The Manual of Trigger Point and Myofascial Therapy

226 Part B FLEXOR HALLUCIS BREVIS First metatarsal head �f-+-- Flexor hallucis longus tendon ORIGIN Cuboid and cuneiform bones. INSERTION Base of the proximal phalanx of the great toe. RPP Region of both surfaces of the great toe. TP Two FB below the first metatarsal head. MFS Extension of the great toe. The clinician facilitates the stretch. PSS Not detected. HEP Same as MFS. The patient facilitates stretch with the hand. BIOMECHANICS OF INJURY Same as the abductor hallucis.

Lower Extremity Region 227 TRIGGER POINT THERAPY MYOFASCIAl STRETCHES The clinician facilitates great toe extension while supporting above the first metatarsal head. HOME EXERCISE PROGRAM

228 Part B FLEXOR DIGITORUM BREVIS Third metatarsal head ,j��--+ Calcaneus ORIGIN Calcaneus and plantar aponeurosis. INSERTION Both sides of the middle phalanges of the lateral four toes. RPP Heads of the second to fourth metatarsals. TP Midway between the third metatarsal head and the calcaneus. MFS Extension of the four toes. The clinician facilitates stretching and stabilizes the calcaneus. PSS Not detected. HEP Same as MFS. The patient facilitates stretch with one hand while supporting the calcaneus with the other. BIOMECHANICS OF INJURY Same as the abductor hallucis.

Lower Extremity Region 229 TRIGGER POINT THERAPY MYOFASCIAL STRETCHES HOME EXERCISE PROGRAM

23 0 Part B QUADRATUS PLANTAE tr.1\\�'.'r-'-I Second metatarsal head w.'i'*+--+ Flexor digitorum longus Quadratus plantae --\\--�/fI'+,1 Calcaneus --+�� Flexor digitorum brevis (cut) ORIGIN Medial head-Medial surface of the calcaneus. Lateral head-Lateral surface of the calcaneus. INSERTION Into the flexor digitorum longus tendon. RPP Plantar surface of the heel. TP Proximal and middle one-third of the line between the calcaneus and second metatarsal head. MFS Extension of the four toes. The clinician stabilizes the calcaneus bone with one hand and facilitates stretch with the other hand. PSS Not detected. HEP The patient applies the same stretch as MFS. BIOMECHANICS OF INJURY Re triction of toe movement, prolonged immobilization.

Lower Extremity Region 23 I TRIGGER POINT THERAPY MYOFASCIAL STRETCHES HOME EXERCISE PROGRAM

23 2 Part B ADDUCTOR HALLUCIS Third metatarsophalangeal jOint ORIGIN Second to fourth metatarsals (oblique head) and third to fifth metatarsophalangeal joints (transverse head). INSERTION Proximal phalanx of the great toe. RPP Plantar surface of the forefoot. TP Over the belly of the muscle. Rarely a trigger point. MFS The clinician stabilizes the second to fifth metatarsals, and extends and abducts the great toe. PSS Not detected. HEP The patient applies the same stretch as MFS. BIOMECHANICS OF INJURY Restriction of toe movement, prolonged immobilization.

Lower Extremity Region 23 3 TRIGGER POINT THERAPY MYOFASCIAL STRETCHES HOME EXERCISE PROGRAM

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5-hydroxytryptamine, 25 attachment trigger point, 37 and referred pain pattern,33 autonomic disturbances,25-26 axon,13 A-band, 12 abbreviations, 77 back. see lumbar spine region; thoracolumbar spine region abdominal region balance, 25-26 biceps brachii, 128-129 diaphragm, 162-163 biceps femoris, 204-205 rectus abdominis,160-161 biomechanics of injury, 4, 41. see also specific muscles acetylcholine (ACh), 13-14 botulinum toxin A,53 and injury mechanisms, 21 brachioradialis,132-133 acetylcholinesterase (AChE),14 bradykinin,21, 25 and injury mechanisms, 21 \"achi\" point,7 and referred pain pattern, 33 Achilles' tendonitis, 210, 212,216 brain actin, 11 role in muscle contraction, 15 and chronic pain syndrome,4 action potential, 14 and referred pain pattern, 33 active trigger point, 37 subdural hematoma,67 identifying,45-46 acupuncture, 7-9 calcium adductor hallucis, 232-233 binding with tropomyosin, 11 adductor magnus, 190-191 and dysfunctional endplate hypothesis, 21 adductor pollicis,154-155 and injury mechanisms, 21 adenosine diphosphate (ADP), 11 and muscle contraction, 14-15 and muscle contraction,15 and release of acetycholine, 14 adenosine triphosphate (ATP), 11 storage in sarcoplasmic reticulum,13 and muscle contraction, 15 a-motoneuron, 13 calf muscles anesthetic,53,63 gastrocnemius,210-211 aneurysm, 67 peroneus brevis,220-221 anticoagulant therapy, 67 peroneus longus,218-219 arm. see upper extremity peroneus tertius, 222-223 arteriosclerosis, 67 soleus,212-213 asthma, 80 tibialis anterior, 214-215 tibialis posterior, 216-217 cancer,67

236 Index cane length,59 endocrine inadequacies,59 carotid artery, 82 endorphins, 8 cellulite,26 endplate central myofascial trigger point, 37 cervical spine dysfunctional endplate hypothesis, 20 mammalian motor,22 cervicis, 88-89 and muscle anatomy, 13 digastric,84-85 and muscle contraction, 14 levator scapulae, 92-93 as origin of trigger point pain,7 longus colli, 82-83 energy crisis, 20, 21 scalenus, 80-81 enzymes, 14 splenus capitis,88-89 ethylene chloride, 54 sternocleidomastoid,78-79 extensor carpi radialis,142-143 suboccipital muscles,86-87 extensor carpi ulnaris,144-145 upper trapezius, 90-91 extensor digitorum, 146-147 cervicis, 88-89 extensor digitorum brevis,224-225 Chinese medicine extensor indicis proprius,148-149 acupuncture, 4 extrameridian, 7 and history of trigger point therapy, 3 chiropractic,3 fascial tissue, 11 chronic pain syndrome, 4 fatigue, 28 circulatory disorders, 67 fibrositis, 3 cisternae, 13 flexibility. see range of motion cold packs,51 flexor carpi radialis,140-141 after treatment, 54 flexor carpi ulnaris, 138-139 connective tissue, 11 flexor hallucis brevis, 236-237 contract-relax technique, 53 flexor pollicis brevis,150-151 contractile elements,13-14 flourimethane,54 contractile proteins,11 foot muscles. see lower extremity contraction. see muscle contraction contraindications, 63 adductor hallucis, 232-233 coordination. see proprioceptive training extensor digitorum brevis, 224-225 Coumadin, 67 flexor digitorum brevis, 228-229 cross bridges, 15 flexor hallucis brevis,236-237 and muscle weakness, 27-28 quadratus plantae, 230-231 deltoid,120-121 gamma motor neurons, 20 depolarization, 15 gamma spindle response, 53 dermatomal hair loss, 26, 27 gastrocnemius, 210-211 diagnosis, 4 5-47 gluteus maximus,180-181 gluteus medius,182-183 and biomechanics of injury, 41 gluteus minimus, 184-185 diaphragm, 162-163 goose bumps,25 digastric, 84-85 dizziness, 25 hair loss, 26,27 dry needling,63 hand muscles difference from acupuncture, 7-8 adductor pollicis,154-155 dysfunctional endplate hypothesis,7,20 adductor pollicis brevis, 150-151 flexor pollicis brevis, 152-153 and central myofascial trigger point, 57 opponens pollicis, 156-157 headache, 78,86, 90 edema,26, 27 heel spur,216 electrical stimulation, 51 heparin,67 electromyography (EMG) histamine, 21 and dry needling, 63 and muscle spindle hypothesis, 19 history, 3-4 and myofascial diagnosis, 46 and myofascial trigger points, 3

home exercise,54-55 Index 237 hot packs,51 tibialis anterior,214-21 5 I-band,1 2 tibialis posterior,21 6-21 7 iliocostalis lumborum, 172-1 73 vastus intermedius,202-203 iliocostalis thoracis,1 70-171 vastus lateralis,200-201 iliopsoas,1 78-179 vastus medialis,1 98-1 99 infraspinatus,1 1 4-1 1 5 lumbar spine region injury gluteus maximus,1 80-181 gluteus medius, 1 82-183 biomechanics of,41 gluteus minimus,1 84-185 mechanism of,20-22 iliopsoas,1 78-179 innervation ratio,1 3 piriformis,1 86-187 integration model,4 quadratus lumborum,1 76-177 interrater reliability,46 intrafusal fibers,1 9 macrotrauma, 22 iontophoresis,51 malignancy,67 ischemic compression, 29, 46, 52 massage, 3, 53 masseter,96-97 jaw pain. see temporamandibular joint region match stick test,26 jugular vein,82 medications kyphosis, 1 70, 172 anesthetic,53 as contraindications,67 latent trigger point,37 delivery methods,51 identifying,45-46 vapocoolant spray,54 latissimus dorsi,1 06-1 07 meridians,7 leg. see lower extremity metabolic inadequacies,59 leg length discrepancy,59, 1 70, 1 72, 1 76 microtrauma,20-21 levator scapulae,92-93 mitochondria,1 3, 1 4 Lidocaine,53 modalities local twitch response (LTR),27 post treatment,S4 as treatment,51 and myofascial diagnosis,46 Morton's foot condition,1 82 longus colli, 82-83 motor endplate. see endplate low-level laser therapy (LLLT),51 motor neuron, 13 lower extremity motor unit,1 3,1 4 recruitment rate,26 adductor magnus,1 90-1 91 muscle. see also sarcomere biceps femoris,204-205 anatomy,1 2 foot muscles innervation ratio,1 3 local twitch response (LTR),27 adductor hallucis,232-233 physiology,1 1 extensor digitorum brevis,224-225 shortening with myofascial trigger point,22 flexor digitorum brevis,228-229 structure,1 3 flexor hallucis brevis,236-237 taut band,26 quadratus plantae,230-231 muscle contraction gastrocnemius,210-211 length-tension relationships,28 pectineus,1 92-193 mechanism of,1 4-15 peroneus brevis,220-221 muscle fascicles,1 1 peroneus longus,21 8-21 9 muscle guarding,54 peroneus tertius, 222-223 muscle imbalances,59 popliteus, 208-209 and muscle spindle hypothesis,1 9 rectus femoris, 1 96-197 study of,3 semimembranosus,206-207 muscle sensory receptors,20 semitendinosus,206-207 muscle soreness,difference from positive stretch sign,29 soleus,21 2-21 3 muscle spindle function,20 tensor fascia lata,1 94-195

238 Index muscle spindle hypothesis,19 patient pain recognition, 27 muscle weakness, 27-28 and identifying trigger points, 46 muscular rheumatism, 3 myalgia, 3 pectineus, 192-193 myoangelosis, 3 pectoralis major,116-117 myofascial release techniques,5 3 pectoralis minor, 118-119 myofascial stretching exercises (MFS),53-54 peroneus brevis, 220-221 myofibrilogenesis, 5 3 peroneus longus, 218-219 myofibrils,20 perpetuating factors, 59 myofibrositis, 3 pH and pain, 25 myosin, 11 phonophoresis,51 pilomotor reflex, 26 role in muscle contraction,15 piriformis, 186-187 popliteus, 208-209 nebulin,11 positive stretch sign, 28-29 neck. see cervical spine needle penetration description,4 during myofascial stretching exercises, 5 3-54 dry needling, 63 postisometric relaxation technique, 3 , 53 and local twitch response, 46 and muscle spindle hypothesis,19 and referred pain,3 3 posture, 59 nervous system, 13-14 kyphosis,170,172 and acupuncture vs. trigger points,7 scoliosis,170, 172, 176, 178 and referred pain pattern, 3 3 power stroke, 11 role in trigger points, 3 pressure neurofascial integration,4 ischemic compression, 29, 46 neuromuscular junction, 15 progressive pressure technique, 52-53 neuropathic hypothesis,20 procaine injection,53 nociceptor axons, 21-22 progressive pressure technique,52-53 and referred pain pattern,3 3 pronator teres,136-137 nodules, 26-27 proprioceptive disturbances,78 and definition of trigger point, 19 proprioceptive training, 54 and myofascial diagnosis, 46 prostaglandins nutrition, as perpetuating factor, 59 and low-level laser therapy (LLLT),51 and pain,21, 25 opponens pollicis, 156-157 and referred pain pattern, 3 3 osteoporosis,67 proteins accessory,11 pain. see also referred pain pattern contractile, 11 acute, 4 regulatory, 11 chronic, 4 PSS. see positive stretch sign and effectiveness of laser therapy, 51-52 pterygoid local,25 lateral, 100-101 in nodules, 26-27 medial, 102-103 patient recognition of, 27 and myofascial diagnosis, 46 quadratus lumborum, 176-177 positive stretch sign,28-29 quadratus plantae, 230-231 processing by nervous system, 3 3 referred, 25 range of motion role of nociceptor axons, 21-22 limited, 27 loss and injury mechanism, 21-22 palpation technique painful and myofascial diagnosis, 46 and diagnosis, 46 progressive pressure, 52-53 Ranvier's node,14 and referred pain pattern, 3 3 reciprocal inhibition, 53 snapping palpation and local twitch response,27 rectus abdominis,160-161 for taut band,28 rectus femoris,196-197

referred pain pattern,25 Index 239 cervical vertebrae and throat,82 and development of trigger point,21 snapping palpation,27,28 diagnostic value of,46-47 soleus,212-213 facial,96,98 spasm,28 front lower teeth,84 spinal cord,and referred pain pattern,3 3 head,neck and shoulder,88 splenus capitis,88-89 headache,78,86,90 \"spray and stretch\" technique,54 mechanisms,3 3-34 sternalis,124-125 neck,90 sternocleidomastoid,25 neck and arm,80 neck and shoulder,92 referred pain pattern,26 shoulder and arm,106,108 therapy,78-79 strain-counterstrain treatment,19,5 3 reflex,20 strengthening exercises,54 regulatory proteins,11 stretching repetitive motion injuries,20,41 myofascial stretching exercises (MFS), 53-54 positive stretch sign,28-29 to extensor carpi radialis,142 subclavius,122-123 to extensor digitorum,146 subdural hematoma,67 to flexor carpi radialis,140 suboccipital muscles,86-87 rigor mortis,15 subscapularis,11 0-111 RPP. see referred pain pattern and positive stretch sign,28-29 supinator,134-135 saline injection,63 supraspinatus,112-113 salivation,25 sweating,25 saltatory conduction,14 symptoms,25-26 sarcomere,11-12 synaptic cleft,13 and development of trigger point,21 T-tubules,1 3 and length-tension relationship,28 taut band,26 lengthening by myofascial stretching exercises,5 3 structure and nebulin protein,11 and myofascial diagnosis,46 sarcoplasmic reticulum,13 palpation technique,28 satellite trigger point,37 temporalis,98-99 scalenus,80-81 temporomandibular joint region scar tissue hypothesis,20 lateral pterygoid,100-10 1 scoliosis, 170,172,176,178 masseter,96-97 semimembranosus, 206-207 medial pterygoid,102-103 semitendinosus,206-207 temporalis,98-99 sensory cortex,33 tennis elbow,132,134 sensory neurons,20 tensor fascia lata,194-195 shoulder region teres major,108-109 deltoid,120-121 terminal cisternae,13 infraspinatus,114-115 terminal innervation ratio,13 latissimus dorsi, 106-107 thalamus,3 3 pectoralis major,116-117 thick filament,11 pectoralis minor,118-119 thigh muscles and positive stretch sign,28-29 adductor magnus,190-191 sternalis,124-125 biceps femoris,204-205 subclavius,122-123 rectus femoris,196-197 subscapularis,110-111 semimembranosus,206-207 supraspinatus,112-113 semitendinosus,206-207 teres major,108-109 tensor fascia lata,194-195 treatment and PSS, 28-29 vastus intermedius,202-203 sleep disturbances,26 vastus lateralis,200-201 sliding filament theory,14-15 vastus medialis,198-199 thin filament,11

240 Index thoracolumbar spine region ultrasound,51 dlllCo>talis Iumhorum, 172·173 upper extremity liloco�talis thoracis. 170�171 Imddle anJ lower trapeZIUS, 168·169 biceps brachii,128·129 rhomhoiJeu, major, 166·167 brachioradialis, 132·133 eXlensor carpi radialis, 142·143 three knuckle (cst, 96 extensor carpI ulnaris, 144·145 uhlal\" postenor, 216·217 extensor dlgttorum, 146·147 lInnIlU�. 25, 78 extensor muicis propnus,148-149 lIlm, 11 flexor carpi radialis, 140·141 t,xlIh pain, 84,96, 98 flexor carpi ulnaris, 138·139 tr;lpCZIU� hanu mIddle and lower, 168·169 aduuctor pollicis, 154·155 upper, 90·91 adductor pollicis brevis,150·151 trciltmcnt flexor polltcis brevis, 152·153 home exercise, 54-55 opponens polltcis, 156·157 Imv.levcl laser therapy (LLLT), 51·52 pronator teres, 136·137 mnJ'-llltic�1 51 supinator, 134·135 muscle strengthening,54 triceps, 130·131 progrc��lve prct)SlIfc. 52-53 upper trapeZIUS, 90·91 propnoccpuve [milling,54 Incep', 130·13 I vapocoolant, 54 \"astu, Intermeuius, 202·203 rrlj.,(gcr POInts va>tus lateralis, 200·201 va,[Us medialis, 198·199 i.lLllv\"Hion, Z I ventral root, 13 liymptoms, 25 vitamins, 59 ,lav'Ilfication,37-38 weakness, 27·28 ulillparbon to acupuncture, 7-9 wrist muscles dcfinllion, 19 difk-rence from acupuncture. 7-8 extensor carpI rautaltS, 142·143 h\"t\"'\\' 3·4 extensor carpI ulnaris, 144·145 Idcnttfymg, 45·46 extensor digttorum,146·147 palhophy>tology,19·20 flexor carpi radialis, 140·141 tyre' of,19 flexor carpi ulnaris, 138·139 tropomYOSin, 11 pronator leres, 136·138 imd muscle comraction, 15 rcguL.ttory role of, 17 Z JlSks, 12 Imrnnm, 11 ,lIld 11l1l')Clc contraction,15 rcguLllory role 0(, 17