissue release techniques along side TP release

Itinerary


10.00 - 10.30 - Induction / Arrival10.30 - 10.50 - Quiz – What do you know about trigger point therapy10.50 -11.30 - Theory: Trigger point therapy11.30 -12.00 - Practical: workshop12.00 - 12.30 - Lunch12.30 - 13.00 - Theory: Trigger pointing technique13.00 - 14.00 - Practical: Muscle groups14.00 - 14.30 – Practical: Tools & other STR techniques14.30 - 15.00 - Evidence/Case Studies/Quiz answers

Quiz…What do you know about trigger

point therapy?


Question 1


Name a type of Trigger Point?

Question 2


How would patients describe trigger point pain?

Question 3


Name some indications for Trigger Point Therapy?

Question 4


Name 5 benefits of Trigger Point Therapy

Question 5


Where are the Rhomboid muscles located?

Question 6


Name the muscles in the Hamstring group

Question 7


Name 5 contraindications of Trigger point therapy

Question 8


Name some related symptoms to trigger points in the Sternocleomastoid muscle

Theory: Trigger Point Therapy


What are trigger points?


• Trigger points are hyperirritable areas of contracted muscle fibres that form a palatable nodule

• On a microscopic level, the contracted muscle fibres accumulate into a small thickened area causing the rest of the fibre to stretch

• The areas of contracted muscle restrict blood flow within the tissue causing an accumulation of waste products and reduced levels of nutrients available.

Brief History


• 1930s -Dr Hans Lange used sclerometer to prove that tender areas in muscles are 50% harder than surrounding areas.

• 1940s- Janet Travell developed trigger point injection therapy and termed the “tender areas” described by Dr Hans “Trigger points”.

• Travell's therapy called for the injection of saline (a salt solution) and procaine (also known as Novocaine, an anesthetic) into the trigger point.

• Travell mapped what she termed the body's trigger points and the manner in which pain radiates to the rest of the body.

• Travell's work came to national attention when she treated President John F. Kennedy for his back pain.

• Travell co-authored several books with David Simons which are considered the definitive reference for trigger point therapy.

• Travell & Simons' Myofascial Pain and Dysfunction: Upper half of body• Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual• Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 2

Brief History


• 1976- Bonnie Prudden, a physical fitness and exercise therapist developed Travells trigger point therapy. She found that applying sustained pressure to a trigger point using thumbs, knuckles and elbows produced superior results to those treated with injections when followed by corrective movements and stretching. Prudden later went on to author two books:

• Myotherapy: Bonnie Prudden’s Complete Guide to Pain Free Living

• Pain Erasure the Bonnie Prudden Way

http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjs8vv7m6DMAhWBvhQKHTmsC48QjRwIBw&url=http://www.amazon.com/Pain-Erasure-Bonnie-Prudden/dp/0871319837&psig=AFQjCNEwQPCRZrTwVh3hR0NNDOvIfUMgtg&ust=1461344858449255

Different types of trigger points


• Trigger points are described according to location, tenderness and chronicity as central (or primary), satellite (or secondary), attachment, diffuse, inactive (or latent) and active

• The main types of trigger points are:

Central/ primary trigger points Satellite/ secondary trigger points

Active trigger points Latent trigger points

Central/ primary trigger points


• These are the most well-established and painful points

• Pain is felt by the individual when they are active, and are usually what people refer to when they talk about trigger points

• Central trigger points exist at a neuromuscular point, which is the meeting place of a nerve and muscle

Satellite/ secondary trigger points


• These trigger points are “created” as a response to the central trigger point in neighbouring muscles that lie within the referred pain zone.

• Form in response to central trigger points within the pain referral patterns

• The primary trigger point is still the key to trigger pointing intervention: the satellite trigger points often resolve once the primary point has been effectively rendered inactive.

• Satellite points may also prove resilient to treatment until the primary central focus is weakened; such is often the case in the paraspinal and/or abdominal muscles.

Active trigger points


• This can apply to central and satellite trigger points.

• A variety of stimulants, such as forcing muscular activity through pain, can activate an inactive trigger point.

• This situation is common when activity is increased after trauma i.e a road traffic accident, where multiple and diffuse trigger points may have developed.

• This trigger point is both tender to palpation and elicits a referred pain pattern.

• Pain can limit range of movement

Latent trigger points


• This applies to lumps and nodules that feel like trigger points. These can develop anywhere in the body and are often secondary.

• These trigger points are not painful, and do not elicit a referred pain pathway.

• The presence of inactive trigger points within muscles may lead to increased muscular stiffness and tension. They can build up for years.

• It has been suggested that these points are more common in those who live a sedentary lifestyle (Starlanyl & Copeland 2001)

• These points are “potential” trigger points and may reactivate if the central or primary trigger point is (re)stimulated

• Reactivation may occur following trauma and injury

Symptoms of Trigger Points


Active trigger point referral symptoms

•Dull ache•Deep•Pressing pain•“Stabbing”•Burning•Referred pain

•Common reports of headaches, dizziness and pins and needles

Referral Pain GuideSternocleomastoid and Masseter


Referral Pain GuideTrapezuis


Referral Pain GuidePectorals


Referral Pain GuideQuadratus Lumborum


Referral Pain GuidePiriformis


Referral Pain GuideGlute maximus, medius and minimus


Referral Pain GuideTFL


Referral Pain GuideVastus Lateralis


Referral Pain GuideHamstrings


Other Symptoms


A sensation of:

•Numbness•Fatigue•Weakness

A loss of:

•Flexibility•Range of movement•Muscular power and strength

Why are they present?


• Repetitive overuse injuries (using the same body parts in the same way hundreds of times on a daily basis) from activities such as typing/mousing, handheld electronics, gardening, home improvement projects, work environments, etc.

• Sustained loading e.g heavy lifting, carrying babies, briefcases, boxes or lifting bedridden patients.

Why are they present?


•Poor posture due to our sedentary lifestyles, de-conditioning, poorly designed furniture and technology.

•Muscle clenching and tensing due to mental/emotional stress.

•Direct injury such as a strain, break, twist or tear e.g car accidents, sports injuries, falling down stairs.

•Trigger points can even develop due to inactivity such as prolonged bed rest or sitting.

The Trigger Point Complex


How are they formed?• Within the muscle structure trigger points lye

within a single muscle fibre

• They are located within each sarcomere which is where muscle contraction takes place

• Sarcomeres often get overstimulated and become difficult to release their contraction

• Each segment of sarcomeres becomes longer and shorter which stretches the rest of the fibres in the band



How are they formed?• Multiple sarcomere knots form trigger points

• Stretched segments of fibres give increased tension to the taut band of fibres.

• Blood flow is restricted in these fibres which reduces oxygenation and accumulative of waste products which irritate trigger points

• The body responds by sending out pain signals

• The brain stimulates decreased movement into these muscles which further tightens the structure



https://www.youtube.com/watch?v=sltGyJvbvWw

The Trigger Point Theories


“Integrated trigger point hypothesis”

•Injury or overuse can stimulate release of acetylcholine (ACh).•This stimulates the release of calcium from the sarcoplasmic retinaculum. •The presence of calcium can allow muscular contraction through the sliding filament theory. •Prolongs muscular contraction and reduces blood circulation which prevents the calcium pump receiving the energy needed to withdraw the calcium.•Muscles stay contracted.

The Trigger Point Theories


“Muscle spindle hypothesis”•Proposes inflamed muscle spindles cause trigger points.

•Sustained muscular overload causes fatigue, muscular spasm and restricted blood flow.

•Causes muscle spindles to be surrounded by waste products e.g. lactic acid, potassium ions and inflammatory chemicals such as histamine.

•This results in inflammation of the muscle spindle and spasm of the extrafusal muscle fibres, forming the taunt band that we can palpate.

Indications and Outcome Measures


Indications Outcome measures

Pain VAS scale & subjective symptoms

Reduced AROM Active range of movement

High muscle tension and tone Muscle testing

Muscle tightness Palpation

Muscle weakness


Outcome measure:VAS/ Numeric Pain Scale

• Simple and easy

• Before, during and after massage

• Record change

• Use with patient to see reduction in pain over the progression of treatments


Outcome measure:Range of movement

• Pre and post measurements• Goniometer or visual• Standardise to produce reliable results • Review each session • Used to distinguish areas to treat and

techniques types • Valuable in the success of treatment


Outcome measure:Muscle testing

• Measure nerve conduction, muscle recruitment to determine a deficit

• Test uninjured side for norm

• Patient will see and feel a progression

• Strengthening exercises needs to be used along side massage


Outcome measure:Palpation

• Use palpation as a measure • “the four T’s”

TemperatureTissue may be hot or cold, indicating inflammation or ischaemia

TextureSwelling (acute-hard, chronic – “boggy”, congested)healthy tissues should have an even textureAdhesions feel like tissues are “stuck” and less mobile “audible crunching”


Outcome measure:Palpation

TendernessPain can be indicated through response/ use vas scores Structures that are too painful to palpate

ToneTissues may be hypertonic or hypotonic Use to compare

Practical:Trigger point workshop: Symptoms


Lunch


Theory: Trigger Pointing Therapy


How to treat a Trigger Point


Assessment

•Find the most painful TP using patient response and Numeric Rating Scale or (VAS)

•Treat the highest rated point and radiate out from this point

•Once the points are found – a good amount of pressure is applied (perform with precaution - keep communication with patient)

•Initial pain is stimulated and you hold the pressure until the pain has eased completely or in some cases reduced slightly

•Reapply pressure onto the same point until the pain eases off quicker or it isn’t felt anymore

•Thumbs/elbows or tools can be used

How to treat a Trigger Point


Guidelines

Application of direct pressure onto the trigger points for around 30 seconds or until the patient’s pain has decreased to at least 3/10 VAS score.

The applied pressure help breakup the adhesive fibre connections within the trigger points and push out blood containing waste products and toxins.

After 30 seconds the pressure is released allowing a rush of fresh blood containing nutrients to circulate the trigger point.

Repeat 3 times in conjunction with deep massage strokes.

• This can depend on the severity of pain/ how deep or superficial the TP is – subjective and variable to each patient

The Benefits


• Reduced pain

• Increased range of motion

• Decreased muscle stiffness and tension

• Reduction in headaches

• Improved flexibility

• Improved circulation

• Fewer muscle spasms

Precautions


• High pain scales• Patient Anxiety• Acute/ Inflammatory stage of

healing• Hypersensitivity• Pregnancy• Epilepsy • Asthma• Hypertension• Prescribed medication

Contraindications


General Local Acute conditions requiring medical attention Acute flare-up of inflammatory arthritides

Acute pneumonia Aneurysms deemed life-threatening (may be

general contraindication depending on location)

Advanced kidney, respiratory or liver failure Local contagious condition

Diabetes with complications such as gangrene, advanced heart or kidney disease or very unstable or high blood pressure

Local irritable skin condition

Hemorrhage

Malignancy

Severe atherosclerosis

Open wound or sore

Severe and unstable hypertension

Recent burn

Shock

Undiagnosed lump

Systemic contagious or infectious condition

Manual Handling and Body Position


• Posture– Bed height– Stance– Patient position

• Use different parts of your hands/ arms to apply pressure• Keep arms straight to utilise body weight when applying

pressure/resistance.• Move from the hips and knees as much as possible• Oil (or cream)- only needs to be a little bit, if any.

Look after yourself before you look after the patient!

Post Treatment Irritation


Very common for people to experience irritation for up to 72 hours after treatment.

Side effects can include:• Bruising• Redness• Tenderness/Increased Sensitivity• Increased symptoms• Aching similar to DOMS

Post Treatment Irritation


Causes

• The release of toxins/waste products from muscular tissue • Neurological sensitisation• Increased blood flow and micro trauma can lead to bruising and redness

Advice

•Reassure the patient it's a normal response to be sore after soft tissue treatment•Recommend they drink water to keep hydrated

Practical:Trigger pointing muscles


• Sternocleomastoid • UFT• Rhomboids • QL • TFL • Vastus Lateralis • Hamstrings

Sternocleomastoid


Anatomical Highlights:

• Each SCM group has two divisions that originate off the mastoid process behind the ear. The sternal division runs diagonally downward to attach to the sternum, while the clavicular division attaches right behind it on the medial clavicle.

• Acting unilaterally, contraction of the SCM muscle turns the head towards the opposite side, while bilateral contraction flexes the neck and head forward.

• The most important function of the SCM is to control and monitor the head’s position in space. Proprioceptive feedback from the SCM is essential to being able to maintain one’s balance, and is also important for interpreting visual information.

Sternocleomastoid Trigger Points


• The SCM muscle group can contain a up to seven trigger points, making it’s trigger point density one of the highest in the body.

• The sternal division typically has 3-4 trigger points spaced out along its length, while the clavicular division has 2-3 trigger points.

• Trigger points typically develop in one SCM muscle group first, but quickly spread to the SCM on the opposite side of the neck.

Sternocleomastoid Pain


Each SCM division has a separate and distinct referred pain pattern:

• The sternal division’s referred pain is felt deep in the eye socket (behind the eye), above the eye, in the cheek region, around the TMJ, in the upper chest, in the back of the head, and on the top of the head.

• The clavicular division’s referred pain is felt in the forehead, deep in the ear, behind the ear, and in the molar teeth on the same side.

Related symptoms

• Sore Neck• Tension Headaches• Migraine• Dizziness

RX: Sternocleomastoid


• Locating and releasing these trigger points can be complicated due to their proximity to many blood vessels and nerves in the neck region.

• Because of this, the application of direct pressure is limited to the superior trigger point only, with the rest of the trigger points released with a specific squeezing-type of technique.

Upper Fiber Traps


The trapezius is not one, but three separate muscles:

•The upper trapezius•The middle trapezius•The lower trapezius

All three trapezius muscles originate along the spine and extend laterally to attach to the shoulder girdle, but each muscle has a different fiber direction and pull.

Upper Fiber Traps


The whole trapezius muscle creates various movements of the shoulder blade, neck, and head.

An example, the simple act of flexing the head to the right requires:

•Contraction of the lower trapezius on the right side to fix the right shoulder blade in place.•Contraction of the right upper trapezius to pull the neck and head to the right.•Relaxation of the left lower trapezius to allow the left shoulder blade to rise.•Relaxation of the left upper trapezius to allow the neck and head to move to the right.

This type of complexity makes it easy for trigger point activity to spread quickly through the muscle group as a whole.

UFT Trigger Points


Four primary trigger points in the trapezius muscle group; two trigger points in the upper fibers, and one each in the middle and lower fibers.

• The anterior trapezius trigger point

• The upper trapezius trigger point

• The middle trapezius trigger point

• The lower trapezius trigger point

UFT Pain


• “Pain in the neck”

• The mental and emotional stress of modern day life often takes physical form as trigger points in the lower and upper trapezius muscles.

• The lower trapezius trigger point is the most sensitive to psychological and projects pain and tenderness upward into the neck and shoulder region.

• The anterior trigger point refers pain to the side of the neck, jaw, and face, but it is notorious for producing a throbbing headache in the temple region. This headache pain may also be described as “behind the eye.”

• Middle trapezius trigger point, which produces a localised burning-type pain along the spine. It will often recruit the rhomboid trigger points as they share a similar intra-scapular pain pattern.

RX: UFT


• The anterior trapezius trigger point

• The upper trapezius trigger point

• The middle trapezius trigger point

• The lower trapezius trigger point

Rhomboids


“That Nagging Pain Between the Shoulder Blades”

• Location: The rhomboid muscle group is found between the spine and the scapula in the mid- back region. It lies deep to the Trapezius muscle and is composed of the rhomboid major and rhomboid minor muscles.

• Structure: The rhomboid minor is smaller than and lies above (superior to) the rhomboid major. Both muscles originate along the thoracic spine with their fibers running diagonally downward and outward to attach along the inside border of the scapula.

• Function: In everyday life, the rhomboid muscles function to position the scapula during various movements of the shoulder and arm.

Rhomboids


“That Nagging Pain Between the Shoulder Blades”

•The rhomboid minor originates on the spinous processes of C7 and T1 and attaches to the medial border of the scapula near the root of scapular spine.

•The rhomboid major originates from the spinous processes of T2 to T5 and attaches along the lower half of the scapular border.

Rhomboid Trigger Points


3 primary trigger points

• The rhomboid minor trigger point lies just medial to the inside edge of the scapula, level with the scapular spine.• The rhomboid major trigger points lie one above the other, along the lower part of the scapular border.

It should be noted that all three of the rhomboid trigger points lie beneath the trapezius muscle and may be difficult to palpate if there is tension or trigger point activity in the trapezius.

Rhomboid Pain


Referred Pain: The pain concentrates in the region between the spine and the shoulder blade. It may also extend to the region above the shoulder blade as well.The rhomboid and levator scapulae trigger point pain patterns are very similar except that the rhomboid pattern does not involve the neck.

Symptoms/ Clinical Findings•Pain Between the Shoulder Blades: an aching (but not deep) pain that is felt along the inside of the shoulder blade.•Pain is usually felt at rest and not typically affected my movement.•A patient will typically present with rounded-shoulder, sunken chest posture where tight pectoralis muscles pull the shoulder forward, producing a chronic strain and stretch on the rhomboids and middle trapezius muscles.•Rhomboid weakness •Patients may hear snapping or grinding noises from the region around the shoulder blade during movements of the arm.

RX: Rhomboids


• Make sure that you have released any trapezius trigger points first.

• If you don’t, you will never be able to accurately locate the rhomboid trigger points by palpation. Even with a relaxed trapezius muscles, these trigger points will feel rather deep to your touch (even though they really aren’t that deep)

Positions:

• Side-lying position to allow more forward movement of their shoulder• Prone to allow more pressure to be applied

RX: Rhomboids


Have a go!


QL – Quadratus Lumborum


• A small and hidden muscle that plays a prominent role in normal body mechanics that without its functioning, the upright posture of the human being is impossible to maintain.

This muscle group has three subsections that each have a distinct fiber direction:

• The Iliocostal fibers (shown in the following picture as blue) attach on the Iliac Crest and run vertically upward to attach to the 12th rib.• The iliolumbar fibers (shown in the following picture as green) attach on the Iliac Crest and run diagonally upward and medially to attach to the transverse processes of the lumbar vertebrae (L1 > L4)• The lumbocostal fibers (shown in the following picture as red) attach on the lumbar vertebrae and run diagnonally upward and laterally to attach to the twelfth (lowest) rib

QL – Quadratus Lumborum


QL Trigger points


• The primary antagonist to each QL muscle is the opposing QL muscle on the other side of the body.

• If one muscle develops trigger point activity, the muscle on the other side will become overloaded and develop trigger points as well.

• From a clinical perspective, you should always address the trigger points in both the left and right QL muscles, even if the pain is limited only to one side.

QL Trigger points


There are four potential trigger points in the QL muscle:

• The upper QL trigger point is found just lateral to where the lumbar paraspinal muscles and the twelfth rib meet.

•The lower QL trigger point lies deep in the region where the paraspinal muscles meet the hip crest (iliac crest).

•The middle or deep QL trigger points lie closer to the spine than the superior or lower trigger points, next to the third and fourth lumbar vertebrae.

QL Pain


• Usually described as an intense, deep ache but occasionally can initiate a sharp, knifelike symptom, particularly during movement.

The distribution of the referred pain from each TP is:

• The upper trigger point refers pain to the flank region of the low back, along the crest of the hip, and around the front to the upper groin region.

• The lower trigger point refers pain and tenderness to the hip joint region, making laying on that side too painful during sleep.

• The middle trigger points refer pain and tenderness strongly to the S.I. joint and lower buttock regions. Occasionally, these trigger points may refer a sharp, “lightening bolt” of pain to the front of the thigh.

QL Pain


RX: QL


• The first step in the effective treatment of the QL trigger points is being able to accurately locate and contact the trigger points.

• Prone position

• Extended side-lying position

TFL - Tensor Fasciae Latae


Location: •A small muscle found on the side of the pelvis and runs downward in front of the hip joint to blend with the iliotibial tract just below the hip joint.

Function:• Its function is primarily to control movement of the leg during the stance phase of walking.

• It also works to keep the pelvis level when the opposite leg is raised off the ground during walking (assisting the gluteus medius and gluteus minimus muscles).

•It may also help to stabilise the knee joint during weight bearing activity.

TFL - Tensor Fasciae Latae


Muscle Structure: •The upper attachment of the TFL originates along the outer aspect of the Iliac Crest (of the pelvis) and Anterior Superior Iliac Spine (A.S.I.S).

•Two functionally distinct sections, the anterior and posterior fibers.

•The anterior fibers become tendinous as they run down the outside of the thigh and attach to the connective tissue encapsulating the knee joint.

•The posterior fibers join the iliotibial tract (a central thickening of the large fascial sheath covering the outside thigh) and attach to the lateral tubercle of the tibia leg bone.

TFL Trigger Point


• There is only one trigger point found in the TFL and it is located in the upper region of the muscle just below where it attaches to the A.S.I.S.

TFL Pain


• The referred pain pattern associated with this trigger point covers the entire hip joint and extends down the outside aspect of the thigh, sometimes nearly to the knee joint. Tenderness to touch may also be prominent in the hip joint and down the thighSymptoms/Clinical Findings

• Pain and/or soreness in the hip joint (greater trochanter) and down the outside thigh during movement of the hip.• Pain prevents them from walking quickly.• Unable to sit in a deep (or low) chair or flex their hip more than 90°.• Unable to lie on the affected hip during sleep and unable to lie on the unaffected side during sleep without a pillow between their knees.• Adduction of the thigh at the hip is limited to 15° or less.• Swinging the leg on the affected side up and to the side (hip abduction) may be painful.

RX: TFL


Vastus Lateralis


Location: The quadriceps femoris muscle group form the thigh musculature found on the front of the upper leg. The group is comprised of four muscles:

• The Vastus Lateralis

• The Rectus Femoris

• The Vastus Medialis

• The Vastus Intermedius

Vastus Lateralis


Function•The quadricep muscle group as a whole functions to allow a person to squat, bend backwards, walk up or down stairs, and move from a standing to a seated position (or vice-versa). •These muscles are not active while standing with the knees locked, but become active during the heel-strike and toe-off phases of walking.

Muscle Structure and Actions•The vastus lateralis is the largest muscle in the group.•It originates along the posterior-lateral aspect of the femur bone and runs down the outside of the thigh to attach to the lateral aspect of the patella bone.•Contraction of this muscle produces extension of the lower leg at the knee.

Vastus Lateralis Trigger Points


There are two sets of trigger points in the vastus lateralis muscle:

• The upper vastus lateralis trigger points are located in mid-thigh region on the outside aspect of the leg.

• They refer pain all along the outside of the thigh and knee, from the pelvic crest down to the lower leg region just below the knee.

• The lower vastus lateralis trigger points are found just above and to the outside of the knee joint. They refer pain around the outside aspect of the knee joint and below it, sometimes extending up into the lower lateral thigh region.

• The pain may also be experienced as going “through the knee” and into the back of the knee, especially if it occurs in children.

Vastus Lateralis Trigger Points


RX: Vastus Lateralis


Hamstrings


Muscle Structure & Attachments: The four components of the hamstring muscle group are detailed below:

The semitendinosus •Medial aspect of the posterior thigh•Originates on the ischial tuberosity of the pelvis and runs down the leg to attach below the medial condyle on the tibia. •The belly of this muscle is found in the top portion of the posterior thigh.

The semimembranosus•Also lies on the medial aspect of the posterior thigh•It attaches to the ischial tuberosity of the pelvis and runs deep to the other hamstring muscles to attach to the medial condyle of the tibia just below the knee joint capsule.

Hamstrings


The bicep femoris

• It has two heads that lie on the lateral aspect of the posterior thigh; the long head and the short head.

•The long head of the biceps femoris attaches to the ischial tuberosity and runs diagonally downward and laterally to attach to the head of the fibula bone.

•The short head of the biceps femoris attaches along the linea aspera on the shaft of femur bone and runs diagonally outward to join the tendon of the long head as it attaches to the head of the fibula.

Hamstring Trigger Points


The hamstring muscle group contains two clusters of trigger points:

• The medial cluster can contain up to 5 trigger points that are located about mid-thigh, along the inside of the leg.

• The lateral cluster can contain up to 4 trigger points that are located about mid-thigh along the outside aspect of the leg.

Hamstring Pain


• The medial cluster trigger point(s) refer pain strongly upward to the gluteal fold/upper posterior thigh region and down the back of the thigh to the medial calf region.

• The lateral cluster trigger points refer pain primarily to the back of the knee, with some spillover referral to the back of the thigh.

Symptoms/Clinical Findings of active hamstring

• Posterior thigh or posterior knee pain, worse when walking, often causes a limp.• Pain in buttocks, back of the thigh and/or knee while sitting• Leg pain that disturbs sleep• Quadriceps femoris trigger point symptoms due to the prominent antagonistic relationship between these muscle groups.

RX: Hamstring


+ Active Release Technique

Have a go!


The use of other STR


•Helps warm up an area

•Removes waste products

•Increases oxygenation

•Increases new blood flow

•Further breaks down collagen

•Helps sooth an area after deep pressure has been applied

•Nice, relaxing end to a treatment


Effleurage • Technique used to warm up or warm down the tissues

• Tensile force, works as a mechanical pump

• Increases fluid flow encourages venous and lymphatic return

• Increases tissue mobility

• Dilation of capillaries

• Can increase or decrease tone depending upon speed


Petrissage • Examples of petrissage- Kneading, wringing & skin rolling

• A group of techniques that are applied with pressure and are deep and compress the underlying muscles

• Movements should be slow and repetitive with pressure in order to loosen the muscles and increase blood flow to the area

• Promotes relaxation • Increases fluid flow• Increases mobility of fibrous tissue• Decreases tone


Why should you stretch post-massage?

• Excessive tension may still remain post-massage.

• It takes up to two days post-massage to experience full effects.

• Essential to use other techniques to restore good functioning and reduce tension.

• need to stretch the collagen fibres that have been “knotted” to allow them to regain their full length.


Post treatment stretches Passive static stretching

•Involves taking the muscle belly to its outer range until you can feel a gentle stretch.

•Static stretches are usually held for at least 30 pain free seconds.

•Research suggests static stretches should be repeated from 2 to 4 times. As further repetitions do not promote any further muscle elongation (Bandy, 1997).

Practical:Tool and other STR techniques


Supporting Evidence


Myofascial trigger points in subjects presenting with mechanical neck pain: a

blinded, controlled study


Fernandez-de-las-penas, 2006•Aim: To highlight the presence of trigger points in subjects complaining of mechanical neck pain within the upper trapezius, sternocleidomastoid, levator scapulae and suboccipital muscles.

•Method: 20 subjects with mechanical neck pain matched with 20 healthy subjects. TrPs were identified, by an assessor blinded to the subjects' condition, when there was a hypersensible tender spot in a palpable taut band, local twitch response elicited by the snapping palpation of the taut band, and reproduction of the referred pain typical of each TrP.

•Results: the mean number of TrPs present on each neck pain patient was 4.3 (SD: 0.9), of which 2.5 (SD: 1.3) were latent and 1.8 (SD: 0.8) were active TrPs. All the examined muscles evoked referred pain patterns contributing to patients' symptoms. Active TrPs were more frequent in patients presenting with mechanical neck pain than in healthy subjects.

•Link: http://www.manualtherapyjournal.com/article/S1356-689X(06)00031-2/fulltext?refuid=S1479-2354(07)00108-3&refissn=1479-2354

Effectiveness of Myofascial Trigger Point Manual Therapy Combined With a Self-Stretching Protocol for the

Management of Plantar Heel Pain: A Randomized Controlled Trial


Renan-Ordine et al, (2011)•Aim: to assess the effect of trigger point therapy and stretching or stretching alone in the treatment for plantar heel pain.

•Method: 60 patients with plantar heel pain were divided into 2 groups a)self-stretching b) self-stretching and trigger point therapy.

•Outcome measures: assessed at baseline and at a 1-month follow up.

– Physical function and bodily pains assessed through a quality of life questionnaire. – pressure pain thresholds were assessed over affected gastroc, soleus muscles and

over the calcaneus using a mechanical pressure algometer.

•Results: trigger point therapy and self-stretching is superior to stretching alone in the treatment of patients with plantar heel pain.

•Link: http://www.jospt.org/doi/full/10.2519/jospt.2011.3504

Comparative study on effects of manipulation treatment and transcutaneous electrical nerve stimulation on patients with

cervicogenic headache


Li et al, (2007)•Aim: To compare the effects of trigger pointing and transcutaneous electrical nerve stimulation (TENS) on patients with cervicogenic headache.

•Method: 70 patients with cervicoigenic headaches were randomly allocated to receive trigger pointing or TENS every other day for 40 days.

•Outcome measures: taken 2 weeks pre-treatment and 4 weeks post-treatment.– headache degree, frequency and lasting time using a numeric rating scale – ROM of cervical spine.

•Results: Trigger pointing was superior to TENS in headache frequency, lasting time and ROM scores. Response rate of trigger pointing treatment was 94.5%, significantly higher than 64.5% of TENS treatment.

•Link: http://europepmc.org/abstract/med/17631795

Immediate effect of activator trigger point therapy and myofascial band therapy on non-specific neck pain in patients

with upper trapezius trigger points compared to sham ultrasound: A randomised controlled trial


Blikstad and Gemmell, (2007)•Aim: To determine the immediate effect of activator trigger point therapy and myofascial band therapy compared to sham ultrasound on non-specific neck pain

•Method: 45 patients with non-specific neck pain of at least 4 on an 11-point numerical rating scale and upper trap trigger points, decreased cervical lateral flexion away from the active trigger points participated. Participants were assigned to one of three treatment groups; trigger point therapy, myofascial band therapy or sham ultrasound.

•Outcome measures: assessed before and 5 min after treatment– pain levels assessed using numerical scale– cervical ROM using goniometer – pain perceived thresholds using pain pressure algometer.

•Results: For the primary outcome measure of pain reduction the odds of a patient improving with activator trigger point therapy was 7 times higher than a patient treated with myofascial band therapy or sham ultrasound.

•Link: http://www.sciencedirect.com/science/article/pii/S1479235407001083

Cervicogenic headache caused by myofascial trigger points in the sternocleidomastoid: a case report


Case report: •45 year old male patient with 25 year history of chronic headaches and neck pain. •Patient had seen many medical specialists and had received multiple facet blocks, radiofrequency ablation, selective C2 nerve blocks, occipital nerve blocks, multiple pharmacological regimes and behavioural therapy. All producing no change in symptoms.•Patient was referred back to physical therapy to assess musculoskeletal contributions to head pain. •Patient reports 5/5 pain scale, had a slumped sitting posture, restricted right cervical rotation, extension and muscular tightness in right pectoral muscles and active trigger points in sternocleidomastoid muscle which on palpation reproduced the patients pain. •Patient given treatment including kinesiology taping, trigger point therapy and postural training.•After 4 weeks he reported pain reduction of 70%.•6 months after being discharged from 16 sessions he reported being pain free approximately half of the time with only mild discomfort the rest.

•Link: https://deepblue.lib.umich.edu/bitstream/handle/2027.42/74754/j.1468-2982.2007?sequence=1

Supporting Evidence:Other STR techniques


Therapeutic evaluation of lumbar tender point deep massage for chronic non-specific low

back pain


Zheng et al, 2012•Aim: To investigate the effects of lumber traction along and in combination with deep tissue massage in patients with chronic low back pain.

•Method: 64 patients with LBP were divided to two groups A) lumber traction and deep tissue massage or B) lumber traction who both received treatment twice a week for 3 weeks.

•Outcome measures: tissue hardness meter/algometer and VAS pain scores.

•Results: Patients receiving deep tissue massage and traction experienced significant decreases in muscle hardness and pain intensity when compared to those who received lumber traction alone.


Massage therapy as an effective treatment for carpal tunnel syndrome


Elliott and Burkett, 2013•Aim: To investigate the effects of massage therapy as the treatment for carpal tunnel syndrome.

•Method: 21 participants received 30 min of massage including trigger point therapy twice a week for 6 weeks.

•Outcome measures: Carpel tunnel questionnaires, Phalen and Tinel test assessment. •Results: Participants experienced a significant reduction in symptom severity and improvements in physical function.


Case Studies


Case Study: Shoulder pain


PC/HPC -21 year old female with an gradual onset of ache pain in shoulders over past 1/12 rating 4/10 on VAS scale. The pain is aggravated by sitting at a desk for long hours and eased with the application of heat.

SH- final year art student with a sudden increase in workload as final project is due in 2/12. Carry heavy art portfolio to and from university. Attends a LBP class at the gym 1 x a month.

PMH- nil to note

DH- paracetamol when needed



Objective signs

• Increased UFT tone • Reduced cervical lateral flexion due to UFT tightness• TOP of L and R UFT and Rhomboids• Active Trigger points in R and L Rhomboids• No neurological symptoms

Case Study: Buttock pain


PC/HPC- 25 year old male 5/10 pain in L buttock. 1/12 ago increased pain following legs gym session, gradually worsening since. Aggravated by climbing multiple flights of stairs at work. Eased by resting.

SH- Started going to the gym 1/12 ago after a 5 year break. Doesn’t do any stretching because he doesn’t know how to. Works on the 8th floor of a office building.

PMH- over pronate both feet, especially bad in L side.

DH- nil to note



Objective signs

•Over pronation in L > R foot

•Valgus position of knees

•Poor hamstring flexibility on 90/90 test in L>R legs

•No neurological symptoms during SLR

•PALP: tension L>R hamstring, glutes and piriformis

•Very tender on PALP of piriformis



Diagnosis?

How would treat this?

Case Study: Lower back pain


PC/HPC – 39 year old male 8/10 sharp pain in R lower back. Pain began suddenly when after lifting heavy box up which sent shooting pains down R leg. Aggravated by bending down and putting shoes on and eased by lying down flat. SH- full time receptionist, doesn’t perform regular exercise.

PMH- history of lower back pain

DH- analgesics



Objective signs

•Limited Lumber range of movement•Increase in pain during flexion and L lateral flexion •Pain eased during extension.•PALP – pain on palp of QL and L3 spinous process

Case Study: Calf pain


PC/HPC – 35 year old male runner. Felt a 6/10 sharp pain in R calf towards the end of a 5K run 2/52 ago. Had to stop running. No swelling or bruising was present. Pain reduced since 3/10 ache pain, tried running again but still feels painful. SH- work in a warehouse, on feet all day up and down ladders.

PMH- prev R lateral ankle sprain 12/12 ago

DH-nil to note



Objective signs

•Increased calf bulk L side•Thickening of R Achilles tendon •Reduced dorsiflexion of R ankle•Reduce muscular strength in R resisted plantarflexion•Reduced R calf length •PALP- pain on palp of medial gastroc•-ve Thomas test

Quiz…Answers


Question 1


• Central/ Primary• Satellite/Secondary • Active • Latent/potential

Question 2


• Dull ache• Deep • Sharp• Pressing pain • Stabbing • Burning • Travelling pain • Head pain

Question 3


• Pain • Reduced AROM• High muscle tension or tone• Muscle tightness

Question 4


• Reduced pain

• Increased range of motion

• Decreased muscle stiffness and tension

• Reduction in headaches

• Improved flexibility

• Improved circulation

• Fewer muscle spasms

Question 5


• The rhomboid muscle group is found between the spine and the scapula in the mid- back region. It lies deep to the Trapezius muscle and is composed of the rhomboid major and rhomboid minor muscles.

• The rhomboid minor originates on the spinous processes of C7 and T1 and attaches to the medial border of the scapula near the root of scapular spine.

• The rhomboid major originates from the spinous processes of T2 to T5 and attaches along the lower half of the scapular border

Question 6


The semitendinosus •Medial aspect of the posterior thigh•Originates on the ischial tuberosity of the pelvis and runs down the leg to attach below the medial condyle on the tibia. •The belly of this muscle is found in the top portion of the posterior thigh.

The semimembranosus•Also lies on the medial aspect of the posterior thigh•It attaches to the ischial tuberosity of the pelvis and runs deep to the other hamstring muscles to attach to the medial condyle of the tibia just below the knee joint capsule.

• The long head of the biceps femoris attaches to the ischial tuberosity and runs diagonally downward and laterally to attach to the head of the fibula bone.

• The short head of the biceps femoris attaches along the linea aspera on the shaft of femur bone and runs diagonally outward to join the tendon of the long head as it attaches to the head of the fibula.

Question 7


General Local Acute conditions requiring medical attention Acute flare-up of inflammatory arthritides

Acute pneumonia Aneurysms deemed life-threatening (may be general

contraindication depending on location)

Advanced kidney, respiratory or liver failure Local contagious condition

Diabetes with complications such as gangrene, advanced heart or kidney disease or very unstable or high blood pressure

Local irritable skin condition

Hemorrhage

Malignancy

Severe atherosclerosis

Open wound or sore

Severe and unstable hypertension

Recent burn

Shock

Undiagnosed lump

Systemic contagious or infectious condition

Question 8


• The sternal division’s referred pain is felt deep in the eye socket (behind the eye), above the eye, in the cheek region, around the TMJ, in the upper chest, in the back of the head, and on the top of the head.

• The clavicular division’s referred pain is felt in the forehead, deep in the ear, behind the ear, and in the molar teeth on the same side.

Related symptoms

• Sore Neck• Tension Headaches• Migraine• Dizziness

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