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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


9 781582 558004
Health
Williams & Wilkins
NEUROMUSCULAR
TH ERAPY MANUAL
Jocelyn Granger, NCTMB
Founder and Director
Ann Arbor Institute of Massage Therapy
Ann Arbor, Michigan

Health
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9 8 7 6 5 43 2 1

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. 2. Myofascial pain syndromes. I. Title.
[DNLM: I. Massage-methods. 2. Myofascial Pain Syndromes-therapy.
3. Soft Tissue Injuries-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.

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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. Key terms: are listed and defined at the beginning of
This text is devoted to providing a concise manual of each chapter, boldfaced on first mention in the text,
neuromuscular therapy that contains the most relevant con and appear in a glossary at the end of the book.
tent from Travel! and Simons' Myofascial Pain and Dysfunction: Chapter introductions provide a brief overview of
T he Trigger Point Manual, volumes 1 and 2, in a highly struc each chapter's contents.
tured, regionally organized, accessible, and user-friendly text 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 sented are included at the end of each case study.
gap and highlights the information that is most helpful to a
Sample routines sections include step-by-step massage
massage therapist.
procedures for each body region.
Chapter summaries briefly review the content covered
OVERVIEW OF CONTENTS in each of the first four chapters.
Chapter review questions, appearing at the end
Part I of the book gives an in-depth overview of the basics of
of each chapter, allow readers to test their knowledge
neuromuscular therapy, including information about its his
of the content covered in each chapter and consist of
tory, the phy iological basis on which neuromuscular ther
multiple choice questions, short answer questions,
apy is founded, client assessment, body mechanics, and
true/false, and matching.
more. Part II is divided into sections by body region. Each
chapter gives specific information regarding the muscles in
that region, such as origin and insertion. Also included here USE OF THIS BOOK
is further information regarding trigger points and referral
It will be imperative for you to read and study the chapters
zones, perpetuating factors, and massage considerations for
in Part I and gain a comprehensive understanding of the
each muscle, along with color pictures of the anatomy and
theory of neuromuscular therapy before attempting to mas
trigger points. There is also a step-by-step guide to perform
ter the techniques in Part II. This is very advanced work
ing the treatment of each muscle, which is coordinated with
and it will be important that you also have an excellent
online videos of the same making it easy to practice this
grasp on anatomy to be able to master this work. A neu
work at home.
romuscular therapist must work from the heart, wh ich
means working with integrity. Integrity means to be mas
PEDAGOGICAL FEATURES 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
E-mail: jgranger@aaimt.edu
FEEDBACK
This author appreciates any feedback from students, profes
sional therapists, school instructors, etc. Any ideas for
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 Finally, I extend my appreciation to Melanie Gibbs,
keep my energy at a high level during those very long days. 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
Serratus Anterior: Stitch in the Side Muscle / 778
Anterior Cervical Muscles / 66
Sternocleidomastoid: Amazingly Complex / 66 Rhomboids, Major and Minor: Superficial Backache
and Round Shoulder Muscles / 779
Scalenes: Anterior, Medius, and Posterior:
Deltoid: A Dull Actor / 727
The Entrappers/ 68
Serratus Posterior Superior: Cryptic, Deep, Upper
Anterior Suboccipitals / 70
Back Pain / 723
Rectus Capitis Anterior and Rectus Capitis
Lateralis / 70
Thoracolumbar Paraspinals: Lumbago / 124

Longus Capitis and Longus Colli: Military Neck / 77 Spinalis / 724

Suprahyoid Muscles / 72 Longissimus / 726


Iliocostalis / 728
Mylohyoid / 72
Semispinalis / 730
Geniohyoid / 73
Digastric: Pseudo-sternocleidomastoid Pain / 74 Multifidus / 737
Rotatores / 733
Head and Face Muscles / 75
Occipitalis: The Scalp Tensor / 75 Anterior Shoulder/Chest Area / 135
Sternalis: Anomalous Substernal Ache / 735
Frontalis: The Scalp Tensor / 77
Corrugator Supercilii / 78 Pectoralis Major: The Poor Posture and Heart
Attack Muscle / 737
Temporalis: Temporal Headache and Maxillary
Pectoralis Minor: Neurovascular Entrapper / 740
Toothache / 79
Masseter: The Trismus Muscle / 80 Subclavius: Poor Posture and Heart Attack / 742
Subscapularis: The Frozen Shoulder Muscle / 744
The Pterygoid Muscles / 82
Medial Pterygoid: Ache Inside The Mouth / 82
ARM,WRIST,AND HAND / 163
Lateral Pterygoid: TMJ Dysfunction / 83

Upper Arm (Brachium) / 164


UPPER TORSO / 103 Biceps Brachii: A Three-Jointed Motor / 1 64
Coracobrachialis: Hide and Go Seek / 1 66
Posterior Shoulder/Upper Back Area / 104 Brachialis: Workhorse Elbow Flexor / 1 67
Trapezius: The Coat Hanger / 704
Triceps Brachii: Three-Headed Monster / 1 69

xiii
x iv LIST OF MUSCLES

Forearm / 171 HIP, THIGH,AND ANTERIOR KNEE / 245


Brachioradialis: Painful Weak Grip / 1 71
Supinator: Tennis Elbow / 1 73
Posterior Hip / 246
Gluteus Maxim us: The Swimmers Nemesis / 246
Extensor Group: Painful Weak Grip / 175
Gluteus Medius: Lumbago Muscle / 248
Extensor Carpi Radialis Longus / 1 75
Gluteus Minimus: Pseudo Sciatica / 250
Extensor Carpi Radialis Brevis / 1 77
Piriformis: The Double Devil / 252
Extensor Digitorum / 1 78
The Other Five Short Lateral Hip Rotators / 253
Extensor Carpi Ulnaris / 1 80
Anconeus: The Little Helper / 1 81 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
Anterior Thigh / 257
Flexor Carpi Ulnaris / 1 85
Tensor Fascia Latae: Pseudotrochanteric
Flexors Digitorum Superficialis and Profundus / 1 87
Bursitis / 257
Palmaris Longus / 1 89
Sartorius: Surreptitious Accomplice / 258
Pronator Teres / 1 91
Quadriceps: The Four-Faced Troublemaker / 259
Wrist and Hand / 192 Lateral Thigh / 263
Adductor and Opponens Pol/icis: Weeders
Iliotibial Band / 263
Thumb / 1 92
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


LEG WITH POSTERIOR KNEE,ANKLE,
Quadratus Lumborum: Trochanteric Bursitis / 216 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:
Dorsal Foot Area / 290
Pseudovisceral Pain / 223
Extensor Digitorum Brevis, Extensor Hal/ucis
Iliopsoas: The Hidden Prankster / 226
Brevis, and the Dorsal Interossei: Sore Foot
Intercostals / 228
Muscles / 290
Diaphragm / 230
LIST OF MUSCLES xv

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
Flexor Longus Group / 305
Quadratus Plantae, Lumbricals, and Interossei:
Flexor Digitorum Longus and Flexor Hallucis Longus:
Vipers' Nest / 294
Claw Toe Muscles / 305
Adductor Hallucis, Flexor Hallucis Brevis, and Flexor
Tibialis Posterior: Runner's Nemesis / 308
Digiti Minimi Brevis: Vipers' Nest / 296
Posterior Knee Area / 310
lateral leg Area / 298
Popliteus: Bent-Knee Troublemaker / 370
Peroneal Group: Peroneus Longus, Peroneus Brevis,
Plantaris: Jogger's Heel / 372
and Peroneus Tertius-Weak Ankle Muscles / 298
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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 Neuromuscular therapy has many broad applications in
point release. today's health care setting. It is used to treat people who suffer
Neuromuscular therapy techniques, along with a thorough from acute or chronic pain stemming from various injuries, such
structural evaluation, are needed to understand and treat the causa 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, Repetitive strain injuries, such as epicondylitis, carpal tun
tendon, and ligaments. It is also used to lengthen chronically short nel syndrome, etc.
ened muscles and balance muscle groups, especially when working Accumulative trauma injuries, such as temporomandibular
with people suffering from postural dysfunction or distortion, such joint dysfunction
as internal rotation of a shoulder girdle or scoliosis. Skeletal problems, such as spinal disc herniation
Thus, being trained in this therapy will allow a massage thera
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 PART I NEUROMUSCULAR THERAPY BASICS

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
causes the most wear and tear on the muscle tissue in our
HOW ITWORKS
bodies. If the client is experiencing pain as the sensation of
In neuromuscular therapy, therapists first assess the body's 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
are used. The technique approach in this text is an integration of sev
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:
pathologicall y shortened muscles. A concentric contraction Health history intake, evaluation, and assessment skills
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 Myofascial release and other lengthening techniques
cer technique is used to deactivate the trigger points formed
Passive stretches, muscle energy technique, and active
in the soft tissues (Fig. 1-1). Once a client is able, practi
stretching
tioners add active stretching to the treatment schedule.
Postural stress analysis
This helps the client to increase range of motion, or the
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
function. Lief and Chaitow, also trained in osteopathy and
FIGURE '-1 Horse receiving neuromuscular therapy. Even horses
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 know this information along with fiber direction of each
muscle in both theory and practice. That is, the therapist
As with any type or style of bodywork, the therapist's intent
should not only be able to cite attachments but should also
is important. With the proper intent, the therapist's energy
find them on the body and palpate them. The therapist
may actually help make the work more dynamic. This, along
must also have an understanding of nerve reflexes and
with choosing the correct approach for the area of the body
nerve physiology to be effective when using neuromuscu
being worked, should be given serious consideration.
lar therapy, as the nervous system plays a central role in
Historically, neuromuscular therapy involves a thorough
producing and perpetuating chronic pain.
and systematic examination of the muscles and other soft
tissues to isolate and identify "noxious" (harmful or painful) "If you really want to utilize your intuition, know your anatomy!"

points and then treat these tissues with various methods. An -Paul St.John
essential theoretical component to the approach is that the
Along with anatomic precision comes a much more com
practitioner is working directly and therapeutically with the
prehensive style of bodywork that invites one's intuition to
neuromuscular system, function of which is adversely
come into play. To be able to use intuition, there must be a
affected in the establishment of chronic myofascial pain.
core body of knowledge to draw on. A neuromuscular thera
The goals and therapeutic intent of neuromuscular ther
pist armed with precise anatomical and kinesiological
apy are as follows:
knowledge, along with an understanding of the theory and
Identify and isolate tissue irregularities related to
practice of neuromuscular therapy, will be able to use any
chronic myofascial pain, perhaps mapping these on a
intuitional responses he comes across when reading over a
body chart for future reference
client's health history form and assessment information and/
Restore local tissue circulation and reduce ischemia
or when actually working with the client's soft tissues.
local and temporary deficiency of blood supply-so
Without the core body of knowledge, the intuition has no
that the tissues there will begin to heal
way of producing information.
Reduce hype r tonicity-excess muscular tonus-and
This is a faSCinating subject that takes interest or passion,
spasm to regain integrity
study, practical use, and time to master. You are encouraged
Reduce soft tissue pain
to continue to study anatomy through all available means.
Reduce and eliminate noxious or excessive nerve stim
Being able to palpate and work at an exact attachment site
ulation and normalize reflex activity of the neuromus
of any muscle is crucial to the success of this work.
cular system
Reduce and eliminate trigger points
Analysis and Kinesiology
Restore normal range of motion to affected muscles
The therapist also needs to develop an overall orientation to
Release related adhesions or fascial binding and
stress and trigger points with respect to the interrelatedness of
lengthen chronically shortened muscles, fascia, and
the body's structure and position. An understanding of struc
other soft tissue
tural kinesiology is a must here. Body reading, postural stress
Identify and reduce or eliminate the perpetuating fac
analysis, and an examination of the client's everyday use of his
tors that continue to aggravate the trigger points and
or her body must become a part of a therapist's repertoire to
chronic pain patterns
reduce and eliminate structurally based soft tissue problems.

KNOWLEDGE AND TO O LSREQUIRED 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 As with many forms of massage, an effective lubricant is
of this work. needed. Small amounts of lubrication-using gel, oil, lotion,
or cream-are required at certain times during each session' to
Anatomy 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 recovery rather than expecting us to do it all for him.
with rubber or plastic tips that can be used to apply pressure into
For a client to recover and stay healthy, he must take on
the tissues.
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,
Client-Therapist Communication
when using any myofascial release techniques during a ses
To succeed in this vital work and to encourage participation
sion, begin with them so they can be done before lubricating
. from the client, you must establish effective, two-way com
for best effectiveness.
munication with the client. Specifically, during the first ses
In addition, pressure bars can be an invaluable asset in
sion, communicate with the client to determine the extent of
performing this modality. Pressure bars are wooden tools
ischemia in tissues, find the location and referred zones of trig
with rubber or plastic tips that can be used to apply pressure
ger points, and determine the ability of the tissues to release
into the tissues. One such tool, a TBar with a beveled rub
spasms and respond to the therapy. This communication can
ber tip, is used in routines presented in this book (Fig. 1-3).
be accomplished by asking the client the following three ques
Pressure bars are particularly useful to reduce strain on the
tions and listening carefully to his or her responses.
thumbs in doing extensive amounts of therapy, such as six to
eight sessions per day. When using a pressure bar, be sure to 1. Where is it tender or sensitive to my touch? Tlssues
hold it in a stable manner. With enough practice, the pres that are in a hypercontracted state are more tender

sure bar will become a natural extension of the hand. than that of healthy, flexible tissues. In questioning the

Another tool, called "Thumby," may be used to apply client about this, be careful not to use words that may

effleurage, friction, and trigger point pressure. It is also an have a negative connotation, such as "painful" or "hurt

excellent tool for a client to use at home for trigger point ing." Use more positive terms when referring to tissues,

work. This is a device made of silicone and, like a pressure such as "tender" or "sensitive," so that the client does

bar, can help reduce the strain on hands and thumbs, not associate your work with causing pain. Furthermore,

in particular. 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
RElATING TO THE CLIENT 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 PRECAUTIONS


sensation may be something other than pain. Without
Precautions must always be taken when working with a cli
that knowledge, a client might not relate to the thera
ent. This helps us keep our work safe for the client to receive.
pist certain sensations that may be coming from trig
Some precautions are very general and are used with any
ger points and the work you are doing with them.
massage work, whereas others are quite specific to an area.
Often when discussing trigger points, therapists,
These precautions include, but are not limited to, things
teachers, and authors call the referral sensation a
such as being sure the client does not have an unstable heart
referral pain only. When this is the case, some may
condition, untreated high blood pressure, brittle diabetes
not understand that pain is only one of several sensa
(especially when working on legs), varicosities, bruises, phle
tions that can occur because of trigger points.
bitis, broken bones, inflammation, and sunburn. Fears of
3. Do you feel a release or decrease in discomfort as I
being injured during bodywork need to be considered, along
press on this area? Ask this question as you are pressing
with restricted range of motion, very recent surgery, an
and holding a trigger point for 10 or more seconds. If you
upcoming sports event within the next 5 days, or degenera
are using the numbered scale, as described above, have
tive arthritis, pregnancy, and disc herniation.
the client rate the level of discomfort from moment to
Precautions regarding the performance of this work
moment to indicate any changes. Some therapists, how
include being sure that the referral patterns, pain, and trigger
ever, find this method distracting to clients-possibly
points you are treating actually lend themselves to neuromus
causing them to focus more on the discomfort itself than
cular therapy. A client demonstrating signs of swelling,
on the release-and simply ask clients to let them know
discoloration, or neurological symptoms should be referred
when the discomfort changes or lessens. Try both systems
to the appropriate health care provider.
to see which works best for you.

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 C. Good jokes, problems with coworkers, and family
issues
1. Describe neuromuscular therapy.
D. All of the above
2. List at least three of the goals and therapeutic intents of 10. Which types of injuries may be treated using neuromus
neuromuscular therapy. cular therapy?

3. Regarding the approach for neuromuscular therapy, list 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
D. Inflammation and open wounds
4. Name three techniques that are used to help locate
chronically shortened muscles and trigger points. True/False

5. Neuromuscular therapy is a specialized technique. 11. The techniques we use to assess and locate chronically
Which systems of the body does it tend to balance? shortened muscles and trigger points arc effleurage,
petrissage, and friction.
Multiple Choice Questions

6. What is necessary to apply neuromuscular therapy


12. Paul St. John was the first person to discover and
develop neuromuscular therapy in Europe.
effectively and with confidence?
A. Palpatory artistry and good luck 13. The term acute usually refers to an injury of recent
B. Preci e and thorough knowledge of anatomy onset.
C. A medical degree
14. We u e very small amounts of lubrication when treat
D. Really strong hands ing with neuromuscular therapy so that we can use

7. Who are known as the pioneers of trigger point therapy friction to more effectively stimulate the nerve endings

and myofascial pain? in skin.

A. Raymond Nimmo and James Vannerson 15. It is not necessary to have an understanding of struc
B. Stanley Lief and Boris Chaitow tural kinesiology when using neuromuscular therapy.
C. Peter Lief and Leon Chaitow
Matching
D. Janet Travell and David Simons
a. Pressure bars d. Range of motion
8. In communicating with clients, many therapists like to
b. Postural dysfunction e. Referral sensation
use which of the following to evaluate the client's dis
c. Concentric contraction f. Eccentric contraction
comfort level and the effectiveness of trigger point
release? 16. What one feels at a distance from an active trigger

A. A verbal discomfort scale from 1 to 10 point?

B. A stethoscope 17. Internal rotation of a shoulder girdle and scoliosis are


C. A medical reflex hammer examples of what?
D. Needles
18. Name a wooden tool with various rubber or plastic tips.
9. When establishing communication with the client, what
19. A type of contraction in which the muscle shortens in
three areas are important to discuss with the client?
response to tension.
A. Codependency, delinquency, and stress levels
B. The extent of ischemia, location of trigger points 20. Name the term used for the available movement at a
and referrals, and whether the tissues are releasing/ given joint?

responding to the work


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 TRIGGER POINTS


first have an understanding of the underlying physiology of the
neuromuscular system. That is, you need to know on a physio Daily activity, along with its corresponding stress to muscle
logical level what causes pain and trigger points and how they tissue, is our primary source of postural dysfunction and,
may be effectively treated. Specifically, this chapter introduces hence, trigger points. Trigger poihts can develop in any of
stress factors, along with the physiology involved with trigger our 200 pairs of skeletal muscles, which are responsible for
points and referrals. It then presents rehabilitation and, finally, a almost 50% of body weight. In this section, we will briefly
discussion of the laws of physiology. 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


A
Trigger Point Complex
interaction of trigger points with the nervous system, and
Nodule
trigger point activation.

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 B
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.
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:
Anatomy of a Trigger Point
Lippincott Williams & Wilkins, 1999. Trovel! & Simons' Myofascial Pain
A trigger point is a relatively small hard lump typically ond Dysfunction: The Trigger Point Manual; vol 1. p. 70, Fig. 2.25).

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 These muscle fibers containing contraction knots are
muscular nodule, or the trigger point. When there is a trig clearly under increased tension at the knot itself and beyond.
ger point present, there is intense contractile activity in the Part A of Figure 2-1 indicates that this sustained tension
absence of nerve excitation. This is similar to a muscle could produce local mechanical overload of the connective
cramp but will be a small, circumscribed area within the tissue attachment structures in the vicinity where the taut
muscle rather than the entire muscle. There is usually not band fibers attach. This type of distress to soft tissue would
any inflammation present, yet Travell and Simons cite stud most likely induce the release of sensitizing agents to local
ies that seem to indicate there may be ischemia present. See nociceptors, producing local tenderness and the characteris
Figure 2-1 for further information. tics of a trigger point.
In Figure 2-1, we see a trigger point complex. This is show
ing contraction knots that most likely make trigger points feel Characteristics of Trigger Points
nodular and cause a taut band within a muscle. This figure A trigger point in a muscle prevents the muscle from being
presents an explanation of the palpable nodules and the taut able to stretch to its full range because of a sensation, usually
bands associated with trigger points. P art B illustrates three pain. It also restricts the muscle's strength and endurance.
single contraction knots within normal muscle fibers, show This restriction of stretch range along with a palpable
ing that beyond the thickened segment of contractured mus increase in the muscle's tension is usually more severe in
cle fiber at the knot, the muscle fiber becomes quite thinned, more active trigger points. An active trigger point, accord
consisting of stretched sarcomeres in compensation for the ing to Travell and Simons, is identified when a client can
contractured ones in the knot. The upper right portion of part recognize the pain or other sensation that is induced by
.
B shows contraction knots separated by empty sarcolemma. applying pressure to the trigger point.
According to Travell and Simons, this may represent one of The therapist can gently apply transverse friction across
the first irreversible complications that result from the con a superficial muscle to feel the nodule at the trigger point as
tinued presence of the contraction knot. 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 The myosin filament heads are actually a form of the
palpable signs will become less and, at times, disappear. enzyme adenosine triphosphatase (ATP) that contacts and
This nodule within the muscle will be extremely sensi interacts with actin to be able to produce a contractile force.
tive when palpated. A therapist using the correct pressure to H observed under a microscope, these appear as cross bridges
this nodule can markedly reduce this pain response. between the actin and myosin filaments. It takes ionized
Most likely there will be limited range of motion when calcium to trigger the interaction between the filaments,
an active trigger point is present. If a therapist attempts a and the ATP provides the energy. With each cycle, the ATP
passive stretch beyond this limit, there will be severe pain releases a myosin head from the actin and then immediately
present due to muscle fibers that are under substantial gets ready for another cycle. The presence of calcium is
increase of tension at its resting length. This limitation will what triggers another cycle. It takes many of these cycles to
not be so great during active movement due to reciprocal produce what Travel! and Simons call a "rowing motion, "
inhibition. Range of motion will return to normal upon which is required of many myosin heads o f many filaments
inactivation of the trigger point and normalization of the to accomplish one smooth twitch contraction.
taut band. According to Travell and Simons, some muscles In the presence of both free calcium and ATP, the actin
demonstrate a more marked limitation due to trigger points and myosin continue to interact, using energy and force to
than do others. For example, subscapularis is likely to be far shorten the sarcomere. This interaction cannot happen if
more limited by trigger points than would latissimus dorsi. the sarcomeres are lengthened until no overlapping remains
Travell and Simons state that when a client takes an between the actin and myosin heads, in other words, when
affected muscle into a strong isometric contraction, he will the muscle is being stretched. This is what is beginning to
feel pain, and the pain felt will be more marked when the happen in the lower portion of Figure 2-2. Each sarcomere
contraction is done when the muscle is in a shortened of a given muscle can generate maximum force only in the
position. midrange of its length, but it can expend energy in a fully
Regarding weakness in an affected muscle, Travell and shortened position trying to shorten further.
Simons discuss electromyographic (EMG) studies that indi It is the absence of free calcium that stops the contracti Ie
cate that muscles with active trigger points start out being activity of the sarcomeres. 1n the absence of ATP, the myosin
fatigued. These muscles will fatigue more rapidly and become heads remain firmly attached and the muscle becomes stiff.
exhausted sooner than unaffected muscles.
Motor Units
Muscle Structure and Contractile Mechanism According to Travell and Simons, motor units are the final
To understand trigger points, it is important to understand common pathway through which the central nervous sys
various points of basic muscle structure and function. Often tem controls voluntary muscular activity. Figure 2-3 illus
this information is not emphasized in detail during an initial trates a motor unit consisting of a cell body of a motor
massage therapy training program. neuron in the anterior horn of the spinal cord, its axon
Striated, or skeletal, muscle is a grouping of fascicles with that is passing through the motor nerve to enter the mus
each being a bundle of many muscle fibers. The upper por cle at its branching into fibers, and the motor end plates
tion of Figure 2-2 shows the muscle bundle broken down. where each nerve branch terminates on one muscle fiber
Each fiber, or muscle cell, is a grouping of thousands of or cell. The motor unit contains all of those muscle fibers
myofibrils in most skeletal muscles. A myofibril is made up innervated by one motor neuron. So, we could say that a
of a chain of sarcomeres connected continuously, end to motor unit includes one motor neuron and all of the mus
end. The basic contractile portion of skeletal muscle is the cle fibers that it supplies. One muscle fiber normally
sarcomere. The sarcomeres are connected to each other by receives its nerve supply from only one motor endplate and
Z lines, which are like links of a chain. Each sarcomere has therefore only one motor neuron. The motor neuron deter
many filaments, which consist of actin and myosin mole mines the fiber type of all of the muscle fibers that it sup
cules interacting ro produce a contractile force. The middle plies. In postural as well as in extremity muscles, one motor
portion of Figure 2-2 shows a sarcomere in rest length with unit supplies between 3 00 and 1 500 muscle fibers. The
complete overlap of actin and myosin filaments during max smaller the number of fibers that are controlled by an incli
imum contractile force. When in maximum contraction, vidual motor neuron, the finer the muscle control in that
the myosin molecules push against the Z line to block fur muscle will be.
ther contraction. The lowest portion of Figure 2-2 shows an When the cell body of a motor neuron initiates an action
almost fully stretched sarcomere with incomplete overlap of potential, the potential propagates along the nerve fiber or
actin and myosin molecules. axon to the specialized nerve terminal that helps to form the
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 Sarcomere I

Ca+ +-, Zline_


----, " " / / / ""-

;;
/ / / " " "-

I A band I
_I band-----l 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 The Motor Endplate


fiber. On arrival at the nerve terminus, the electrical action In terms of what actually causes trigger points on a physio
potential is relayed chemically across the synaptic cleft of the logical level, it seems that the motor endplate is central.
neuromuscular junction to the postjunctional membrane of Research done by Travell and Simons indicates that spikes in
the muscle fiber. This message is now an action potential electrical activity, along with spontaneous electrical activity,
again that propagates in both directions to the ends of the found in trigger points arise from motor endplates, which are
muscle fiber, causing the fiber to contract. It is the firing of all plates ending where a branch of the axon or a motor neuron
the muscle fibers innervated by one neuron at the same time makes synaptic contact with a striated muscle fiber.
that produces a motor unit action potential. To summarize, to contract a muscle fiber must be stimu
Interestingly, the diameter of one motor unit in the lated by nerve impulses. These nerve impulses are carried
biceps brachii muscle can vary from 2 to 15 mm. This gives from the brain or the spinal cord to a muscle fiber by axons.
space for the intermingling of the fibers of approximately 15 Axons are part of a motor neuron. Motor neurons are action
to 30 motor units. According to Travell and Simons, both causing neurons; that is, their impulses produce action in
EMG and glycogen depletion studies show that the density target cells. Each muscle fiber is innervated and controlled
of muscle fibers supplied by one neuron is greater in the by a motor neuron. This is considered to be neuromuscular
center of the motor unit than toward its periphery. interaction.
C H A P TER 2 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
---f---:i-- Anterior horn
onstrate by way of EMG studies that neuropathic changes
are significantly related to trigger points in the paraspinal
Cell body of motor neuron
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
Muscle nerve 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
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.
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. The nerve terminal responds by opening calcium chan
Baltimore: Lippincott Williams & Wilkins, 1999. Travell & Simons' nels, which allow ionized calcium to move from the synaptic
Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1. p. 48, cleft into the nerve terminal. The channels are located on
Fig. 2.7).
both sides of the specialized portion of the nerve membrane.
When many packages of ACh are released, this quickly
A motor neuron along with the muscle fibers to which overwhelms the chemical barrier in the synaptic cleft. Quite
it is attached form a motor unit. A muscle fiber is a bit of the ACh then crosses the synaptic cleft, reaching
attached to only one motor neuron; a single motor neu the postjunctional membrane of the muscle fiber, where the
ron can innervate from 3 to 2,000 muscle fibers. A motor ACh receptors are located. The chemical barrier decomposes
endplate is where each axon attaches to and innervates any remaining ACh, limiting its time of action. The synapse
muscle fiber. can now respond quickly to another action potential.
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. ."""""!'!"I-P'!"!"'!Il-.-J. / Synaptic cleft
(cholinesterase)
Understanding the location of motor endplates is very

important when it comes to management of trigger points, Acetylcholine


according to Travell and Simons. They claim that it appears receptors

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. FIGURE 2-4 Cross section of a neuromuscular junction. (Reprinted
with permission from Simons D G, Travell J G, Simons LS. Upper Half of
Endplates in almost all skeletal muscles are located near the
Body. 2nd ed. Baltimore: Lippincott Williams & Wilkins, 1999. Travell &
middle of each fiber, midway between its attachments, or Simons'Myofascial Pain and Dysfunction: The Trigger Point Manual; vol 1.
within muscle bellies. A study done by Coers and Woole 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 Sensation from an active trigger point can cause a person to
and Simons, requires a separate book to adequately cover it. be aware of the dysfunction it causes. On the other hand,
What follows, then, is a brief summary. sensation and/or dysfunction from latent trigger points may
There are several substances that can sensitize muscle noci be overlooked by a person experiencing them. This person
ceptors. These would be bradykinin, E-type prostaglandin , will connect this sensation to a trigger point only if the trig
and 5-hydroxytryptamine. The combination of these has ger point is pressed upon.
the potential to sensitize. The release of prostaglandins by We must also look at key and satellite trigger points. A
noradrenalin may influence the trigger point mechanism at key trigger point is responsible for the activity of satellite
the endplate. Peripheral sensitization of nociceptors would be trigger points. One key trigger point may actually control
responsible for local tenderness to pressure, and most likely for more than one satellite trigger point. When inactivating a
referred pain. It is unknown which of these is responsible for key trigger point, one or more satellite trigger points may
this sensitizing of nociceptors at this time. Travel! and Simons also become inactive without any direct treatment. Table 2-1
state that this offers a fertile field of research investigation that shows key and satellite trigger points mostly based on
may involve drugs. a report by HongS about keys in the upper trapezius and
According to Travell and Simons, much of the suffering sternocleidomastoid muscles and their satellite trigger
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 TABLE 2-1 Muscles That Exhibit Corresponding Key
increasing rapidly. Specifically with regard to trigger points, Trigger Points and Satellite Trigger Points
they refer to Hong and Simons' study4 showing that the
MUjch s.wltbe'yJriggpoil1t i!tellite Tngg.PfJlojnt
length of treatment required for patients who had devel Sternocleidomastoid Temporalis
oped a trigger point in a pectoralis muscle because of whip Masseter
lash injury was directly related to the length of time Lateral pterygoid
between the accident and the beginning of trigger point Digastric
therapy. With longer initial delay, more treatments were Orbicularis oculi
required and the likelihood of complete symptom relief Frontalis

decreased. Masseter

Travell and Simons discuss that there are more recent stud
Upper trapezius Splenius capitis and cervicis
ies that show that different areas of the brain become activated
Semispinalis capitis
in response to an experimentally induced acute pain as com
Levator scapulae
pared with chronic neuropathic pain. Neuropathic pain shows
Rhomboid minor
by positron emission tomography a striking preferential acti
Occipitalis
vation of the right anterior cingulated cortex regardless of the
side of the painful mononeuropathy. Activation of this region Lower trapezius Upper trapezius
of the brain is associated with emotional distress and suffering.
Acute pain activates both motor and sensory portions of the Scalenes Serratus posterior superior
cortex, producing a cognitive and motor behavioral experi Pectoralis major and minor
ence rather than an emotional experience. Deltoid

Travel! and Simons state that these findings emphasize Extensor digitorum communis

the importance of the affective-motivational dimension in Extensor carpi radialis and ulnaris
Triceps brachii: long head
chronic ongoing neuropathic pain that is not involved in
acute pain. Chronic pain causes suffering that is processed
Infraspinatus Anterior deltoid
differently in the brain than is the experience of acute pain.
Biceps brachii
These neurophysiological facts emphasize the importance to
the patient and to the health care delivery system of pre
Latissimus dorsi Triceps brachii: long head
venting chronic pain and properly interpreting patients' Flexor carpi ulnaris
descriptions and behavior. Newly activated trigger points
that are poorly identified and poorly managed can become a Reprinted with permission from Hong Cl. Considerations and recommendations regarding myofascial
major unnecessary cause of expensive, misery-producing trigger paint injection. J Musculoskel Pain 7994;2(1):29-59.

chronic pain.
C H A P TE R 2 / NEU RO M U S C UL A R P HY SIO LO GY 17

Direct
-----
stimuli

-Acute overload
-Overwork fatigue
-Radiculopathy
-Gross trauma
visceral disease
-Joint dysfunction
-Emotional
Spinal distress

reference zone 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 Satellite trigger points are prone to develop in muscles
ralis muscles. that are within the reference zone of key trigger points, or
Key trigger points and satellite trigger points are always within the referral zone from a diseased visceral organ.
related, and there is usually a hierarchy. This hierarchy may Examples of this would be the area of referred pain from a
not be clear when it comes to which came first. What is clear heart attack, peptic ulcer, or renal colic. Perpetuating fac
is that certain trigger points in certain muscles are related to tors will increase overload stress that converts latent trigger
those in certain other muscles and that inactivating one of points to active trigger points.
these related trigger points may inactivate others. It may be With enough rest, along with the absence of perpetuat
easy to overlook a key trigger point when the client is com ing factors, an active trigger point may become latent on its
plaining of the sensation caused by a satellite trigger point. own. Pain and other sensations disappear but can reactivate
Travell and Simons cited a case study done by J. Whiteside with new stress. This, according to Travell and Simons, may
(personal communication, 1995). This is an interesting exam explain recurrent episodes of the same symptoms over a
ple of a three-step satellite trigger point system that had set period of time.
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 SOURCES OFTRIGGER POINTS
of time. She had undergone extensive dental work, includ AND REFERRALS
ing a root canal, without getting any relief. When pressure Although trigger points usually set up within somatic tis
was applied to a trigger point in her right lower trapezius, sue, they are actually capable of setting up within any of
she felt the dull ache in the upper trapezius, just as when she the body's soft tissues and visceral organs. Also, most trig
studied. Then, in response to pressure on the trigger point in ger points refer from the trigger point in somatic tissue into
the upper trapezius, she experienced a pain she had not pre a referral area also within somatic tissue in a specific pat
viously felt in the right temporal region. Then, in response tern. However, it is possible that a trigger point may refer
to pressure on the right temporalis, she felt the pain in the into any area of soft tissue or visceral organ in the body.
tooth that had been bothering her when studying. There are four distinct patterns of trigger points to referral
The inten ity and extent of the referred sensation areas:
depends on the degree of irritability of the trigger point, not 1. From somatic tissue into somatic tissue
on the size of the muscle. 2. From somatic tissue into a visceral organ
Trigger Point Activation 3 . From a visceral organ into somatic tissue
4. From a visceral organ into a visceral organ
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
LAWS OF PHYSIOLOGY
vated indirectly, as well, by other existing trigger points,
visceral disease, arthritic joints, joint dysfunctions, and As a massage therapist, and especially as a neuromuscular
emotional distress (Fig. 2-5). therapist, it will be important to develop a deep understanding
18 PART I / NEU R O M U S C UL A R T H E R A P Y B A S I C S

of what you are doing when working with others who are in create a release of spasm in deeper tissues of the body. The
pain. The laws of physiology will be an important tool to help second is why applying the skin rolling technique works to
explain what it is we do. It is necessary to learn these laws to help decrease tenderness in the deeper tissues.
be able to properly grasp the physiological principles on which
neuromuscular therapy is based. Arndt-SchultzLaw
Taber's Cyclopedic Medical Dictionary defines a law of
Weak stimuli activate physiological processes; very strong
physiology as a scientific principle that is uniformly true for
stimuli inhibit physiological responses. This law indicates
a whole class of natural physiological occurrences. A law is
that one should use a gentle approach, slower and less stim
defined as a uniform or constant fact or principle. The fol
ulating, if one's intent is to activate physiological responses.
lowing is a list of laws of physiology that correspond to
Using force to an area will be less effective than a gentle,
what we work with as a neuromuscular therapist.
slow approach to deeper work. If we gently stimulate the
tissue, it will heal faster than if it is ignored. A weak stimu
Law of Facilitation lus activates tissue healing and growth processes.
When an impulse has passed through a certain set of neu Trigger points usually give strong impulses that tend to
rons to the exclusion of others, it will tend to take the same tum off certain processes. An example of this is that a whip
course on future occasions, and each time it traverses this lash injury may actually affect the thyroid gland in a nega
path, the resistance will be less. The nervous system tends to tive way. So, to tum off a physiological response, one may
train itself to find the path of least resistance. When a neural use a strong stimulus. Thus, we could use deep transverse
pathway is activated, this is a habitual pattern produced by friction for several minutes to actually stop pain.
the body. This law explains why pain often occurs in the
same place. It does not take much to aggravate an old injury Pfluger's Laws
again. The patterns of pain will usually become a set pattern
Pfluger's laws are a series of laws that explain how a body can
in the body. With an area that was previously injured or
transition from acute pain to chronic pain. These describe the
compromised in some way, it is likely that it will take far less
progress from acute injury left untreated to chronic pain.
stimulation to reinjure. Also, it will take less time to heal
that area again. This seems to also explain why the more Law of Unilaterality
massage one receives, the easier it is to relax. If mild irritation is applied to one or more sensory nerves,
the movement will take place usually on one side only, on
Davis'Law the side that has been irritated. This law explains that at the
If muscle ends are brought closer together, the pull of tonus site of an injury, the body will respond to the tral.ma with
is increased, thereby shortening the muscle, which may cause the sensation of pain. Any light stimulation will remain
hypertrophy. If muscle ends are separated beyond normal, localized. If this person were to experience mild irritation, it
then tonus is lessened or lost, thereby weakening the muscle. may affect the localized site and stay on the side of the body
If soft tissue is placed under unremitting tension, the tissue that has been injured.
will elongate by adding more material. This law seems to
Law of Symmetry
indicate that if we do not use it, we will lose it. Imagine a
If the stimulation is sufficiently increased, motor reaction
muscle imbalance in which the set of hypertonic muscles has
is manifested not only by the irritated side but also in
chronically shortened and become hypertrophied while the
similar muscles on the opposite side of the body. This law
antagonist set of muscles has become chronically over
indicates that if the trauma to the body was great enough,
stretched and weakened. An example of this might be hyper
the opposite side of the body may also begin to feel pain.
tonic pectoralis major and minor muscles versus weakened,
If the therapist uses increasing levels of pressure on one
overstretched rhomboid major and minor muscles.
side only during treatment sessions, there will be a bilat
eral effect. If the unaffected side were also massaged, the
Hilton'sLaw
therapist would actually be addressing the injured side
A nerve trunk that supplies a joint also supplies both the muscles indirectly.
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 Law of Intensity
is coming from the skin, muscle, or joint. Stimulation of any of Reflex movements are more intense on the side of irritation
these areas will have an effect on all of the areas. This seems to and less intense on the opposite side. This law is similar to the
explain two things. The first is why working superficially may law of symmetry, but now the levels of pain have increased.
C H A P TER 2 / N E UR O M US CUL AR P H YS I O L O G Y 19

Law of Radiation traumatize this individual's body if gentleness and sensitiv


If me excitation continues to increase, it is propagated upward ity are not used. This person's body will react with a general
and reactions take place through centrifugal nerves coming ized contraction of the entire body.
from the cord segments higher up. This law indicates that
irritation will move up the spinal cord and create reactions in Wolff'sLaw
corresponding areas of the body that are innervated by those Every change in the form and the foundation of a bone, or
nerve segments impacted. Spasms and pain above the actual in its function alone, is followed by certain definite changes
site of injury are possible, which is called "muscle guarding. " In in its internal architecture and secondary alterations in its
this case, the body is trying to protect the site of injury. external conformation. This law is also known as the law of
bone transformation. It states that form follows function.
Law of Generalization
When the irritation becomes very intense, it is propagated Righting Reflexes
in the medulla oblongata, which becomes a focus from Righting reflexes are reflexes through various receptors in
which stimuli radiate to all parts of the cord, causing a gen the labyrinth, eyes, muscles, or skin that tend to bring the
eral contraction of all muscles of the body. When a client is body back to its normal position in space and which resist
in this state, the therapist must not use rough or intense any force acting to put it into an abnormal position. This law
massage techniques, as they can cause the person's body to speaks to why we can, for example, have a high shoulder on
go into muscular contractions or complete muscle guarding. one side of our body with a tilted occiput high on the other
This condition is sometimes called "general adaptation syn side of the body and still see levelly on a horizontal plane and
drome." When a client receives work that is too rough or not feel dizzy. The bones of the face and head will become
too deep too quickly, the body's experience is identical to asymmetrical to realign the eyes and ears to the horizon,
that of receiving trauma. In other words, the therapist can 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 system, and activation. The laws of physiology have been
principles involved with the physiology of neuromuscu presented to give you the information necessary to help
lar therapy. You should now have a basic understanding a client understand his or her condition and why it will
of trigger points and referrals, including their anatomy, be important for him or her to follow a specific plan to
biochemistry, sources, interaction with the nervous rehabilitate.
20 PART I / N E U R O M US C U L A R T H E R A P Y B A S I C S

REVI EW QU ESTIO N S

Short Answer Questions 9. Trigger points are activated by

1 . Describe a motor end plate. A. playing sports while not eating in a nutritious way.
B. uncaring massage therapists applying incorrect
2. What is a statin? pressure during a massage.
3. What does it take to aggravate a trigger point and its C. acute overload, overwork fatigue, direct impact
referral pattern? trauma, and radiculopathy.
D. only indirect methods.
4. What is a law of physiology?
10. Which are patterns of trigger points to referral areas ?
5. Name one law of physiology.
A. From somatic tissue into a visceral organ
Multiple Choice Questions B. From somatic tissue into somatic tissue
6. The following are characteristics of trigger points: C. From a visceral organ into somatic tissue
A. Referred pain, local tenderness upon palpation, D. All of the above
adhesion formation E. None of the above
B. Jump sign, local twitch response, nerve entrapment,
True/False
ischemia
C. Paresthesia, local twitch response, referred sensa 1 1 . There should be no concern regarding where one begins
tion, tight bands when it comes to rehabilitation after a soft tissue injury,
because everything helps.
D. Ischemia, referred sensation, hyperirritable upon
palpation 1 2. As a neuromuscular therapist, it is not important to
have an understanding of the laws of physiology to be
7. The difference between a latent and active trigger point
able to properly grasp the physiological principles of
is that
neuromuscular therapy.
A. a latent trigger point does not exhibit referred sen
sation patterns. 1 3. Trigger points usually set up within somatic tissue;
B. an active trigger point is usually in spasm. however, they are capable of setting up within any of
C. an active trigger point is clinically painful, whereas the body's soft tissues as well as in visceral organs.
a latent one is painful only upon palpation. 1 4 . Radiculopathy is the sensation referring from a trigger
D. a latent trigger point has not come out of the closet. point.
8. Which is a suggested reason for why the calcium 1 5 . Neuropathy is a disease of the bones.
switch will not tum off in the presence of a trigger
Matching
point?
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 c. Hilton's Law i. Law of Generalization
much calcium d. Arndt-Schultz Law j. Wolff's Law
D. The person is not taking the right kind of drugs e. Law of U nilaterality k. Righting Reflexes
f. Law of Symmetry
C H A PT E R 2 / N E U R O M U S C U LA R P H Y S I O LO G Y 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 rinth, eyes, muscles, or skin tend to bring the body i nto
the same course on future occasions, and each time it its normal position in space and that resist any force
traverses this path, the resistance will be less. 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
tation and less intense on the opposite side. nerves, the movement will take place usually on one
side only, on the side that has been irritated.
1 8. 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.

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. ] Musculoskel
Simons ' Myofascial Pain and Dysfunction: The Trigger Point Pain. 1 993 ; 1 ( 1 ):9- 1 3 1 .
Manual; vol 1 . 5 . Hong CZ. Considerations and recommenclations regard i ng
2 . Coers C, Woolf AL. The Innervation of M uscle , A Biopsy Study. myofascial trigger point injection. ] Musculoskel Pain. 1 994;
Oxford: Blackwell Scientific Publications, 1 9 59; Fig. 9- 1 5 . 2( 1 ) : 29-59.

3 . Gunn Cc. Prespondylosis and some pain syndromes following


denervation supersensitivity. Spine . 1 980; 5 ( 2 ) : 1 85 .
THIS PAGE INTENTIONALLY
LEFT BLANK
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


our breathing apparatus
Inert tissue: tissue remaining in a sluggish state until acted
upon by an outside force Perpetuating factor ' Something that prolongs the existence of
a condition, such as neck pain due to improper work station
IsometrIC contraction' a contraction in which a muscle
setup causing neck strain daily; also, a chronic condition or
increases its tension without shortening
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 Rotoscoliosis: rather than or along with a lateral curve of the
the locomotor structures of the body, especially the skeleton, spine, the vertebrae are rotated to one side or the other
joints, muscles, fascia, and other supporting structures such
Thoracic kyphosis: derived from Greek, meaning humpback or
as ligaments and cartilage
hunchback; an exaggeration or angulation of the normal
Orthopedic testing various tests developed to help in the posterior curve of the spine
assessment of disorders and injuries of the locomotor
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 well-rounded and comprehensive treatment plan.
as much of the client's lifestyle as possible. Some therapists like to 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
24 PA R T I / N E U RO M U S C U LAR THERAPY B A S I C S

HEALTH INFORMATION FORM Another statement you may wish to place in this final sec
tion is a statement of your policy regarding change or can
As a therapist, it is your responsibility to gain comprehen cellation of an appointment. The final thing for this form
sive health information from the client as the initial por would be a line for the client's signature and the date.
tion of your assessment of each client you treat. It is this There are many more things that could appear on such a
information that governs your analysis as well as your for form, however. It might be wise to check out others' health
mulation of a therapeutic regimen, or plan, for each client. information forms to see what you would like to include.
This health information gives you clues as to contraindica The part of the health information form that is especially
tions, for instance. It is always important to be safe in regard important in helping you locate trigger points and pain refer
to treatment of a client. This information from the client ral patterns in your client consists of simple sketches of the
will also help decide where to begin your work, how long it human body, both anterior and posterior views, on which
might take to complete the work, which techniques to clients may indicate the areas in which they feel discomfort
employ, and possibly where you might expect to find trigger by drawing. On questioning a client who has completed such
points. This information must be recorded in a health infor a drawing, you may darken in the areas that are worse while
mation form and include a date and the client's signature leaving the other areas of discomfort lighter. This will give
(Fig. 3-1 ) . Moreover, it is wise to include a disclaimer of you an "at-a-glance" summary of the information regarding
diagnosis and any policies regarding treatment and pay the person's pain. When compared with a good trigger point
ment in a statement in the form prior to the signature. This chart, this is very valuable information, as it may show the
way, there can be no miscommunication of either your referral areas from the trigger points this person is experienc
expectations of the client or your intent and treatment ing, helping you pinpoint the actual trigger points.
policy. Also, be sure to record any additional information regard
The health information form is a legal document and ing the quality of the client's discomfort gained from inter
must be filled out, dated, and signed by the client in ink. viewing the client, as discussed below, on the chart next to
Should you ever be involved in a lawsuit either as the the drawings. As the quality of discomfort changes, be sure
defendant or as a witness, it will be important to have writ to chart this information as well.
ten on the form further information gained by questioning You may go back over this history form again and again
the client. This should also be in ink with a date and your looking for more clues as to how to proceed with treatment.
signature. This information should be preceded by a state The more information that is provided on this form, the
ment such as "As stated by the client." This proves that you more clues there are to consider-it is that simple.
have done your job well while placing the responsibility for
this information on the client. It also demonstrates that the
INTERVIEWING THE CLIENT
therapist has gained informed consent from the client
before beginning treatment. Another critical component of the assessment process is to
You will most likely want several sections to this form. thoroughly interview the client regarding his or her health.
The first section will contain personal information, such as Clients will often not record key information about their
name, phone number, address, birth date, occupation, and health on a health information form, and in other cases infor
so on. Within this first section be sure to include space for mation that they do provide will require further explanation.
the client's physician and phone number. The second sec In interviewing the client, remember to be sensitive to
tion could include any present symptoms the client is pres the client's feelings regarding his or her pain and previous
ently experiencing; for this you might want to consider treatment. Be sure to actively listen to the client's responses
check boxes so the client does not have to write much. A to questions while maintaining eye contact. Gaining this
third section could have illustrations of bodies, both ante person's trust and confidence will be extremely important to
rior and posterior, with instructions to color in any area that the outcome of the course of treatment you decide upon. If
has difficulties. A fourth section might include information the client has no confidence in you or does not think you
about previous massage the client has had, any medications are competent, he or she will not return for more sessions
being taken and what the medications are taken for, and any and/or will not be compliant regarding home care.
previous injuries with the dates they happened. For the final Another tip regarding interviewing is to have a few refer
section, you might wish to include a disclaimer that massage ence books on anatomy and good, comprehensive trigger
therapists do no diagnosis or prescribing, nor do they perform point charts on hand. Using these references, you may be
spinal manipulation, and so on. Also consider including a able to show clients where the work must be done on them,
positive statement about the benefits of massage therapy. along with confirming their pain. Again, this goes toward
C H A PT E R 3 C L I ENT ASSESSMENT 25

Manual Therapist HEALTH INFORMATION


Patient Name _______ Date ________ _

Date of Injury ID#/DOB

A. Patient Information

Address ______________ ___ List Daily Activities Limited by Condition

City _______ State __ Zip _ _ __


Work ___________________

Phone: Horne
Work ______ Cell __ __ _ ___
Horne/Family _ _ __ _ _ _ _ __ _ ___
_

Employer ________________

Sleep/Self-care ___ _ _ _ _ __ _ _ __

Work Address _____________ _

Occupation ________________
Social/Recreational _____________

Emergency Contact __ __________

Phone: Horne ______________


_
List Self-Care Routines
Work ______ Cell ________ _

How do you reduce stress? ____ _ _ _ _

Primary Health Care Provider

Name _ _________________
Pain? __________________

Address _________________

City/State/Zip _____________
List current medications (include pain relievers
Phone: _______ Fax __ _ __ __ _ and herbal remedies) ____________

I give my massage therapist permission to


consult with my health care providers
regarding my health and treatment.
Comments ________________
Have you ever received massage therapy
Initials ______ Date _ _ _ _ __ __ before? ___ Frequency? ________

B. Current Health Information What are your goals for receiving massage

List Health Concerns Check all that apply therapy? ____ _ __ ___ ___ _ __

Primary __________________

D mild D moderate D disabling


D constant D intermittant
C. Health History
D symptoms i w/activity D J, w/activity
List and Explain. Include dates and treatment
D getting worse D getting better D no change
received.
treatment received _ ___________

Surgeries _________________

Secondary _ _______________

D mild D moderate D disabling


D constant D intermittant
D symptoms i w/activity D J, w/activity
D getting worse D getting better D no change Injuries _________________

treatment received _ __ _________

Additional _ _ __ __ _ _ _ _ _ _ ___

D mild D moderate D disabling


D constant D intermittant Major Illnesses
D symptoms i w/activity D J, w/activity
D getting worse D getting better D no change
treatment received _ _ __________

FIGURE 3-1 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.)
26 PA R T I / N E U ROMUSCULAR THERAPY BASICS

HEALTH INFORMATION page 2

Check All Current and Previous Conditions Please Explain

General Nervous System Allergies


current past comments current pas t comments current past comments
D D headaches _ _ _ __
D D head injuries, concussions D D scents, oils, lotions __

D D pain ______ _
D D detergents __ _ __

D D sleep disturbances D D dizziness, ringing in ears D D other ___ ____

Digestive /Elimination System


D D D loss of memory, confusion current past comments
D fatigue _____ _

D D infections ______
D D bowel problems __ __

D D numbness, tingling
D D fever
D D gas, bloating
_______

_ _ _ __

D D sinus
D D sCiatica, shooting pain D D bladder/kidney/prostrate
____ _ __

D D other _______

Skin Conditions D D chronic pain D D abdominal pain ____

current past comments D D other


D D depression ______ _

D D rashes
D D other Endocrine System
D D athlete's foot, warts __ current past comments
D D other D D thyroid ______

Respiratory, Cardiovascular
D D diabetes
current past comments
___ __ _

Muscles and Joints


current past comments D D heart disease Reproductive System
D D rheumatoid arthritis current past comments
D D pregnancy ______

D D blood clots
D D osteoarthritis
D D stroke D D painful, emotional menses
D D lymphadema
D D osteoporosis
D D high, low blood pressure D D fibrotic cysts
D D scoliosis
_____

D D broken bones Cancer /Tumors


D D irregular heart beat current past comments
D D spinal problems
D D benign _______

D D poor circulation D D malignant ______

D D disk problems
Habits
D D lupus D D swollen ankles
current past comments
D D TMJ,jaw pain D D varicose veins D D tobacco __ _ _ __

D D spasms, cramps D D chest pain, shortness of D D alcohol _ __ _ __

breath D D drugs __ _ _ _ __

D D sprains, strains D D asthma D D coffee, soda ______

D D tendonitis, bursitis Contract for Care


I promise to participate fully as a member of my health care team. I will make
sound choices regarding my treatment plan based on the information provided by
D D stiff or painful joints __ 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
D D weak or sore muscles 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
treatment.
D D neck, shoulder, arm pain
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 I am aware of and will
inform my practitioner of any changes in my health.

D D other Signature _______________ ____ Date _ ___

FIGURE 3-1 (Continued)


C H A PT E R 3 I CLIENT ASSESSMENT 27

Manual Therapist HEALTH REPORT


Patient Name ____ ________ ______ ____ __
_ Date _ _ __ _ __

Date of Injury 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 = pain or tenderness
S = joint or muscle stiffness
N = numbness or tingling

"' /
) \

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 _ ___ ______________ _______ _ Date _ _ ____ _

FIGURE 3-1 (Continued)


28 PA R T I I N E U R O M U S C U L A R T H E R AP Y B A S I C S

trust and informed consent. This too will be charted on the has been a negative experience, try to refocus this person on
history form by you. his current treatment so that he is feeling positive.
Two specific areas to cover when interviewing a client There will be quite a bit of information you can use due
are the cause of the client's pain and previous treatment that to his previous treatment, however. By finding out what
the client has undergone for the condition. worked and what did not work, you can more easily setup
your treatment plan while avoiding those things that pre
Cause of Pain viously did not work. This information also gives you fur
Of specific interest in this interview process is to learn more ther information regarding any contraindications that may
about the origination of the client's pain. For instance, a person be present.
may or may not write down how his or her pain originated, Another factor to consider here is the opportunity to
even though there is a portion of the health information form contact the client's other health care professionals to gain
that asks about the reason for making the appointment or even further information about his condition. You will most
about previous injuries. Whether the client has it written down, likely want to have a permission for medical information
it is imperative to ask many questions about injuries. It is impor form for the client to sign. Often this client has had various
tant to know about the injury or event that led this person to testing such as MRI, CAT scan, X-rays, and so on, amI you
the therapist as well as about all previous injuries. The therapist will be able to receive a copy of the reports from these tests.
must determine whether the pain is stemming from an acute These reports will often give you very valuable information
trauma, chronic overload, or some other source. regarding the client's condition. Should the client still be
Any or all previous injuries may have set up trigger points working with these other health care professionals, you will
that have remained latent until the event that brought the have the opportunity to work with them as a team, which
client to seek treatment caused them to become active. may lead to future referrals.
Again, it is imperative that you ask as many questions as you A series of questions about previous treatment will be
can think of. helpful to gain the information you will need. Here are some
Here are some sample questions: sample questions:
Have you sought medical attention for this problem
How exactly did this injury occur?
before coming here?
In what position did you land?
If so, what was the diagnosis and course of treatment?
How did it feel as you landed?
What was the outcome of the treatment?
How did it feel to get up?
Do you feel this diagnosis and/or treatment was com
Were you sore immediately after the accident, or only
prehensive and/or correct?
after a day or two?
How do you feel about your outcome from the previous
When did you first notice that you were experiencing
treatment?
the pain/discomfort?
What activities do you do on a daily basis?
What makes it feel better? Can you demonstrate that? ORTHOPEDIC TESTING
What makes it feel worse? Can you demonstrate that? Once you have an understanding of the client's health his
How does it feel right now? tory, current pain or discomfort, and previous treatment, it
may be helpful to put the client through a series of ortho
The goal of this questioning is to understand your client's pedic testing procedures. Orthopedic testing may also be
pain and discomfort as clearly as possible. To this end, try to referred to as manual muscle testing or evaluative muscle
imagine how this individual feels, possibly by putting your testing. There is an art to these tests. A therapist must be
body into the client's dysfunctional posture so you may very carefu l when handling an injured body part, for
experience a similar discomfort. This exercise may give you instance, being very gentle when positioning the person for
even more questions and insights. Again, be sure to write the test to avoid any pain or discomfort, being very careful
the answers to all questions down in ink with your initials and working slowly with a muscle that is either very weak or
and the date right on the health information form. fatigued, and also having the ability to give the right amount
of counter pressure to allow the client to give the optimal
Previous Treatment responding pressure.
Often, clients will have undergone medical diagnosis and There is also a science to these tests. The therapist must
treatment before seeking massage therapy. These experi be attentive to each detail that has the capacity to change
ences could have been either positive or negative. If there the test's accuracy and alter results. The tests will only be
CHAPTER 3 / CLIENT ASSESSMENT 29

useful if they are accurate. Accurate muscle testing must tests, although discrepancy between the types of tests should
include knowledge, skill, and experience by the therapist. be noted.
Orthopedic testing is a very important part of client intake,
Passive Testing
as it will give usable information regarding specific muscles and/
Passive testing provides information about passive struc
or joints to help us plan the course of treatment. This testing
tures, such as joints, bursas, or ligaments, also known as
can also be used at various times during the course of treatment
inert tissues. The client stays relaxed while the therapist
to help keep the treatment plan on track.
moves the joint in question in each direction. The effect of
There are many neuromuscular conditions that include
conscious control and muscular effort is eliminated; thus,
muscle weakness, muscle fatigue, and muscle imbalance;
this test separates the muscles from the passive structures.
orthopedic testing will give insight regarding these condi
The client should report whether pain is provoked.
tions. A therapist with extensive knowledge of muscle action
Keep in mind that even relatively small differences in
and joint range of motion will usually be able to perform well
range of motion, in conjunction with varying levels of
in regard to this testing. Keep in mind that our ultimate goal
pain, can be significant. For instance, 5 degrees of limita
with treatment is to restore and maintain good range of
tion of movement without pain could indicate a signifi
motion, good postural alignment, and muscle balance.
cantly different condition from full range of motion with
Be sure to document all findings of each test, as this
pain, in a given joint. Thus, it is important to be precise in
information will help you determine where to begin and
your assessment. Moreover, you may need to persuade a
what the exact course of treatment must be. Once you note
client to move through a painful arc to find out whether
that the client's condition is changing, these tests may be
the pain ceases at full range. The beginning of pain may
used again and again to measure improvement.
not correspond with the extreme range; for example, a
In fact, demonstrating improvements in range of motion
straight-leg raise may start to hurt at 45 degrees, but con
and level of discomfort the client is experiencing through
tinue to 90 degrees without increased discomfort. Thus,
repeated tests can be a significant psychological boost to the
the examiner must determine whether the appearance of
client. Having objective proof of improvement can moti
pain and the extreme of the range of motion are reached
vate the client to continue and help him or her heal com
together or separately.
pletely and as quickly as possible.
Each primary movement of the joint must be tested pas
As this text was not meant to teach orthopedic testing, it
sively to allow the emergence of a pattern, the relation
will be important that you take a course to learn these tests
between the degree of movement obtainable in all directions.
if this information was not included in your initial massage
This will distinguish capsular from noncapsular limitation of
therapy program.
movement. If there is pain upon this passive movement, most
Range of Motion Assessment likely the problem will be within a passive structure.
Be sure to refer back to your information on this type of
One type of orthopedic testing is range of motion assess
testing from your general therapeutic massage course. Again,
ment. Along with inflammation that stems from an injury
as this book is about performing neuromuscular therapy, it is
comes loss of function or range of motion. This loss of func
suggested that you take a class or perhaps purchase a hook
tion may begin simply in response to pain, but then may
for further study of these tests. The author's favorite refer
continue to develop because of scar tissue that is not prop
ence book for orthopedic testing is Muscles, Testing and
erly formed. The longer a person experiences loss of range of
Function with Posture and Pain, Fifth Edition, by Kendall,
motion, the greater the loss of range of motion becomes. In
McCreary, Provance, Rodgers, and Romani published by
time, a person will have no use of the area and will be in
Lippincott Williams & Wilkins.
danger of developing a compensatory injury.
First, however, you must have an understanding of the Active Testing
normal range of motion of each joint in question, so you Active testing will give you a sense of the involvement of
will know whether the test is positive. Table 3-1 lists the the injury-the seriousness of the injury. In this type of test
degree of motion each joint should be capable of. Range of ing, the client provides all of the effort to move a joint
motion refers to the number of degrees of motion that are through its range of motion. For example, an active test
present in a joint. might involve having a client begin to lift his arm out to the
These tests can be done actively, passively, or actively side and then above his head to show lateral shoulder move
against resistance, with the last one being more involved ment. If he must also move his shoulder along with the arm
with muscles that are painful and most likely involved in during the test, it will be obvious to the observer. Thus, in
the injury or dysfunction. It may be necessary to use all three this case, an active test is called for instead of a passive test,
30 PA R T I / N E U RO M U SC U LA R T H E RA P Y B A S I C S

TABLE 3-1 Range of Motion for Fundamental Movements

Nck 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
Outward rotation 90
Inward rotation 90
Hori zontal flexion 90
Hori zontal a bd uction 90

Mea1 Wrist
Flexion 90 Flexion 80 -90
Extension 0 Extension 90
Hyperextension 0-20 Hyperextension 80 -90
A bd uction 30 Ulnar flexion 35-45
Adduction 0 Radial flexion 20-25

Proximal lnterjthalangealJoint DistallMerphalal!!ll1aloint


Flexion 1 00-1 1 0 Flexion 200
Extension Extension 0

Knee tata[sal PhalangalJoint


Flexion 1 30-1 35 Flexion 20
Extension 0 Extension 0
Hyperextension 90
Ankle Abduction 1 5-20
Plantar flexion 50 -60 Adduction 0
Dorsi flexion 1 0 -20
J eal JQinJ{fooO
rroximallnterphalanl
Foot Flexion 50
Plantar flexion 50 -60 Extension 0
Dorsi flexion 1 0 -20
Inversion 40-45
Eversion 2 0 -2 5

Distal lnterpl)Miffilel al Joint (FooO


Abduction Flexion
Add uction Extension

, ,

which would not have revealed the restriction resulting ment for that particular joint. No movement takes place at
from injury. the joint; the only tension that alters is within the muscle
itself. The person is using the muscle and tendon but not
Active Against-Resistance Testing moving through space. Both the therapist and the client
The goal of resistive testing is to gain clear information on will push into each other using equal and opposite force, an
the state of each muscle group in question. The client con isometric contraction. An example of pushing into E;ach
tracts his muscles forcibly against resistance using enough other would be having the client lie supine with a leg lifted
strength to prevent all articular movement, or joint move to a 90-degree angle. The therapist provides support at the
ment, while the joint is held somewhere near mid-range. distal end of the anterior femur, just above the patella to be
Mid-range of motion is halfway through the arc of move- sure the client does not bend his knee during the test. With
CHAPTER 3 / CLIENT ASSESSMENT 31

the other hand, the therapist applies pressure to the poste see how well they align with the various anatomical
rior. calcaneus. Both the therapist and the client push into planes of the body.
each other using the exact same force. The leg will not When a person is off of his anatomical planes, stress is
move through space. If the client tells the therapist that he being placed on certain structures, chronically shortening
feels pain in a hamstring muscle, the test is positive. some muscles while overstretching their antagonists. Either
When muscles contract, they squeeze together the of these extremes will create a condition that allows trigger
opposed cartilaginous material of the joint they span. points to occur, but mostly the trigger points will occur
Cartilage contains no nerves, so this compression is pain within the chronically shortened muscle fibers while the
less. This increased approximation of the bone ends relaxes overstretched fibers feel tight and painful. The overstretched
ligaments and joint capsules. Thus, if the joint is arthritic, muscles are continuously microtearing, causing a feeling of
the resisted movements are found painless. So, this type of discomfort. For example, in an anterior pelvic tilt, the pelvis
test tells us about the muscles, not the joint. This remains is in too much flexion, causing overstretching of the ham
so, surprisingly enough, when a tendon blends with a joint strings and shortening of the quadriceps-especially rectus
capsule, such as in the case of the supraspinatus. femoris, tensor fascia latae, and iliopsoas. The client will
A resisted movement may provoke pain or demonstrate probably complain of pain and stiffness in his hamstrings;
weakness, occasionally both. If this test elicits a pain this will be due to the microtearing. There may be reports of
response, it will help you localize and identify an injury and/ pain or other sensation in the knee and thigh area, low
or weakness in a muscle or muscle group. You must pay close back, and hips. If so, this will most likely be referral from
attention to where you stand and how you apply your hands. trigger points within the shortened muscles.
When strong muscles are tested, minor weakness may not be The therapist can treat the shortened muscles specifically
detected unless your hands are well placed for resistance and using neuromuscular therapy to help lengthen the muscle
counter pressure and body mechanics are proper. It is due to fibers and alleviate the referral issue caused by the trigger
neglect of these simple practices that muscle weakness is so points. The therapist can also help the overstretched muscle
often overlooked. If in doubt, you may have to encourage fibers to unlock and return to their normal resting length
the client to push fairly hard to arrive at a true assessment. with some specific work there.
Below are some basic principles of resistive testing: As a neuromuscular therapist, you will see client who
The first time working with an individual, use very have slight postural distortion along with those who have
gentle force. If the client tolerates it well, next have her whole body dysfunction-the "vertically ill" (Fig. 3-2).
push a bit harder and then possibly with all her might According to Bob King, "when looking at this person, it
Stabilize the joint properly when using this type of is easy to see how they can be compressed, repressed,
testing. For example, stabilize above the wrist at the oppressed, and depressed." The following is a list of some of
styloid processes when testing the wrist. This allows for the postural findings you will encounter during orthopedic
only the movement of the wrist without having to assessment in clients who have whole body dysfunction:
move the forearm Flattening of the arch of the feet

Always begin with the joint at neutral, if possible. If Tibial torsion with improper patellar tracking (the
the client is stronger than you are, try beginning in a patella is not riding properly within the condylar
slight stretch position. This will increase the strain on groove of the femur)
the structure Anterior and lateral pelvic tilting (the pelvis has both
If the client is very strong and can overpower you, too much flexion and is high on one side while being
place him as well as yourself into positions to give you low on the other)
the mechanical advantage Functional leg length differences
Always give equal and opposite force to the effort of Abdominal protrusion (the belly appears to be large,
the client, so there is no movement through space tak such as having a "beer belly")
ing place Diaphragmatic compression (this person has a "banana
back," with rounded shoulders, and his lower rib cage
Postural Assessment has dropped, placing pressure on the diaphragm) and
Another type of orthopedic testing of the body that is intercostal adhesions (the intercostals muscles are
important for neuromuscular therapy is postural assess being squeezed with this posture and the layers are now
ment. This type of testing determines the extent of a glued to each other)
client's postural dysfunction and how it is impacting this Respiratory dysfunction (with the above posture
person. This involves a comparison of bony landmarks to of "banana back" and diaphragmatic compression
32 PA R T I / 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


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:
FIGURE 3-2 "The vertically i l l." Pubis drops anteriorly

Coccyx elevates posteriorly


Excessive lumbar lordosis
Distended abdominal contents
Weakened lower abdominals
CHAPTER 3 CLI ENT ASSESSMENT 33

) ( i 1

A B c D

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.

E F

FIGURE 3-3 Postural d i stortion of the pelv i s.

FIGURE 3-4 Comparing ASIS versus PSIS for anterior pelvic ti l t .


34 PA R T I N E U RO M U SC U LA R T H E R A PY BASICS

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 nerve impingement
Pelvic rotation causes L5 to rotate toward the low hip
People who commonly exhibit an anterior pelvic tilt side (rotoscoliosis)
include the following:
Lumbar vertebrae above LS compensate by laterally
Pregnant women
flexing ( scoliosis)
People who are obese or have a "beer belly"
Disc compression at the level of L4-LS and LS-S 1
Gymnasts, dancers, and skaters
Hyperpronated foot more obvious on low hip side
Hypermobile individuals
Knee pain
Children ages 3 to 8 (at this age it is normal )
Tho e who wear high-heeled shoes People who commonly exhibit a lateral pelvic tilt include
Hyperkyphotic individuals the following:
Mothers of young children who carry them on their
Lateral Pelvic Tilt
hips or those who tend to carrying weight one-sided
Lateral pelvic tilt is a condition in which a person has a high
Those with scoliosis
hip on one side and a low hip on the other side. To check for
Those with a long torso and short humerus
this condition, compare the two sides of the pelvis at the
People with flat feet and/or Morton foot structure
iliac crests, the ASISs, and the PSISs. Upon comparison,
these three readings will confirm this condition ( Fig. 3 - 5 ) . Shoulder Asymmetry
If balanced, each of these three comparisons will b e level. The ideal position for a person's shoulders is for them to be
If not level, one side will be higher than the mher and the level when comparing the two acromions ( Fig. 3 - 6 ) .
postural findings will include the following: Simply looking a t the shoulders may give a false reading,
Body weight sways toward the h igh hip ( most obvi 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 will be certain postural findings that correspond to this pos
is uneven ture, such as the following:
Leg on the side of the high hip appears shorter when One shoulder presents higher than the other
the client is lying down and longer when standing The fingertips of one hand appear to be lower than the
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

FIGURE 3-5 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 CLI ENT ASSESSMENT 35

FIGURE 3-6 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 three-
dimensional 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 FIGURE 3-7 Diagram ofthoracic kyphosis.

Internal rotation of the humerus, scapular abduction


and elevation
Hand position anterior to the thigh w ith palms facing
posteriorly
36 PA R T I N E U RO M U SC U LA R T H E R A PY B A S I C S

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 interverte-
bral 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 1X
factors involved with these postures in the form of chronic 2X
resriratory disorders such as asthma. 3X

Forward Head Posture


FIGURE 3-8 Diagram of the weight of a 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 Anterior pelvic tilt affects the jaw anteriorly
the head is out of alignment in a forward position. Postural
Anterior fascia of the chest pulls into the hyoid area
findings associated with this condition are as follows:
Hyperextension of the atlantooccipital joint Postures that exhibit a forward head would be all
Imringement of occipital nerves descriptions of anterior pelvic tilt, lateral pelvic tilt, and
Chin poking out posture thoracic kyphosis. Forward head posture and thoracic
Stretch strain on the interspinous and supraspinous kyphosis perpetuate cervical hyperextension because of
ligaments the righting reflex.
Radiculopathy in the cervical region For each inch the head migrates forward from an ideal
Increased cervical curve squeezing discs with risk of position, the lower cervicals are compressed by one time the
herniation weight of the head, resulting in fatigued cervical extensor
muscles. The lumbar musculature must then work very hard
Cervical misalignment creates the possibility of arthritis
to maintain an erect posture (Fig. 3 - 8 ) .
Loss of range of motion increases the possibility
of fusion
A powerful fascial downward pull on the mandible PAL PATION
Mandible is pulled posteriorly and superiorly, forcing After performing range of motion testing and postural anal
the temporomandibular joint (TMJ ) forward ysis on your client to gain an understanding of the bigger
Clicking and pain in the TMJ picture, you will need to use palpation to fine tune your
Bruxism and/or malocclusion in effort to hold the jaw assessment. Palpation is examination of the skin and under
in its prorer place lying structures using one's hands. Palpation can be used
Lateral pelvic tilt affects the jaw laterally when assessing, warming, or treating a client. The palpation
C H A PT E R 3 / C L I E NT A S S E S S M E N T 37

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, FIGURE 3-9 Flat palpation. (Reprinted with permission from Simons
which a client feels but is still able to relax. This approach DG, Travell JG, Simons LS. Travel! & Simons' Myofascial Pain and
Dysfunction: The Trigger Point Manual. Vol. 1 : U pper Half of Body. 2nd
working in the zone of discomfort without crossing over into
ed. Balti more: Lippi ncott Williams & Wilkins, 1 999; p. 1 20, Fig. 3.7.)
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 Pincer Pal pation
enced as pain by another. Therefore, be sure to encourage Pincer palpation is the examination of a muscle or a trigger
and respond to clients' feedback regarding pain. point by holding the area in a pincer grasp between the
According to Travell and Simons, there are specific recom thumb and fingers. The therapist may actually roll the tissue
mended criteria for identifying active and latent trigger points. between the tips of the digits in order to detect any taut
1. Taut bands palpable in an accessible muscle bands of fibers, identify tender points in a muscle, and elicit
2. An exquisite spot of tenderness of a nodule in a taut a local twitch response (Fig. 3 - 1 0 ) . This technique will best
band of fiber work with a muscle that can be lifted off of the body, such as
3 . A spot of pain experienced by the client upon pressure the upper and sometimes middle trapezius, brachioradialis,
on the tender nodule and gastrocnemius, to name a few.
4. Compromised range of motion with painful limits of
full stretch Snapping Palpation
5 . Either visual or tactile identification of local twitch In snapping palpation, a fingertip is placed against the tense
response band of muscle at a right angle to the direction of the tight
6. Altered sensation, as with referrals, upon compression band. You then quickly press down while drawing the finger
of the tender nodule back in an effort to roll the underlying fibers under the fin
ger. This motion is quite similar to plucking a guitar string,
Three types of palpation are useful in assessing for trigger except that when "plucking" a muscle fiber, the contact
points. They are flat palpation, pincer palpation, and snap with the surface is maintained. If a tight band is snapped at
ping palpation.

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
FIGURE 3-1 0 Pincer palpation. Reprinted with permission from
nique for palpation can be used on muscles anywhere in the
Simons DG, Travell JG, Simons LS. Travel l & Simons' Myofascial Pain
body and will be quite effective when used on the larger and Dysfu nction:The Trigger Point Manual. Vol. 1 : Upper Half of Body.
muscles. 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. any remaining limb length inequality by adding correction
under the foot until the pelvis appears level. This should also
a trigger point, there should be a local twitch response ( Fig. level out the shoulders and straighten the spine.
3 - 1 1 ) . This technique will work well for almost anywhere In order to confirm accuracy of the correction, add a mil
in the body. 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
considered overcorrection. The cl ient will most likely
PREDISPOSING FACTORS
become aware immediately, as this will be an unfamiliar
In addition to the methods of assessment discussed thus far, 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 three-quarter length orthotics will place this person up on his
equacies. These predisposing factors include leg length dis toes and could end up leading to other pathologies setting in.
c repancy, short humerus, small hemipelvis, and foot
hyperpronation. S h ort H umerus
According to Travell and S imons, shortness of the upper
Leg Length Discrepancy arms in relation to torso height is a rarely recognized but
Leg length discrepancy, also known as lower l imb length not uncommon source of muscle strain and perpetuation of
inequality, is often an important perpetuating factor. 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 ating trigger points in upper trapezius and levator scapulae
by the length d iscrepancy as well as to maintaining a trigger muscles. Travell and Simons mention that this body struc
point-free body. ture is very common among Native Americans, but not
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 upper l imb is short in proportion to the torso, when 't his
correlation between the presence of leg length discrepancies person is standing, the elbows do not reach the i liac crests;
and back pain. As Travell and Simons note, one side of a when this person is sitting, the elbows fail to reach the
person is often slightly smaller than the other. One lower armrests of a typical chair.
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 shorter and the second is longer than "normal," it is the
on a chronic basis. This person must always hold her shoul 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 pensation, most people mod ify their gait by placing more
remain in a hypercontracted state. 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
Small Hemipelvis pattern. Usually, the foot is sl ightly toed outward during
This is a condition in which the pelvis is smaller on one heel strike as well as during stance phase of the gait. The
side than the other. The sacrum will most l ikely be t ilted, ankle then excessively pro nates ( rocks inward ) during
producing a compensatory scoliosis during both standing 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 Trigger points may also set up in the posterior gluteus
upon his ischial tuberosities on a straight, firm surface while minimus, causing referral sensat ion to the posterior th igh
you palpate the iliac crests posteriorly. If one side is smaller, and ca lf. Travel! and S i mons c l a i m these symptoms
the crests will not be even. Refer this client to a chiroprac m i m ic radicu lopathy, which explains why so often there
tor or possibly a physiatrist or osteopath for further assess is a wrong d iagnosis determined .
ment and treatment. To assess a client for this cond ition, have him stand bare
With the muscular effects being similar to those of leg 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
PERPETUATING FACTORS
syndrome, or Morton foot syndrome. According to Travell
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 Part of your role as therapist includes helping cl ients
that bend in medially. identify their perpetuating factors and manage and reduce
Travell and Simons discuss this condition because prob stress in their l ife. Determining client's stress factors requires
lems with the foot can produce asymmetries in the lower limb 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,
use syndromes is biomechanics. Biomechanics is the study as one must have the head and neck turned to one side for
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. Another factor here may be how the person rests while at
Biomechanical overuse syndromes and repe t i t i v e 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 N utrition
day working on a computer using a mouse. A therapist A client's nutrition can also be a stress factor. Note that
must look at the factors stressing this person's body from a although nutrit ion-related concerns are d iscussed here to
biomechanical point of v iew. How is this repetitive action 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
better biomechan ics ? or "prescribing."
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 ments as well as eating habits. One must drink enough water
chance that this activity is impacting h is body in a negative to enable the flushing of toxins from the body. Now, if this
way or if his occupation involves much driving. Again, the person works out on a regular basis, he or she must add more
therapist is considering any repetitive actions causing stress 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 must add that much more water into the diet to help flush
home. Does this person participate in sports or garden, for 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 also help a client in chronic pain. A person with an
hitting a golf ball repeatedly each weekend and possibly dur- 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
Eating processed foods, refined sugars, and excess proteins they, too, are stress factors. While most therapists under
makes it so that we need extra minerals stored in our bodies stand to ask about inj uries and accidents, many do not
to be able to digest and elim inate them. If the body is defi th ink to ask about recent surgery. Surgery shou ld always
cient in minerals, toxins build up in the digestive system be considered as having added stress to a body. If the cli
from unhealthy foods not d igesting entirely and not being ent has had surgery recently, be sure to acqu ire written
eliminated. They are staying in the digestive tract putrefy permission from the client's doctor before beginning mas
ing. A lso, dairy products, alcohol, and h igh-fiber foods sage in the affected area. You m ust be certain that it will
inhibit mineral absorption. These form mucus l ike plaque be doing no harm.
onto the lin ing of the colon preventing minerals and water
from being reabsorbed by the body, according to Stewart Psychoemotional Distress
Hare, C.H. Ed . DIP Nt Th . Avoid, however, vitamins pro
Psycboemot ional distress can, of course, be a maj or stress
duced from chemicals and heavy metals, many of which are
factor. As you work with cl ients, you may learn of specific
not absorbed effectively in the d igestive tract. Different
stressors that affect tbem at home or at work. Perhaps
minerals have different absorption rates. In general, mineral
they have to drive to and from work in te rror due to bad
absorption rates are affected by unhealthy d i ets, by the con
memor i es of an au tomob i l e accident that previously
dition of the intestines, as well as by the form of the mineral
occ ' lrred. Maybe they do not get a long with their boss at
as it is taken into the body. The human body cannot effec
work and l i ve in fear of losing their job. They cou ld be
tively break down heavy metals to convert them to an
considering or in the middle of a d ivorce. These types of
absorbable mineral form.
constant emotional stress will help maintain chronic pain
Chemicals 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
Another stress factor that can aggravate trigger points and
to counsel ing by a qual i fied counselor or therapist. Again,
contribute to pain is exposure to chemicals such as caffeine,
remember to stay within your scope of practice as a mas
alcohol, tobacco, and so on. Such substances dehydrate the
sage therapist.
body's tissues, which can contribute to chronic pain. Avoiding
such substances can help prevent dehydration and promote
Exercise
cleansing at a cellular level.
These lifestyle changes that you may suggest to a client 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 analysis, palpation, and predispos ing and perpetuating
the assessment of the client. The more thorough the 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 cal therapists, and physiatrists will also become impera
have covered include the health information form, inter 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 0. When performing a n active against-resistance test,


what exactly is being tested ?
1 . Orthopedic tests were developed to assess what?
A. An extremity
2. Besides the pelvic tilting, what dysfunction can a lat B. Passive or inert structures such as joint capsules
eralpelvic tilt lead to?
C. A specific muscle or muscle group
3. A person with severe thoracic kyphosis will most l ikely D. Arthritis
demonstrate what sort of breathing patterns/condi
True/False
tions?
1 1 . If there is inflammation stemming from inj ury, then
4. According to Travell and Simons, what are the specific
there will most likely be loss of function as well.
recommended criteria for identifying active and latent
trigger points? 1 2. Passive testing gives us information about the state of
inert tissues.
5. List some perpetuating factors of trigger points.
1 3 . I nert tissues refer to structures such as large muscles.
Multiple Choice Questions
1 4. With active testing against resistance, there is no move
6. It is the responsibility of a neuromuscular therapist to
ment of a l imb through space.
do what as the initial portion of assessment with a new
client ? 1 5 . A joint need not be stabilized when using active testing
A. Gain a comprehensive health history against resistance.
B. Do a postural stress analysis
Matching
C. Gain payment
a. Bruxism f. Malingerer
D. Provide home care instructions
b. Inert tissue g. Rotoscoliosis
7. To form a well-rounded, comprehensive treatment c. Informed consent h. Thoracic kyphosis
plan, the therapist must use d. Malocclusion i. Active Testing
A. all of his intuition e. Isometric contraction
B. tools of measurement
1 6. Clenching the j aw and grinding the teeth.
C. the client's report of symptoms along with various
assessment methods 1 7 . Vertebrae that rotate to one side.
D. a medical model
18. I mperfect contact of the mandibular and maxillary
8. When comparing a client's acromions, what postural teeth.
dysfunction is being considered ?
1 9. A competent and voluntary permission for procedure,
A. H igh hip/low hip
test, or medication based upon ful l understanding by
B. Posterior pelvic tilt the client.
C. Shoulder asymmetry
20. Contraction of a muscle's tension without shortening
D. Leg length discrepancy
its fibers.
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
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
cular facilitation designed to promote or hasten the response
Cryotherapy: the therapeutic use of cold
of the neuromuscular mechanism to lengthen the muscle in
Hypoxia: deficiency of oxygen
question through stimulation of the proprioceptors
Jump sign: a general pain response of a client in the form of
Thoracic outlet syndrome: a condition in which nerves and/or
wincing, crying out, or withdrawing in response to pressure
vessels are compressed in the neck or axilla area. Usually, it is
applied to a trigger point
the first rib pressing into the clavicle, pinching the brachial
Juxtaposition: a position that is adjacent or side by side plexus

After studying this chapter and then practicing the techniques 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 Presented below are some general guidelines o n treat
gentle yet effective, while being anatomically precise. 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 Warming Strokes


therapy are strokes you have been using for relaxation mas
Warming strokes are used to quickly yet gently warm and
sage. Now you will be using them while providing more
bring about hyperemia to the tissues of both the superficial
pressure and specificity. These strokes will be the ones you
and deep structures. These strokes are needed to prepare the
use leading up to applying trigger point release.
client for the more focussed trigger point treatment later.
Note, however, that with a c l ient in pain, there is quite a bit
General Guidelines for Treatment
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 In skin rolling, the therapist lifts, compresses, and rolls the
with chronic pain. The sensitivity of ischemic t issues creates skin between his thumb and fingers to free it from adhering
reduced receptivity, which requires that you be careful not to to the superfiCial fascia and bring about extreme hyperemia
use too much pressure at first, but it still needs to be enough very quickly at the same time. This technique may be used
pressure to bring up hyperemia and allow you to be able to on the back, arms, legs, and abdomen ( Fig. 4-1).
palpate the deeper t issues. This tissue must be warmed
quickly and worked with using integrated techniques before Effleurage
the trigger points may be addressed. 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
mechanics are used, the c l ient w i l l notice less and less
FIGURE 4-2 Use of opposing thumbs for petrissage.
pressure as the therapist becomes increasingly fatigued or
inj u red ( Fig. 4-3).
Petrissage
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 P A RT I N E U RO M U S C U LA R T H E RAPY B A S I C S

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 thenod
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
C H A PT E R 4 B A S I C N E U R O M U S CUL A R T H E R A PY T E C H N I Q U E S A N D B O D Y M E C H A N I C S 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 I 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 There are precautions to take when applying ice accord
is loaded with trigger points may become adhered to other ing to Marybetts Sinclair I ; they are as follows:
structures, causing further dysfunction in the area. Now, If a client is cold, be sure to warm him or her before
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 bottles, and so on
sive range of motion after performing soft tissue manipulation For clients older than 60 years, be especially sure to
( see Chapter 3 for details). A lso, have the client perform the keep them warm as it is easier for them to become
exercises actively at home. chilled
Children, especially preschoolers, have a d ifficult time
Moist Heat and Cryotherapy letting someone know if something is causing pain or
Using hydrotherapy in the form of moist heat as well as cryo too cold; be cautious here
therapy can facilitate the client's recovery, either as a treat Be extremely cautious when applying cold over super
ment you provide in your office or as a self-care treatment ficial nerves; never apply pressure there with a cold
that the client performs at home. Moist heat is very simple to pack and never exceed the recommended time
use. For example, the client could stand in a shower, letting 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 themselves
available, or one could wet and wring out a small bath towel
Periodically check for cold damage when applying ice
and heat it in a microwave. Be sure to use oven mitts or thick
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 There are also contraindications according to Sinclair;
eral layers of dry towels or blankets. The towel may be 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
C HA PTER 4 B A SI C N E U R O M U S C U L A R T H E R A PY T E C H N I Q U E S A N D B O DY M E C H A NI C S 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
52 P A RT I 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. the client to push his lower leg back down toward the table.
Do not allow the lower leg to actually move, turning the
area in question, leaving each application on for about
client's muscular contraction into an isometric contraction.
20 minutes before moving to the next. There are many opin
Hold this for 5 to 8 seconds. Then ask the client to relax the
ions out there as to the t iming when it comes to contrast
muscle, so you may take it into an even greater stretch. This
therapy, with the alternating bouts being as short as 2 to
procedure is to be repeated two or more times until it seems
5 minutes each. You must decide how to most effectively use the muscle has successfully lengthened .
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
NEUROMUSCUlAR THERAPY TOOlS
and reverse it during the summer. 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 and icing roller tools ( Fig. 4-10).
few contra indications here as well: Theracanes and Backnobbers are made specifically to
Diabetic neuropathy 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
T-bar is used for effleurage. A Thumbby can be used by a
Heat-sensitive skin
therapist or as a self-help tool. It is made of silicone and so
Spinal cord injury
has the feel of your thumb to it. It can be used for effleurage,
You can also use cold or moist heat therapies as part of 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 I BASIC N E U RO M U SC U L A R T H E R A PY TEC H N I Q U E S A N D BODY M E C H A N I C S 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 / 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. ening exercises, you can use this same recipe. Remember
If the c l ient has more complex issues, you may want to 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 There are excellent books available on stretching that
C. C. Chan. can be used by both the therapist and client, and several are
listed below.
Development of Proper Postures
Stretch to Win by A. Frederick and C. Frederick
As a neuromuscular therapist, you must help clients under Stretching Anatomy by A. N elson and J. Kokkonen
stand why it is important for them to begin to develop proper The Whartons' Stretch Book: Active-Isolated Stretching
postures when sitting, standing, l ifting, sleeping, and so on. by J . Wharton and P. Wharton
You must al 0 help them find these postures. It may be a
Facilitated Stretching by R. McAtee and J. Charland
good idea to get to know an Alexander technique practi
Stretching by B. Anderson
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. Trigger Point Release
As an example of the above, to help a client when sit 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. The procedure for the cl ient w i l l be simi lar to what you
As the c lient practices his new, proper postures each day 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,
C H A PT E R 4 / 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 55

he should let go, wait a couple of minutes and try again BODY MECHANICS FOR THE
with different pressure, ei ther l ighter or harder. On suc NEUROMUSCULAR THERAPIST
cessful release of the trigger point, he w i l l then do a stretch
Using correct body mechanics is important to the longevity
specific to that musc le.
of your career. Using proper body mechanics means working

Client Compliance smarter rather than harder; it means using your body in uch
a way as to ease your work. Many massage therapists wind up
It will be crucial for the client to be compliant with her home
injuring themselves repeatedly by using poor body mechan
care. The person who chooses to ignore her part in recovery
ics and have a very short career consequently. One of the
will most likely not recover fully and certainly will not recover
goals of this textbook is to bring about an awareness and
as quickly as the person who is compliant. Therefore, d iscuss
interest in the use of proper body mechanics by massage
this with the client. For the person who forgets to do her
therapists. There are textbooks solely devoted to this sub
home care, suggest that she place large notes about home care
ject that you may purchase and study. One in particular is
in places where she will see them daily. If whenever she sees a
Body Mechanics for Manual Therapists, A Functional Ap/)roach
note she does some of her home care, she will not forget.
to Self-Care by Barbara Frye.
Pretty soon, it will become a habit for her.
You not only use your fingers, hands, and forearms when
working on a body, you use your entire body. Your fingers
REASSESSMENT 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).

by what percentage ? Strive to save your back, neck, shoulders, arms, and hands
from strain when working. When at all possible, keep your
The client's level of tolerance for the work. This should
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.
56 PART I / 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 as little as possible. Overuse of wrist movement may lead to
rotated. This helps you to keep a straight neck. If you con 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 A l l of this information regarding body mechanics is
ened so you can move back into proper body mechanics. 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 thrapy on
tant element of treatment is provid ing home care assign- your cl ients.
C H A PT E R 4 / 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


D. Effleurage
1 . When performing neuromuscular therapy, why would a
therapist not want to use much wrist movement ? 1 0. Cryotherapy is the therapeutic use of wha t ?
2. What might happen to a therapist who works with A . Water

shoulders that are constantly internally rotated ? B. Steam


C. lee
3. How could a therapist help strengthen his hand and
D. Heat
finger flexors ?
True/False
4. Why are proper body mechanics important to a neu
romuscular therapist ? 1 1 . lee massage is easy for c l ients to perform on them
selves.
5. What are the various areas of consideration for reassess
ment of a cl ient's progress? 1 2. Use of moist heat will anesthetize an area.

Multiple Choice Questions 1 3 . The use of either heat or ice will bring about hyperemia.

6. Examination of deeper tissues using finger pressure 1 4. The c lient should be actively stretching all involved
moving acros the muscle fibers at a right angle while muscles at home regularly.
compressing against a deep structure is called:
1 5 . A neuromuscular therapist should be able to do gait
A. pincer palpation
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
a. Carpal tunnel syndrome d. Local twitch response
7. Use of opposing thumbs is a technique that fal ls into
b. Hypoxia e . Anesthetize
which category ?
c. J ump sign f. Cryotherapy
A. Effleurage
B. Petrissage 1 6. Sorenes , tenderness, and weakness of the muscles of

c. Vibration the thumb caused by pressure on the medial nerve at


the carpal tunnel of the wrist.
D. Tapotement

8. Thumb stripping is a technique that fal ls into which 1 7. A transient contraction of a group of tense muscle fib
ers that traverse a trigger point in response to stimu la
category ?
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 1 9. A deficiency of oxygen.


technique ?
20. To induce anesthesia.
A. Trigger point pressure
B. Petrissage

REFERENCE

1 . Sinclair M. Modern Hydrotherapy for the Massage Therapist.


Baltimore: Lippincott Will iams & Wilk ins, 2008.
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 lamina groove: the flattened part of the vertebral arch, which
numbing, tingling, prickling, burning, or cutting pain extends between the vertebral spinous processes and the
transverse processes
Eagle syndrome: an elongated styloid process of the temporal
bone that punctures the sternocleidomastoid muscle and Occlusal imbalance: an uneven bite causing the muscles of the
may cause dizziness and pain jaw to be in disharmony

Entrapment of the brachial plexus: an endangerment site 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

the temporomandibular joint (TMJ) area. Information pre


OVERVIEW OFTHE HEAD
sented will include trigger points and referrals along with
AND NECK REGION
anatomical and treatment considerations. This information
In this chapter, we will concern ourselves with the muscles will be helpful to you in meeting the goal of normalizing the
of the head and neck, both anterior and posterior, including body's tissue and regaining integrity for the client.

61
62 PART I I / 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

POSTERIOR CERVICAL MUSCLES Posterior Suboccipital Muscles


The posterior suboccipital muscles are four pairs of very
The first portion of this chapter presents the muscles of the
short and small muscles. They can create severe headaches,
posterior cervical region in detail. Routines for working
usually due to mechanical overload on a chronic basis.
these muscles are provided at the end of the chapter for
cl ients in both prone and supine positions.

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) Major

INSERTION Oblique
capitis i
Rectus capitis posterior major: lateral portion of the
inferior nuchal line of the occiput
Rectus capitis posterior minor: medial half of the infe
rior nuchal line of the occiput
FIGURE 5-1 Attachment sites for the suboccipitals. Rec tus capitis
Obliquus capitis superior: between the superior and
posterior major: spinous process of the a xis, lateral portion of the
inferior nuchal lines of the occiput inferior nuchal line of the occiput. Rectus capitis pos terior minor:
Obliquus capitis inferior: transverse process of the tubercle on the pos terior arch of the atlas, medial half of the inferior
atlas ( Cl) 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 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.
Control movements of nodding, side bending, and
Kinesiology. Baltimore, MD: Lippincott Williams & Wilkins, 2 004.)
rotation of the head (nodding: rocking; looking upward
with a rotation: tilting)

TRIGGER POINTS AND REFERRAL ZONES Trigger points in these muscles are one of the most com
These muscles are deeply placed at the upper posterior neck mon sources of head pain. The pain seems to be inside the
area, j ust below the skull bilaterally. The trigger points are head but is diffic ult to isolate. A person with these trigger
found in the belly of the muscles. The referral sensations points will most likely describe a headache as hurting all
.
will be strongly felt behind, above, and in front of the ear, inside the head. If questioned further, the client will likely
with quite a bit of spillover extending further in those d irec describe pain extending forward unilaterally to the occiput,
tions ( Fig. 5-2 ) . eye, and forehead. The sensation typically does not have
I t i s often difficult to distinguish the difference between clearly definable limits, however. It will not be the stra'ight
referrals from trigger points in these muscles and those from through-the-head quality, such as that from the splenius
semispinalis. It is rare that the suboccipital muscles develop cervicis muscle. These muscles are usually quite tender to
trigger points without associated involvement of other the touch, especially considering the depth of tissue one
major posterior cervical muscles. must press through to palpate.
CHAPTER 5 / 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 Uncorrected nearsightedness


complain of horrible headaches when their head rests on Lenses with too short a focal length
their pillow at night. The weight of the head presses the pil A chill or draft to the back of the neck while maintain
low against the occiput, placing pressure on these muscles. ing the head to the side
Such a client might be able to locate the sore spot by palpat Whiplash injury
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 PRECAUTIONS
when necessary in trying to back up when driving a car. Avoid working too deeply too quickly
Initial warming should include the location of the
TRIGGER POINT ACTIVATION
bony landmarks in the area
As these muscles are mostly responsible for moving the head
Palpation should be gentle: avoid poking or jabbing
at the top of the spine, they will probably develop trigger
points when trying to control flexion, when held in a short movements. This is a very sensitive area for most people
ened position maintaining extension looking upward for
MASSAGE THERAPY CONSIDERATIONS
long periods of time, or when held in a shortened position
Be sensitive to the client's pain threshold, yet apply
looking to the side for prolonged periods of time.
appropriate pressure to allow the tissue to respond
Often a person with forward head posture will also have
correctly
the head in hyperextension (chin poking up and out). This
Treatment of the suboccipital tissues between C l and
accommodates the line of vision for the person. This will likely
activate trigger points in the posterior suboccipitals along the occiput will ensure that the head will be able to

with other posterior cervical muscles. These muscles are a very move without restriction
common source of posttraumatic headache trigger points. Treatment between Cl and C2 will ensure that the
head will be able to rotate fu lly
STRESSORS AND PERPETUATING FACTORS This is a common area for the therapist to overwork
Lying on the floor propped up on elbows watching using friction and pressure
television An effective technique for warming with the suboc
Looking to the side or reading copy from a flat surface cipitals is to use a wave-like motion utilizing fingertips
while keyboarding when doing computer work at the base of the skull while resting the head on the
Sustaining an upward gaze with head tilted up (paint palm of the hand (please see the online video for this
ing a ceiling or using binoculars) technique)
Any sustained awkward head position Be sure not to push the atlas forward but to make the
Maladjusted eyeglasses or use of trifocals direction of pressure upward under the occipital ridge
64 PA 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 A P Y R O U T I N E S B Y B O DY R E G I O N

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
FIGURE 5-3 Atta ch ment sites for the levator s capula. Transverse
ACTION
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. 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
When the trigger points are severe, a person will com
of the n e ck and just below with very strong referral around them .
plain of pain at the angle of the neck and/or a painful, stiff There is often spil lover down the med ial border of the s capulae and
neck. Symptoms of these trigger points may mimic torticol a cross the posterior shoulder. (Reprinted with permission from Medi
lis. Other clients experiencing these trigger points may have Clip, Lippin cott Williams & Wilkins.)

diagnoses of stiff neck syndrome, levator scapulae syndrome,


or scapu locostal syndrome, according to Travel and Simons.
C H A PT E R 5 / H E AD A N D N E C K 65

With extremely activated trigger points, a person may be Sitting in a chair with armrests that are too high
unable to turn the head fully to the same side because of Sleeping with the head tilting backward or to one side,
pain upon contraction and not fully to the opposite side such as when in an airplane seat or on one's stomach
because of painful increase in muscle tension. To look Whiplash from any direction
behind, he or she must turn the body rather than the neck. Asymmetries in the lower part of the body providing
Pain from the trigger points actually limits neck rotation, an uneven gait
and so it is named the "stiff neck" muscle. If active enough,
the trigger points will refer extreme pain even when at rest. PRECAUTIONS
When working with a client in the prone position,
TRIGGER POINT ACTIVATION take care not to mistake the lateral border of trapezius
Postural stress is the main activator here. Trigger points for the levator scapulae
are most likely to develop because of occupational stress or Be sure to observe the bony landmark of the transverse
sleeping position. Psychological stress that creates tense, process of C l and apply techniques to the lateral aspect
hostile, aggressive posture of the shoulders can also activate of the neck, not at an oblique angle toward the occipi
trigger points. Activities that keep the levator scapulae in a tal ridge
shortened position can activate latent trigger points. Specific
examples of these postures and activities are discussed in the MASSAGE THERAPY CONSIDERATIONS
next section. A strain in levator scapulae will restrict range of motion
to the opposite side and will be painful upon rotation
STRESSORS AND PERPETUATING FACTORS to the same side
Overexertion in sports such as tennis or swimming, The attachment on Cl transverse process requires spe
particularly when out of shape cial attention due to its hidden location deep to sterno
Rotating the head back and forth repeatedly, such as cleidomastoid; this will also treat the splenius cervicis
when observing a tennis match at center court attachment there
Keyboarding with the head and neck turned to one The tendonous attachment at the superior angle of
side or with the keyboard too high the scapu l a is often fibrotic and easy to locate.
Talking for long periods of time to a person sitting to Stand at the head facing the scapula to work on this
one side attachment
Carrying a purse on the shoulder by a long strap Be sure to use muscle stripping and friction to work on
Looking ideways for long periods of time the transverse process attachments
Cradling the telephone between the shoulder and the This muscle should always be examined during any
ear work for the cervical area
Using crutches or a cane that are too long Use of forearm compression into the belly of the mus
Tense or aggressive postures, such as occurs when hold cle at the angle of the neck is a nice way to give a bit of
ing one's shoulders up high when driving aggressively a stretch when completing work here
66 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 BY B O D Y R E G I O N

ANTERIOR CERVICAL MUSCLES 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,
The anterior cervical muscles should be worked with the you must be precise with your positioning.
client in a supine position. As most people have never had When a person has had a whiplash injury and the only
their anterior cervical muscles work on, be sure to explain muscles being dealt with are in the posterior neck, pain in
what will be going on during this work and why it is neces that area will actually increase. Because the t.herapist is giv
sary. Especially when a person has had any whiplash inj ury, ing this person a muscle imbalance by loosening the poste
the anterior cervical muscles will be involved. Most massage rior musculature while leaving the anterior musculature
therapists avoid doing this type of work as it frightens them tight, this person may begin to lose the curve of their cervical
due simply to the area being worked and the fact that to spine and end up with what is called a "military neck." This
work in this region a therapist must really know their anat- 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 (unilat-
eral)

.. ..... .,.
Flexion of head and neck (bilateral)

...-.-..
Auxiliary muscle for inhalation (bilateral) :

Control of posterior head and neck movements


(bilateral) :

TRIGGER POINTS AND REFERRAL ZONES


FIGURE 5-5 Trigger points and referral zones for the sternal head of
The sternal and clavicular portions of this muscle each have the sternocleidomastoid. There wi ll most likely be trigger points set
their own referral patterns. Mostly, however, both refer pain into this portion of the muscle along its entire length. There will be
to the face and the head, not the neck. The referrals often 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
mimic the symptoms of atypical facial neuralgia or tension
top of the head, from the ear to the eye and entire maxilla as we ll as
headaches. Often dentists recognize these referrals as a com lateral to the strong referral at the stern um. (Reprinted with permis
ponent of facial pain complaints. sion from Medi Clip, Lippi ncott Williams & Wilkins.)
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 may even be sinus congestion present. Occasionally, there
strongly felt at the attachment on the mastoid process and may be unilateral deafness occurring without tinnitus or a
occipital ridge and arcing around the medial, lateral, and supe crackling noise (Fig. 5-5).
rior aspect of the eye and the eyebrow. There may be spillover From the clavicular portion of this muscle, the referrals are
referral to the top of the head, behind the eye, and to the max pain with the actual trigger points all along the length of
illa and mandible, throat, chin, and sternal attachment. this division. The referrals will be felt mostly into the fron
There may be symptoms of the eye such as excessive lac tal area of the head and behind and deep into the ear.
rimation, reddening of the conj unctiva, or visual distur Occasionally, there is spillover referral to the cheek and the
bances such as blurred vision or a dimming sensation. There 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
Hyperextension of neck, as when painting a ceiling,
of the sternocleidomastoid. As with the sternal head, the trigger
writing on a blackboard, hanging curtains, or sitting in
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 a front-row seat at a theater with a high stage
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
from Medi Clip, L ippi n cott W illiams & W ilkins.)
the side
Protracted head, slouched posture
Forward head posture while driving
A person may complain of proprioceptive difficulties
such as spatial disorientation, dizziness, and/or vertigo.
Wearing collars or ties that are too tight
Mechanical stimulation of active trigger points in the cla Drooping shoulders (wearing too heavy of clothing or
vicular division can refer autonomic phenomena of local feeling "down")
ized sweating and vasoconstriction to the frontal area of
PRECAUTIONS
referral (Fig. 5-6).
When working on the sternocleidomastoid, avoid the
Interestingly, there usually is no neck pain or stiffness
carotid artery, which lies medial to the sternal fibers.
reported from trigger points in sternocleidomastoid. However,
there may be complaints of soreness in the anterior neck MASSAGE THERAPY CONSIDERATIONS
area, which mimics the symptoms of tender lymph glands. Rotating the head slightly toward the side being worked
Extreme referrals into the head and face from these trigger will slacken the muscle fibers and make it easier to
points will also resemble a tension headache. It is rare that pincer grasp this muscle
this person will complain of restricted neck motion. Using a pincer compression is very effective for this
Mostly complaints will be of vision blurring, dizziness, problematic muscle
profuse tearing of the eye, frontal headaches, and nausea. It may be necessary to use a tissue or paper towel to be
able to grasp the muscle securely if lubricated
TRIGGER POINT ACTIVATION
Stretching and range of motion exercises may be
Any posture or activity that activates these trigger points will
also perpetuate them if not corrected. Excessive forward head effectively done by rotating the head without lateral
posture will shorten this muscle and activate trigger points flexion
there. Also, having the head turned to one side for long peri Sternocleidomastoid is the most superficial of the three

ods of time will activate trigger points, along with sleeping on muscles that attach at the mastoid process
one's back using two or more pillows to keep the head up. The referral pattern of the sternal division of sterno
Mechanical overload is a frequent cause of activation, such cleidomastoid mimics the classic migraine arc
as when the neck is hyperextended for a prolonged period dur Thorough treatment of this thick upper half of the
ing an activity. Activation could also be induced accidentally muscle, including the tendon at its attachment at the
by injuries such as falling on one's head, or whiplash. mastoid process, is extremely important
A person with a deformity or injury that restricts upper Always note the location of the stylOid process prior to
limb movement requiring awkward compensatory neck treatment so as not to intrude onto it
68 PART I I / M U S C LE 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

Scalenes: Anterior, Medius, and Posterior: The Entrappers

Scalene muscle trigger points and their associated thoracic the scalenes rarely refer to the head, they are associated with trig
outlet entrapment syndrome are often overlooked sources of ger points that do refer to the head. Travell and Simons quote a
pain in the shoulder-girdle region and upper limb. Scalene study4 that shows that more than half of those in the study who
trigger points are among the more difficult to identify and had celvicogenic headaches also had associated active scalene
treat effectively but are also the most important of the myo trigger points that were contributing to their pain.
fascial trigger points. Scalene muscles are among the most common sources of
All of the scalene muscles are variable in their attach back pain. Pain from these trigger points is usually described
ments. The most variable is scalene minimus. This muscle as being persistent and aching, coming in two finger-like
exists in approximately 50% to 7 5 % of people on at least proj ections over the upper chest area. If on the left side, it
one side of the body. may be mistaken for angina pectoris and will most likely be
associated with muscular activity.
ORIGIN
The less common referral into the thumb will usually be
Anterior: transverse processes of C3-C6
described as numbness and may or may not include
Medius: transverse processes of C2-C7
hypoesthesia with or without a thermal sensitivity (usually
Posterior: transverse processes of C5-C7
this will be cold).
Minimus: transverse processes of C6-C7
TRIGGER POINT ACTIVATION
INSERTION
Often trigger points in the scalene muscles are activated sec
Anterior: rib 1
ondary to trigger points in the sternocleidomastoid. This ster
Medius: rib 1
nocleidomastoid forms a functional unit with the scalenes.
Posterior: rib 2
Also, a severe stiff neck syndrome from trigger points in levator
Minimus: rib 1 scapulae will sometimes include trigger points in the scalenes.
ACTION
STRESSORS AND PERPETUATING FACTORS
Forward flexion of the neck
Accidental trauma
Lateral flexion to same side
Pulling or lifting heavy items (hauling on ropes when
Stabilize cervical spine against lateral movement
sailing)
Assist in elevating first two ribs for forceful inspiration
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 Holding awkwardly large objects
cles. With medius, however, the trigger points are usually Playing certain musical instruments
found in the lower portion of the belly. Overuse as with paradoxical breathing
Active trigger points in the anterior, medial, or posterior Coughing hard very often (asthma, bronchitis, etc.)
scalenes may refer sensation anteriorly to the chest, laterally Sleeping with the foot of the bed higher than the head
to the upper arm, and posteriorly to the medial scapular of the bed
border and interscapular area. It could be all of this area A tilted shoulder girdle when standing
referred to or any portion of it.
A small hemipelvis when seated
The posterior referral is usually from scalene anterior,
Loss of an upper limb or surgical removal of a heavy
especially along the border of the scapula. Anteriorly, there
breast
may be referrals into the pectoral region coming from sca
Scoliosis
lene medius or posterior.
Having to lean awkwardly when seated because of
Also, referral may be down the front and back of the
short upper arms not reaching armrests of a chair
upper arm, skipping the elbow, and then into the radial side
A whiplash-type injury
of the forearm, the thumb, and the index finger. This refer
ral usually comes from trigger points in the upper scalene Carrying heavy shoulder bags

anterior along with medius (Fig. 5-7). Upper chest breathing (asthma, etc.)

Trigger points from the scalenes are commonly overlooked Reading in bed with head tilted forward
sources of back, shoulder, and arm pain. As trigger points from Limping
CHAPTER 5 I HEAD A N D NECK 69

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.)

depress. This combination can close the thoracic out


PRECAUTIONS
let and cause the brachial plexus to become entrapped,
Avoid direct pressure on the brachial plexus, an endan
which is thoracic outlet syndrome
germent site, which lies between anterior and medius
If there is ulnar pain, tingling, numbness, and dys
MASSAGE THERAPY CONSIDERATIONS esthesia along with hand edema, then the client likely
Very tight scalenes will cause entrapment of the bra has thoracic outlet syndrome
chial plexus Trigger points here may cause symptoms similar to
When using gliding thumb strokes with the head those of carpal tunnel syndrome
rotated to the side, avoid direct contact with the clavi Because the brach ial plexus and a x i l lary artery
cle by engaging thumb posteriorly and inferiorly toward emerge above rib 1 while between the anterior and
the first rib attachment (area of brachial plexus) medial scalene, be careful not to intrude into it.
Tightness of scalenes will e levate the first two ribs. The person w i l l fee l an e lectric- like shock if this
Tightness of pectoralis minor will cause the clavicle to happens
70 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 PY R O UTI N E S BY BODY R E G I O N

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 cles are a very common source of posttraumatic headache
major role in head and neck pain, especially when injured. trigger points.
Rectus capitis anterior lies deep to the upper portion of lon
STRESSORS AND PERPETUATING FACTORS
gus capitis.
Lying on the floor propped up on elbows, watching
ORIGIN television
Anterior: anterior transverse process of atlas (Cl) Maladjusted eyeglass frames
Lateralis: transverse process of atlas (Cl) NearSightedness that goes uncorrected
Lenses with too short a focal length
INSERTION
Use of trifocal lenses that require frequent and/or sus
Anterior: occipital bone, anterior to foramen mag
tained fine adjustment of head position to see properly
num
A chill or draft to the back of the neck while maintain
Lateralis: j ugular process of occipital bone
ing the head to the side
ACTION Whiplash injury
Anterior: flexes head Sustaining an upward gaze with head tilted up (paint
Lateralis: laterally flexes head ing a ceiling or using binoculars)
Any sustained awkward head position
TRIGGER POINTS AND REFERRAL ZONES Prolonged typing while reading copy from a flat surface
Actual locations for trigger points as well as specific referral or reading to the side
patterns for most of the deeper anterior neck muscles have
not been established yet. Most agree, however, that trigger PRECAUTIONS
points can refer to the laryngeal area, anterior and posterior Palpate the styloid process to ensure knowledge of
neck, and sometimes into the mouth, as well. its exact location; never press on it as it is quite
A person with trigger points in this area may complain of sharp and could cause trauma to the stylopharyngeus
anterior and neck pain or possibly a lump or tickle in the muscle and the glossopharyngeal nerve. Also, the
throat or difficulty with swallowing. styloid process is small enough to fracture or snap off
completely
TRIGGER POINT ACTIVATION Palpation should be gentle; avoid poking or jabbing
As these muscles are mostly responsible for moving the head movements. This is a very sensitive area for most
at the top of the spine, they will probably develop trigger people
points when trying to control flexion, when held in a short
ened position maintaining extension looking upward for MASSAGE THERAPY CONSIDERATIONS
long periods of time, or when held in a shortened position Be sensitive to the client's pain threshold, yet apply
looking to the side for prolonged periods of time. Often a appropriate pressure to allow the tissue to respond cor
person with forward head posture will also have his or her rectly
head in hyperextension (chin poking up and out). This Unresolved posterior neck pain may result from acti
accommodates the line of vision for the person. These mus- vated trigger points in these muscles
C H A P TE R 5 / HEAD AND NECK 71

,.
't':' "
Longus Capitis and Longus Colli: Military Neck

Longus capitis and longus colli, along with the anterior suboc Most believe they can refer to the laryngeal region, anterior
cipitals, are the deepest muscles of the anterior neck. They are neck, and mouth.
responsible for giving a person what is called a military neck or A client with trigger points in this region may complain
a straight neck when they are chronically contracted. This is a of having difficulty in swallowing, with possible pain in the
painful situation in which the curve is no longer in the neck, vicinity of the cricoid cartilage and a sore throat.
causing the neck to be straight and usually forward,
TRIGGER POINT ACTIVATION
ORIGIN Mostly these trigger points will be caused by flexion/exten
Longus capitis: anterior transverse processes of C3-C6 sion injuries, such as those sustained in automobile injuries
Longus colli, vertical fibers: anterior bodies of CI-C3 or sports injuries, along with a forward head posture. Anyone
and C5-C7 with a military neck will most likely have several trigger
Longus colli, inferior oblique fibers: anterior bodies of points activated here.
TI-T3
STRESSORS AND PERPETUATING FACTORS
Longus col li, superior oblique fibers: anterior tubercles
Whiplash
of transverse processes of C3-C5
Forward head posture
INSERTION
PRECAUTIONS
Longus capit is: occipital bone anterior to foramen
Be sure to explain to the client how and where you will
magnum
be working
Longus colli, vertical fibers: anterior bodies of C2-C4
Palpation should be gentle; avoid poking or j abbing
Longus colli, inferior oblique fibers: anterior tubercles
movements. This is a very sensitive area for most
of transverse processes of C5-C6
people
Longus colli, superior oblique fibers: anterior tubercles
of atlas (C l ) MASSAGE THERAPY CONSIDERATIONS
Be sensitive to the client's pain threshold, yet apply
ACTION
appropriate pressure to allow the tissue to respond cor
Longus capitis: flexes head and neck
rectly
Longus colli: flexes head and neck and assists rotation
Be sure not to move pressure laterally off the transverse
of the head
processes, as this could cause intrusion onto the carotid
TRIGGER POINTS AND REFERRAL ZONES artery
Specific trigger points and referral areas for most of the deep Unresolved posterior neck pain may result from acti
est anterior neck muscles have not yet been established. vated trigger points in these muscles
72 PART 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 U T I N E S B Y B O DY R E G I O N

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 FIGURE 5-8 A ttachmen t s i tes for the suprahyoids. Mylohyoid: supe
Trigger points have not been officially recorded for this rior aspec t of the hyoid bone, e n tire len g th of the mylohyoid line of
muscle as of yet; however, trigger points most l ikely set 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
up in the muscle belly. Referrals are likely to occur on
ysis men ti. (Reprin ted w i th permission from Oa tis CA. Kinesiology.
the lateral side of the tongue. A client w i th trigger Ba l timore, MD: Lippincott Williams & Wilkins, 2 004 .)
points in this muscle would l i kely complain of difficulty
when swal low ing, along with a painful and restrictive
fee l ing.
PRECAUTIONS
TRIGGER POINT ACTIVATION This is inner oral work under the tongue; be sure there are
Trigger points in this muscle can be activated by chronic no tissue abnormalities such as a tumor and open sore.
mouth breathing. Any whiplash-type injury will also acti
MASSAGE THERAPY CONSIDERATIONS
vate trigger points here.
Trigger points in any of the anterior throat muscles
STRESSORS AND PERPETUATING FACTORS could refer viscerally into the thyroid gland
Forward head posture With any whiplash-like accident, always include an
Mouth breathing examination of this muscle
C H A PTE R 5 / H E AD A N D N E C K 73

Geniohyoid

This muscle mainly works synergistically with the digastric TRIGGER POINT ACTIVATION
muscle.
Trigger points will be activated here because of flexion and
extension injuries such as whiplash.
ORIGIN
Inferior inner surface of the mid-mandible at the sym
STRESSORS AND PERPETUATING FACTORS
physis menti
Forward head posture
INSERTION Mouth breathing
Hyoid bone
PRECAU TIONS
ACTION This is inner oral work under the tongue; be sure there
Retraction and depression of mandible are no t issue abnormalities such as a tumor and open
Elevates hyoid bone sore.
.
. . . . . . ..
. . . . . . . . . . . . . . . . , . . . ..... . . .... ..
. . . . . . . . . . . . .
. . . . . . . . . .

TRIGGER POINTS AND REFERRAL ZONES MASSAGE THERAPY CONSIDERATIONS


Nothing has been written regard ing trigger points and refer Trigger points in any of the anterior throat muscles
rals of this muscle as of yet. As with any muscle, it is most could refer viscerally into the thyroid gland
likely that a trigger point will setup within the muscle belly. With any whiplash-like accident, always include an
Referrals will most likely be into the mouth area. examination of this muscle
74 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 OD Y R E G I O N

Digastric: Pseudo-sternocleidomastoid Pain

This is a fascinating muscle in regard to its anatomical If there is a trigger point in the anterior section, the cli
attachments. The posterior bellies are united end-to-end by ent will likely experience pain in the lower front teeth. This
a common tendon that attaches to the hyoid bone through source of tooth pain is often overlooked.
a fibrous loop or sling-like structure.
TRIGGER POINT ACTIVATION
ORIGIN Activation of trigger points in this muscle may be secondary to
Anterior belly: inferior border of mandible dysfunction ofother anterior neck and throat mu cles. However,
Posterior belly: mastoid notch of temporal bone to activate trigger points here, one must only do things sllch as
clenching and/or grinding and mOllth breathing.
INSERTION Mechanical irritation may occur in this muscle if a person
Intermediate tendon attached indirectly to hyoid bone has an elongated styloid process. This is known as "Eagle syn
by a fibrous loop of fascia drome"; the styloid process presses into the muscle belly and
causes some tearing and inflammation. There is typically pain
ACTION
present at the angle of the j aw, with symptoms of dizziness and
Lowers mandible (opens mouth)
visual blurring. There may be a decrease in vision, as well.
Moves hyoid bone upward, forward, and backward
STRESSORS AND PERPETUATING FACTORS
TRIGGER POINTS AND REFERRAL ZONES
Overload from bruxism and/or mouth breathing
Trigger points may be found within the belly area of both
Eagle syndrome
the anterior and posterior portions of this muscle. Referral
Whiplash-type injuries
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, PRECAUTIONS
with spillover up into the occiput. From the anterior sec Be sure to locate the styloid process before working on
tion, referral is often into the lower front teeth (Fig. 5 -9). the posterior portion of this muscle and not to press on
Often, a person with trigger points in the posterior por it as it is small and easily broken
tion may not feel pain but instead have problems with swal
lowing, such as having a lump in the throat or a feeling of MASSAGE THERAPY CONSIDERATIONS
something stuck there. 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.)
CHAPTER 5 / H E AD A N D N E C K 75

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 and through the cranium. There may be intense pain deep
muscle is found in 42% of patients with ipsilateral face and in the orbit of the eye and the eyeball itself (Fig. 5- 1 0) .
head pain associated with myofascial pain/dysfunction syn Clients with trigger points i n thi region often cannot
drome. Ipsilateral means affecting or related to the same side bear the weight of the back of the head on the pillow
of the body. when trying to sleep because of pain from a trigger point
This muscle is usually grouped with the frontalis muscle in the muscle belly. They may report that they must lie on
and is called the "occipitofrontalis" or "the epicranius." For their side to get some sleep. Pain from trigger points in
the purposes of splitting the muscles into anterior and pos this area is a deep aching pain. If the client reports super
terior categories, this text presents them separately. ficial scalp tingling and/or hot prickling, this is most likely
due to the greater occipital nerve being entrapped by pos
ORIGIN
terior cervical muscles. If it is trigger point referral the
Occiital bone at the superior nuchal line client i experiencing, then moist heat wil l usually pro
vide relief; if the pain is due to nerve entrapment, most
INSERTION
likely the client will not be able to tolerate heat but will
Galea aponeurotica
enjoy cold applied there.
ACTION
Draws back scalp TRIGGER POINT ACTIVATION
Trigger points are most likely to occur in this muscle when a
Assists in raising eyebrows and wrinkling forehead
person has decreased visual acuity and/or glaucoma.
TRIGGER POINTS AND REFERRAL ZONES G laucoma is a disease of the eye characterized by increase in
From trigger points in the muscle belly, sensation is referred intraocular pressure, which atrophies the optic nerve, caus
laterally and anteriorly, diffusely over the back of the head 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.)
76 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

strong contraction of the forehead and scalp muscles. These PRECAUTIONS


trigger points may also be activated as satellites of posterior This area may be quite sensitive
cervical trigger points that refer sensation to the occipital
area. MASSAGE THERAPY CONSIDERATIONS
Teach clients to use trigger point pressure to release
STRESSORS AND PERPETUATING FACTORS trigger points here for themselves
Decreased vision Be sure to inactivate all key trigger points in the cla
Trigger points in posterior cervical muscles causing vicular division of the sternocleidomastoid and all pos
satellites in occipitalis terior cervical muscles
C H A PT E R 5 / H E AD A N D N E C K 77

, Frontalis:The Scalp Tensor

This muscle is usually grouped with the occipitalis muscle The main complaint of clients with trigger points in this
and is called the "occipitofrontalis" or "the epicranius," muscle is pain in the forehead.
For the purposes of splitting the muscles into anterior and
TRIGGER POINT ACTIVATION
posterior categories, this text presents them separately.
Travell and Simons label these two muscles as the "scalp Trigger points here are most likely to be satellites from those
tensors." set up in the clavicular portion of the sternocleidomastoid.
Also, activation could be from work overload; in this case,
ORIGIN constant facial expressions showing anxiety, tension, sur
Galea aponeurotica prise, and distrust. The forehead stays wrinkled with these
expressions.
INSERTION
Fascia of fac ial muscles and skin above the nose and STRESSORS AND PERPETUATING FACTORS
eyes Longstanding trigger points in the clavicular head of
sternocleidomastoid may be forming satellites here
ACTION
Chronic frowning or other expressions that include
Draws scalp back
wrinkling the forehead
Raises eyebrows
Wrinkles 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 headache
refer strongly around the trigger point itself. There may be
some feather-like extensions upward on the forehead of MASSAGE THERAPY CONSIDERATIONS
spillover referral (Fig. 5 - 1 1 ) . 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.)
78 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 BY B OD Y R E G I O N

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
FIGURE 5-12 Attachment sites for the corrugator supercilii. Medial
points here. This is a person who mostly wears an expression end of the superciliary arch of the frontal bone above the nasal bone,
of concern or anger on their face, pulling their eyebrows the skin above the middle of the supraorbital margin and above the
together creating a furrow between them. Probably the per nasal bone. Note that one end of this muscle does not attach to bone.

son who looks surprised will also activate trigger points here.

STRESSORS AND PERPETUATING FACTORS


PRECAUTIONS
Frowning
There are no precautions for this muscle.
Wearing an expression of attention, concern, anger, or
surprise, with eyebrows raised and forehead wrinkled MASSAGE THERAPY CONSIDERATIONS
May be satellites from trigger points in frontalis and Using a pincer grasp is the only way to effectively work
the posterior cervical muscles on this muscle
CHAPTER 5 I H EAD A N D N E C K 79

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, FIGURE 5-1 3 Trigger Points and Referral Zones for the temporalis.

and into the temporal area (Fig. 5 - 1 3 ) . Mostly the trigger points occur near or within the large tendinous
area above the zygoma and refer strongly into the upper teeth, the
A person with trigger points i n this muscle typically com
eyebrow, and parietal bone with spillover in between all of those
plains of head pain and headaches, as well as toothaches or points. (Reprinted with permission from Medi Clip, Lippincott Williams
gum pain. Rarely will this person complain of jaw restric & Wilkins.)
tion, yet there will be a reduction in its ability to open.
There may be complaints of the teeth not meeting correctly, Chronic infection or inflammation of the TMJ
however. Cold drafts over the muscle
The hypersen itivity in the teeth may present as a reac Any overuse of masticatory structures
tion to thermal conditions when eating either hot or cold
foods. PRECAUTIONS
Avoid putting oily fingers in your cl ient's hair when
TRIGGER POINT ACTIVATION working on this muscle
See section "Stressors and Perpetuating Factors." The tendon above the zygomatic arch is often fibrotic
and quite tender
STRESSORS AND PERPETUATING FACTORS
Clenching and grinding of the teeth (bruxism) MASSAGE THERAPY CONSIDERATIONS
Direct trauma to the muscle, such as getting hit in the Temporalis is a key player in the function of the TMJ
side of the head 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
immobilize the mandible in the fully closed position the fan-shaped muscle fiber direction
Forward head posture Work slowly and gently while being very deliberate to
Excessive use of the jaw, as when chewing gum alleviate trigger points here
80 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 OD Y R E G I O N

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 Deep portion
of masseter
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
Superficial portion
muscle is typically pain in the teeth and the j aw area. Often, of masseter
the cl ient is actually feeling referral sensation into the TMJ
FIGURE 5-1 4 Attachment sites for the masseter. Zygomatic arch and
it elf along with hypertension of this muscle, rather than
the process of the maxilla; ramus, angle and neck of the mandible.
actual TMJ derangement. Active trigger points often mimic (Reprinted with permission from Medi Clip, Lippincott Williams &
symptoms of dysfunction of the joint. The client also fre Wilkins.)
quently reports significant restriction of the jaw opening.

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 / H E A D A N D N EC K 81

There may be a unilateral tinnitus associated with trigger Crushing ice or nuts with the teeth
points in the upper posterior part of the deep layer. If there An uneven bite ( occlusal imbalance)
is bilateral tinnitus present, it is most likely to be a systemic
cause rather than trigger point activity. PRECAUTIONS
When muscle stripping here, avoid pu lling the skin of
TRIGGER POINT ACTIVATION the face downward
See section "Stressors and Perpetuating Factors," below.
MASSAGE THERAPY CONSIDERATIONS
STRESSORS AND PERPETUATING FACTORS For its size, the masseter is the strongest muscle in
Excessive forward head posture the body. This means that it can hold quite a bit of
Tension and unresolved anger (clenching teeth) tension
Bruxism (grinding teeth when at sleep) Hypertonicity of the masseter is a major factor in the
Pipe smoking, chewing gum, nail biting, thumb sucking function of the TMJ and its dysfunction, along with
Improperly fitting dentures craniomandibular pain
82 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 OD Y R E G I O N

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
FIGURE 5-1 6 Attachment sites for the medial pterygoid. Angle of the
TRIGGER POINTS AND REFERRAL ZONES mandible and lateral pterygoid plate. (Reprinted with permission
Trigger points usually set into the belly of this muscle, with from Medi Clip, Lippincott Williams & Wilkins.)
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.

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 The trigger points here can be anywhere within the belly of the muscle
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
permission from Medi Clip, Lippincott Williams & Wilkins.)
J aw clenching
Anxiety and other emotional tension
Occlusal imbalance
MASSAGE THERAPY CONSIDERATIONS
PRECAUTIONS Trigger points should be inactivated before initiating
This muscle is usually extremely tender; be gentle any prosthodontic treatment
CHAPTER 5 / H E AD A N D N E C K 83

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 FIGURE 5-1 8 Attachment sites for the lateral pterygoid. Superior
division: sphenoid bone, medial su rface of the neck of the mandible
Superior division: opens and protrudes jaw
just below the articular disk. Inferior division: lateral pterygoid plate,
Inferior division: opens and protrudes j aw, lateral devi neck of the mandible adjacent to the superior division. (Reprinted
ation to other side 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
referral into the maxilla. There may be some spillover around the
Bruxi m strong referrals. (Reprinted with permission from Simons DG, Travell JG,
Gum chewing, nail biting, thumb sucking Simons LS. Upper Half of Body. 2nd ed. Baltimore: Lippi ncott Williams &
Wilkins, 1 999. Trovell & Simons' Myofascial Pain and Dysfunction: The
Playing a wind instrument with the mandible fixed in
Trigger Point Manual; vol 1 . p. 38 0, Fig. 1 1 . 1 .)
protrusion
Playing the violin holding the mandible against the
in trument
MASSAGE THERAPY CONSIDERATIONS
PRECAUTIONS Trigger points should be inactivated before init iating
This muscle is usually extremely tender; be gentle any prosthodontic treatment
84 PA R T I I / M U S C L E S A ND N E U RO M U S C U LA R T H E R A P Y R O U T I N E S BY BODY R E G I O N

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 I H E AD A ND N E C K 85

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
86 PA R T I I I M U S C L E S A ND N E U R O M U S C U LA R T H E R A P Y R O U T I N E S BY BODY R E G I O N

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 / H EAD A N D N E C K 87

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.
ROUTINE 5-1 1
3. Perform effleurage to the rhomboids, working deeply a n d
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
88 PART I I / 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

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
ROUTIN E 5-1 3
eral aspect of the spinous processes. Work from (7 to T5 using
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 / H E AD A ND N E C K 89

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
ROUTI N E 5-1 7
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).
90 PART I I I 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 O D Y R E G I O N

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 / H E AD A ND N E C K 91

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).
92 PA R T I I / 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

Levator Scapula
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 ROUTI NE 5-25

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.


CHAPTER 5 / H E AD A ND N E C K 93

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
94 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 OD Y R E G I O N

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 / HEAD AND NECK 95

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.

ROUTIN E 5-34
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.


96 PA R T I I / 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

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
ROUTIN E 5-35
length of the muscle thorough ly.

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
ROUTI N E 5-36
pterygoid between the upper and lower molars (Routine 5-37).

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
ROUTI N E 5-37
ing space to pal pate the lateral pterygoid.
C H A PTER 5 I H E A D A N D N EC K 97

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
ROUTIN E 5-38
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?
98 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 DY R E G I O N

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
to it upon complete relief of the tinnitus. Per the therapist's
Treatment 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 trigger points causing nausea and tinnitus?
spent a few minutes loosening the muscul ature in the lamina 2. Which muscles would you have checked when looking for
groove of his cervical a rea with a focus to his posterior suboc trigger points into the ear?
cipitals. This a rea was quite tight, giving the impression that
3. How could poor body mechanics when working out cause
he was straining with his neck when he was working out with
trigger points to set into the anterior cervical muscles?
the machines a nd weights. Upon q uestioning him regarding
4. Had there been excessive posterior neck pain a s well,
his workout form, he agreed that was probably what he had
been doing. would working on the a nterior cervical m uscles help this,

G a ry assumed the s u pi n e position, and the therapist and why?

focused on his anterior cervical muscles. She found referrals of 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 / HEAD AND NECK 99

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


Critical Thinking Questions
playing hockey. He then began to regu l a rly work out using
1 . Why wou l d the therapist work with M a rk's lower back
machines and free weights f? r strengthening in genera l .
m uscles when his pain was in his head and neck?
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 2. Which lower back m u scle specifically would be i m portant
and having to carry a bag ful l of files a long with his carry-on to work with?
baggage through airports, often running to catch his flight. 3. Why was it i m portant to work with the more superficial
He felt this was the cause of the neck pain and headaches. m uscles before getting deeper?

4. Which muscles were i m portant to work with on the occiput


Treatment
a nd mastoid process?
Mark began receiving neuromuscular therapy whenever he
5. Which muscles a re usually responsible for headaches?
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 6. Would it be i m portant to work both the anterior and pos
beginning superficially. The therapist a lso worked with Mark's terior cervical muscles; why?
1 00 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 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

----f REVIEW QUESTIONS

Short Answer Questions 1 0. Which muscle makes up the majority of the bulk run
ning parallel to the cervical spine ?
1 . How is soft tissue compromised in a whiplash inj ury?
A. Semispinalis capitis
2. Describe the condition named torticollis. B. Levator scapula
3. Which muscle may be entrapping the supraorbital C. Splenius capitis
nerve ? D. None of the above

4. What causes TMJ syndrome/dysfunction ? True/False

5 . If one has Eagle syndrome, what symptoms might he 1 1 . The sternal division of sternocleidomastoid is usually
experience ? tighter than the other.

Multiple Choice Questions 1 2. Travell and Simons labeled the splenii muscles "the
stiff neck" muscles.
6. Which cervical muscles attach to the occipital ridge
and/or mastoid process ? 1 3 . Splenius capitis trigger points can produce a "dome
A. Upper trapezius, rectus capitis posterior major and headache."
minor, semispinalis capitis, splenius cervicis 1 4. The galea aponeurotica is an attachment site for both
B. Sternocleidomastoid, rectus capitis anterior, obliq the occipitalis and frontalis muscles.
uus capitis superior, upper trapezius
1 5 . Holding a phone to the ear using the shoulder can acti
C. Obliquus capitis superior and inferior, sternocleido
vate trigger points in the levator scapula muscle.
mastoid, splenius capitis
D. All of the above Matching

7. At which joint does most of cervical rotation occur? a. Bilateral d. Tinnitus g. Eagle syndrome
A. C2-C3 b. Ipsilateral e. Hypoesthesia h. G laucoma
B. C5-C6 c. Unilateral f. Dysesthesia i. Lamina groove
C. C6-T l 1 6. A dulled sensitivity to touch.
D. None of the above
1 7. A condition that includes having an elongated styloid
8. The brachial plexus emerges from between which two process causing mechanical irritation to certain muscles.
muscles ?
1 8. Related to the same side of the body.
A. Anterior and middle scalenes
B. Posterior scalene and pectoralis minor 1 9. The area that lies between the spinous and transverse
C. Pectoralis major and pectoralis minor processes.
D. M iddle and posterior scalene 20. A ringing sound in the ears.
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 / HEAD AND NECK 1 01

REFERENCES

1. Menachem A, Kaplan 0, Dekel S. Levator scapulae syndrome: an 3. Sola AE, Ku itert J H . Myofascial trigger point pain in the neck
anatomic-clinical study. Bull Hasp Joint Dis . 1993;530 ):2 1-24. and shoulder girdle. Northwest Med. 1 95 5 ; 54:980-984.
2. Sola AE, Rodenberger ML, Gettys BB. Inc idence of hypersen 4. Jaeger B. Are "cervicogenic" headaches due to Illyofascial pain
sitive areas in posterior shoulder muscles. Am J Phys Med and cervical spine dysfunction! CeJ)halalgia. 1 989;9: 1 5 7- 1 64.
Rehabil. 1 95 5 ;34: 585-590.
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

remember that when working with any section of anatomy,


OVERVIEW OF THE UPPER TORSO REGION
if you discover referral areas outside of that section you must
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.

103
1 04 PART 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 ERAPY ROUTI N E S BY BODY REGION

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 FIGURE 6-1 Attachment sites for the trapezius. (Repri nted with per
According t o Travel! and S imons, there are seven areas mission from Life Art, Lippincott Williams & Wilkins.)

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 angle and back of the neck rather than resting on the
TP7. acromion processes.
Activation of TPI is often associated with constant pos TP3 and TP4 cause sensation in the suprascapular, inter
terolateral neck pain along with temporal headaches on the scapular, acromial, and, possibly, neck areas. There will be
same side. Occasionally, sensation is also experienced along very little restriction of neck motion, however. TP3 is often
the angle of the jaw. This may be misdiagnosed as cervical responsible for persistent upper back and neck pain once
radiculopathy or atypical fac ial neuralgia-severe pain other trigger points have been eliminated. This trigger point
along a nerve. TPl causes similar neck pain but no head may be the key to satellite trigger points in upper back and
ache. Sensation upon motion in this upper section alone neck muscles as well.
will occur when the head and the neck are almost fully TP5 is often associated with a burning interscapular sen
rotated actively to the opposite side. When the trigger sation, whereas TP6 often proj ects referred sensation across
points in this section are active and there is also involve the acromion, rendering the shoulder intolerant of pressure
ment of the levator scapulae and/or splenius cervicis, an from a heavy coat or a large purse carried on the shoulder by
acute stiff neck may develop. This will limit the ability to a strap. TP7 may be associated with goose bumps on the
rotate the head toward the same side, stretching the upper anterolateral upper arm and possibly the thigh. According
trapezius. With activation of both TP I and TPl, there is to Travel! and Simons, it could feel like "shivers running up
likely to be an intolerance of the weight of wearing heavy and down the spine," as though someone has scraped finger
clothing like an overcoat that rests on the trapezius at the nails down a blackboard ( Figs. 6-l through 6 - 5 ) .
C H AP T E R 6 I UPP E R T O R S O 105

FIGURE 6-2 Trigger points and referrals zones for the trapezius. FIGURE 6-3 Trigger points and referral zones for the trapezius.
( Reprinted with permission from Simons DG, Travell JG, Simons LS. ( 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. FIGURE 6-5 Trigger points and referral zones for the trapezius.
( Reprinted with permission from Simons DG, Travell JG, Simons LS. ( 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.)
1 06 P A RT I I / MU S CL E S A N D N EU R O M U S CUL 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

TRIGGER POINT ACTIVATION Hunching because of cold weather


Trigger points may be activated by sudden trauma in any Collapsed chest and protracted shoulders
area of the trapezius. Examples of this may be receiving Kyphotic and scoliotic conditions
whiplash from an auto accident or taking a fall of any type.
In the upper trapezius, the function of neck stabilization PRECAUTIONS
is often ovedoaded by a titted shoutder girdte because of The tower portion of this muscle is usually quite thin
body asymmetry such as a short leg or small hemipelvis. I n and you may not be able to detect the part inferior to
the case of a short leg, there will b e a lateral pelvic tilt, the scapula
which functionally curves the spine taterally ( scoliosis) and When lengthening with a forearm, avoid "flicking" off
tilts the shoulders, causing one side to sag. Now the upper the lower portion of the muscle just medial to the scap
trapezius must work to keep the head and the neck vertical, ula, as this may cause discomfort
and the eyes level ( righting reflex), which, in turn, causes an The lower trapezius tends to become bound up with
overload to this portion of the muscle. The muscle may also adhesion, again at the level j ust medial to the scapula
be strained by other overload situations that seem obscure.
When working on the upper portion at the insertion
These microtraumas can be caused by pressure from cloth
site, be careful to avoid the brachial plexus
ing and accessories, such as too tight and narrow bra straps
supporting the weight of large breasts, the shoulder strap of MASSAGE THERAPY CONSIDERATIONS
a heavy purse on one side, or a backpack or heavy coat. The insertion points are a common site of tenderness
The middle trapezius may also become overloaded by the and fibrotic build-up
arm being held up and forward for long periods of time.
This is a common muscle for adhesions. To be effective
Maintaining this posture will also overload pectoralis major,
when treating the lower portion at the level of the
which may, in turn, develop latent trigger points that
scapula, l ift the muscle off the underlying tissues using
shorten these fibers, causing them to pull the scapula for
a pincer grasp
ward. The antagonistic m iddle trapezius fibers must also
Bolstering under the anterior aspect of the humerus
overload to counteract the constant protraction of the scap
shortens the muscle, allowing better engagement
ula ( rounded shoulders). This severe overload causes the
Be sure to check the lateral border of the superior fibers
middle trapezius to develop painful trigger points.
of upper trapezius in the cervical area
Fibers in the lower trapezius are strained by prolonged
The middle portion of trapezius is usually extremely
bending while reaching forward when sitting or sitting with
fibrous and must be examined using compression along
an elbow on the desk supporting the chin.
with transverse friction
STRESSORS AND PERPETUATING FACTORS Myofascial work may be effective due to the extensive
Hab i tual elevation of the shoulders from anxiety/ 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 Swimming can help release stress in upper trapezius
ear Using a gliding squeeze and the fingertips to unroll the
Rotating the head to one side in a fixed position while upper portion is very effective
sleeping, etc Learn to d istinguish between the upper and the middle
Playing the violin fibers
Driving with hands at the top of the steering wheel The middle fibers become very thick with rounded
Protracted head postures shoulders and head protraction
Wri ting at a desk that is too high Friction to the spine of the scapula will be effective
C H AP T E R 6 / UPP E R T O R S O 107

Splenius Capitis and Splenius Cervicis: Ache Inside the Skull

Bilaterally, the paired splenius cervicis and splenius capitis TRIGGER POINTS AND REFERRAL ZONES
muscles each form a "V" shape (Figs. 6-6 and 6-7) Referral sensation from a trigger point in splenius capitis
usually refers pain to the top of the head on the same side.
ORIGIN
There will usually be a headache.
Splenius Capitis
Referrals from trigger points in splenius cervicis will usually
ligamentum nuchae
present as diffuse pain through the inside of the head and behind
Spinous processes C3-T3
the eye on the same side, and occasionally into the occiput.
Splenius Cervicis From a lower trigger point here will come referral into the angle
Ligamentum nuchae of the neck, or the "crook of the neck" area ( Fig. 6-8).
Spinous processes T3-T6 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
INSERTION neck with limited ability to rotate the head and the neck.
Splenius Capitis A long w ith the eye pain may be blurred vision. This symp
Mastoid process tom has been known to resolve i mmed iately and com
Occipital bone pletely w i th the inact ivat ion of the responsible trigger
po:-,t.
Splenius Cervicis
Transverse processes C I-C3 TRIGGER POINT ACTIVATION
Postural stress causing overload of extension or rotation of
ACTION (BOTH) the head and the neck are most likely to begin as well as
Extension of the neck when used bilaterally perpetuate trigger points in both splenii muscles. Examples
Rotation of the head to same s ide when used unilat here are sitting in a position that extends the neck to
erally compensate for a strong thoracic kyphosis or assuming a

FIGURE 6-6 Attachment sites for the splenius capitis. (Reprinted with FIGURE 6-7 Attachment sites for the splenius cervicis. ( Reprinted
permission from Life Art, Lippi ncott Williams & Wilkins.) with permission from Life Art, Lippincott Williams & Wilkins.)
1 08 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 AP Y R O U T I N E S B Y B O D Y R E G I O N

Splenius
capitis

A
\) \1 v

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 There may be restriction of forward head f.exion, so
ments. Also, working at a desk with the head turned to one again be careful with passive stretching
side and proj ected forward can activate trigger points.
MASSAGE THERAPY CONSIDERATIONS
STRESSORS AND PERPETUATING FACTORS Splenius capitis is frequently overlooked when trying
Use of the dominant eye for reading to understand dome headaches

Cold air blowing on the neck Splenius capitis shares a common attachment on the
Behaviors associated with "protracted head syndrome" mastoid process with sternocleidomastoid and longis
Bird watching with binoculars simus capitis
Sleeping with the head and the neck bent in an awk- Effective work on the attachment of splenius capitis at
ward position the mastoid process requires precise frictioning to make
Any whiplash injury sure the engagement is strong enough to affect all three
Excessive hyperextension of the head/neck muscle attachments there

Painting a ceiling Be sure to friction each origin site on the spinous processes

Pulling a heavy rope or hose with a forward head Those who suffer with problems in the splenius cervi
posture ( Fig. 6-8B) cis often complain of a stiff neck, and rotation is
frequently restricted
PRECAUTIONS Muscle lengthening of spleniu cervicis may be hlpful
B e careful when applying passive stretching t o these in alleviating symptoms of protracted head syndrome
muscles, as there may be painful restriction of rota With the client in a prone position, splenius cervicis
tion of the head to the opposite side if there is an may be engaged using a firm pincer grip in the posterior
issue cervical area
CHAPTER 6 / 'U P P E R T O R S O 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
FIGURE 6-9 Attachment sites for the supraspinatus. ( Reprinted with
lateral arm and forearm. There may also be a concentration permission from Life Art, Lippincott Williams & Wilkins.)
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).

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
FIGURE 6-10 Trigger points and referral zones for the supraspinatus.
by regularly walking a large dog that pulls hard on the leash.
( Reprinted with permission from Simons DG, Travell JG, Simons LS.
Activation can also happen when lifting an object to or Upper Half of Body. 2nd ed. Baltimore, MD: Lippi ncott Williams &
above shoulder height with the arm outstretched or having Wilkins, 1 999. Travell & Simons'Myofascial Pain and Dysfunction: The
to repeatedly do prolonged elevation of the arms. Trigger Point Manual; vol 1 . p. 539, Fig. 2 1 . 1 .)
110 PART I I / M U SCLES A N D N E U RO M U S C U L A R T H E RAPY ROUTI N E S BY BODY REGION

Never twist w ith the pressure bar; use a back-and-forth


STRESSORS AND PERPETUATI NG FACTORS
movement only
Carrying heavy objects, such as a suitcase, at the side
trying to keep it from h itting the knees
MASSAGE THERAPY CONSIDERATIONS
Reaching back to lift a heavy object from the back seat
Rotator cuff problems in supraspinatus may be misdiag
of your car when sitting in the front nosed as deltoid ischemic pain or trigger points: it
mimics subdeltoid bursitis
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

PRECAUTIONS This is a very common area for tendonitis


Apply n o more pressure than necessary t o elicit a mild Remember that this muscle helps maintain balance
state of discomfort as this muscle may be extremely among the scapulohumeral muscles in cooperation
tender to pressure 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
FIGU RE 6-1 1 Attachment sites for the infraspinatus. ( Reprinted with
TRIGGER POI NTS AND REFERRAL ZONES permission from LifeArt, Lippi ncott Williams & Wilki ns.)
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 TRIGGER POINT ACTIVATION
the hand, and occasionally to the fingers. Also, there may be Trigger points here will usually be activated by an acute
times when referral sensation is also experienced in the upper stress or by multiple overload stresses, such as when fre
posterior cervical region. If trigger points are also present in quently reaching out and back to lift heavy objects. This
teres minor, then there may be referral sensation present in muscle is very likely to be strongly active during most move
the back of the shoulder as well ( Fig. 6- 1 2 ). Any pain sensa ments of the arm and the shoulder and so develop trigger
tion felt at or around the shoulder joint will mainly come points as the result of acute overload. The onset of shoulder
from this muscle with representation from the supraspinatus pain is usually within a few hours of the initial trauma.
and sometimes the levator scapulae as well.
People with trigger points in this muscle will often have
STRESSORS AND PERPETUATING FACTORS
Reaching into the back seat of the car to bring an
difficulty reaching into their back pants pockets, fastening
object forward between the front seats
their bras behind their backs, zipping the back of a dress, or
getting their arms into their coat sleeves. They may have Sleeping on the affected side will compress and stimu
difficulty brushing their hair or teeth or, for tennis players, late trigger points
feel pain that limits the strength of their stroke. Often, a Sleeping on the unaffected side will also activate trig
person with active trigger points here will experience a ger points because the arm falls forward, overstretching
weakness or feeling of fatigue in the shoulder. This person the muscle at the musculotendinous junction
may not be able to lie on the painful side at night. Also, Grabbing backward for support on the stairs to regain
when lying on the pain-free side, there may be pain due to balance
the uppermost arm falling forward placing the muscle into a M ishitting a ball during racquet sports
stretch position during sleep. Overuse of ski poles
11 2 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 TI N E S B Y B O D Y R E GI O N

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 .)

People with problems in this muscle find it d ifficult to


PRECAUTIONS
fully use their shoulder
This area may be extremely tender. Work gently, get
ting deeper into the layers of this muscle gradually The insertion to this muscle must be examined in any
rotator cuff inj ury
This is a thin, flat muscle with several overlapping sec
tions. It does an extreme amount of work and is quite This muscle should be examined in all shoulder, arm,
prone to forming trigger points forearm, and hand pain syndromes

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 / UPPER TORSO 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
Laterl rotation and extension of the humerus
Horizontal abduction of the humerus FIGURE 6-13 Attachment sites for the teres mi nor. ( Reprinted with
permission from Life Art, Lippincott Williams & Wil kins.)
TRIGGER POINTS AND REFERRAL ZONES
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 FIGURE 6-14 Trigger points and referral zones for the teres mi nor.
( Reprinted with permission from Simons DG, Travell JG, Simons LS.
Working in cramped quarters with the arm reaching
Upper Half of Body. 2nd ed. Baltimore, M D: Lippincott Williams &
overhead Wi lkins, 1999. Travell & Simons'Myofascial Pain and Dysfunction: The
Playing volleyball Trigger Point Manual; vol 1 . p. 565, Fig. 23.1.)
114 PA R T I I / M U S C L E S A N D N E U RO M U SC U LA R TH ERAPY ROUTI N E S B Y BODY R E G I O N

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


Be gentle with pressure along the lateral border of the person then becomes aware of teres minor referring to the
scapula, as teres minor may be extremely tender back of the shoulder
The therapist may want to consider this muscle as syn
ergistic to the infraspinatus and work the two together
MASSAGE THERAPY CONSIDERATIONS as a pair
When a person experiences pain i n the front of the These tendons must be examined in any type of rotator
shoulder, the cause is l ikely to be trigger points of the cuff injury ( Fig. 6- 1 5 )
CHAPTER 6 / UPPER TORSO 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 lum-
bar 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 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.)
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 awkward. Most sensation from trigger points here will not
arm, and hand, including the ring and little fingers. The be experienced upon movement, only at rest. Often a per
person will have difficulty reaching behind to the lower son w ith this type of pain has been through many medical
scapular region. tests and treatment to the area of referral rather than to the
A key trigger point here might be responsible for setting trigger point as the source of pain.
up a satellite trigger point in muscles located within the
referred zone, such as the triceps brachii and flexor carpi TRIGGER POINT ACTIVATION
ulnaris, along with the lower trapezius and iliocostalis thora Trigger points are most likely t o b e activated when this mus
cis. The inferior trigger point in the long fibers over the cle is stretched by reaching forward and up rather than by
lower ribs will refer sensation to the front of the shoulder overloading it during depression and arm extension. It is
and sometimes to the posterior iliac crest area. There have possible for a tight bra around the chest to also activate trig
been some reports of trigger point sensation at the lum ger points in this muscle.
bosacral area attributed to trigger points i n the fasc ial
attachments to the thoracolumbar aponeurosis ( Fig. 6- 1 7 ).
STRESSORS AND PERPETUATING FACTORS
Reaching repeatedly forward and upward, e ither to
Often this pernicious infrascapular, m idthoracic back
manipulate an awkwardly large object or to pull some
ache that is referred from trigger points in latissimus dorsi
thing down
are extremely unresponsive to stretching or changing posi
tion to achieve relief of the sensation. As this is a very long, Exercising by pulling heavy weights overhead
slack muscle, movement other than depression will rarely Throwing a baseball
cause pain, and acute trauma or overload are unlikely to Hanging from a swing or rope
activate trigger points. Pain will occur from reaching up and Working for several hours with a heavy chain saw at
way out from the body to handle something large and shoulder level
1 16 PA R T I I / 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 MASSAGE THERAPY CONSIDERATIONS
while gardening Determination of trigger points in this muscle requires
Doing the butterfly stroke when swimming careful analysis of activities that require the forceful
depression of the shoulder girdle or repetitive exten
PRECAUTIONS s ion combined with adduction
When performing a pincer compression on the bulk of Latissimus dorsi and teres major make up the lateral
this along with teres major, be sure to firmly grasp the border of the armpit
entire bundle j ust lateral to the armpit. I t will be Pincer compression is a very effective technique. Take
extremely uncomfortable to the client if you press into care not to hyperextend your wrist
the edge of the bundle only A s ide- lying position of the client may allow for bet
The muscle belly that crosses the ribs is often glued ter therapist b iomechanics when working with this
down at the lateral border muscle
CHAPTER 6 / UPPER TORSO 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 FIGURE 6-1 8 Attachment sites for the teres major. (Repri nted with
permission from Life Art, Lippincott Williams & Wilkins.)
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.

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 FIGURE 6-1 9 Trigger points and referral zones for the teres major.
(Repri nted with permission from Simons DG, Travell JG, Simons LS.
MASSAGE THERAPY CONSIDERATIONS Upper Half of Body. 2nd ed. Baltimore, M D: Lippi ncott Williams &
Teres major will feel like it i s within latissimus dorsi Wilkins, 1 999. Trovell & Simons'Myofascial Pain and Dysfunction: The

when using the pincer compression Trigger Point Manual; vol 1 . p. 588, Fig. 25. 1 .) Reprinted with permission
from Simons DG, Travell JG, Simons LS.Travell & Simons' Myofascial
To isolate this muscle, begin at the inferior angle of the
Pain and Dysfunction: The Trigger Point Manual. Vol. 1: Upper Half of
scapula, and then sweep proximal to d istal off the lat Body. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins, 1 999; p. 588,
eral border of the scapula Fig. 25. 1 .
118 PA R T I I / M U SC L E S A N D N E U RO M U SC U L A R THERAPY ROUTINES BY BODY REGION

Serratus Anterior: Stitch in the Side Muscle

This muscle is known as the "stitch in the side muscle" TRIGGER POINT ACTIVATION
because its trigger points, when activated, cause symptoms The trigger points may be activated by muscle strain result
of being short of breath or not being able to take deep ing from excessive exercise or severe coughing.
breaths without hurting.
STRESSORS AND PERPETUATING FACTORS
ORIGIN Excessive running, push-ups, or other exercise
Ribs one through eight or nine Lifting heavy weights overhead
Severe coughing and irritation of the lungs caused by
INSERTION
smoking, asthma, bronchitis, and pollution
Posterior surface of the superior angle of the scapula
Posterior surface of the vertebral border of the scapula

PRECAUTIONS
Posterior surface of the inferior angle of the scapula Be gentle with this muscle, as a burning sensation usu
ally occurs when it is worked on
ACTION
Upward rotation and protraction of the scapula If a client's scapula seems glued down, it will be impor
tant to work toward loosening it to be able to work
Stabilizes the scapula against the ribs, preventing it
more thoroughly on serratus anterior
from "winging out"
Assists elevation of the scapula

MASSAGE THERAPY CONSIDERATIONS
TRIGGER POI NTS AND REFERRAL ZONES Weakness in this muscle will allow a winging out of the
scapula
There may be chest pain present from trigger points in ser
ratus anterior. This sensation may be at rest if severe enough. Travell and Simons also refer to this muscle as "the
When the trigger points are mild, there may be a "stitch in smoker's muscle"
the side" sensation while running. The external oblique Only a small portion of the superior aspect of this mus
muscle interdigitates with the lower area of serratus anterior cle can be palpated ( at attachments to ribs one through
fibers on the ribs and may also have a trigger point that three) because of obstruction by pectoralis major
refers similarly but lower down in the side. A person with Prolonged pressure on this muscle, such as occurs when
this condition may have to stop running occasionally to one sleeps on one's side each night, may cause acute
take in a few deep breaths. Also, this person may not be able pain upon awakening
to lie on the affected side at n ight comfortably. This trigger A client with a breathing problem resulting from trig
point may also contribute to the pain felt from a heart attack ger points, hypercontraction, and/or ischemia may
on the left side. Test ing range of motion at the shoulder will present with a stitch in the side or not be able to finish
rarely aggravate this trigger point ( Fig. 6-20). an ordinary sentence without stopping for a breath

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 .)
CHAPTER 6 / UPPER TORSO 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 FIGURE 6-21 Attachment sites for the rhomboid major and mi nor.
( Reprinted with permission from Life Art, lippi ncott Williams &
stabilizing the scapula in a retracted position
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 FIGURE 6-22 Trigger points and referral zones for the rhomboid
Painting a ceiling major and minor. (Reprinted with permission from Simons DG, Travell
JG, Simons LS. Upper Half of Body. 2nd ed. Baltimore, M D: Lippincott
Leaning forward to work, as when sewing or writing in
Williams & Wilkins, 1 999. Travell & Simons'Myofoscial Pain and
longhand Dysfunction: The Trigger Point Manual; vol 1 . p. 6 1 4, Fig. 27. 1 .)
Having scoliosis in the upper thoracic area: a prolonged
stretch of the concave side
1 20 PART I I / 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

PRECAUTIONS Rhomboids, lower trapezius, and levator scapula create


These are re latively thin m uscles and are located a common biomechanically stressed area at the root of
in the second layer of muscles, being deep only to the spine of the scapula
the trapezius. Be sure not to use so much pressure The rhomboids and lower trapezius often adhere to
that you press right through them i n to the deeper each other in those who have overuse syndrome or
layers chronically rounded shoulders
Rhomboids should be examined when there is a diag
MASSAGE THERAPY CONSIDERATIONS nosis of fibromyalgia
Rhomboid m i nor is often t ighter and more painful Referral sensation may be misdiagnosed as scapulocos
than rhomboid major tal syndrome
CHAPTER 6 / 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 FIGURE 6-23 Attachment sites for the deltoid. ( Reprinted with per
Posterior: extension of the arm and assists lateral rota mission from Life Art, Lippincott Williams & Wil kins.)

tion of the humerus

TRIGGER POI NTS AND REFERRAL ZONES


There are many trigger points in all three parts of the del There will be pain upon movement and, occasional ly, at
toid; it can be riddled with them. Referrals mostly encircle rest as well. The sensation will be directed into the deltoid
the actual trigger point but can also refer a short d istance area itself. If there are multiple trigger points in this muscle,
away. Sensation will be felt mostly in the posterior and mid there will be extreme impairment of strength with the pos
dle parts, with spillover sensation to the anterior, middle, sibility of not being able to reach a 90-degree abductio[\
and posterior parts, along with the lateral humerus to j ust from the shoulder. This person may experience a "catch"
above the elbow ( Fig. 6-24 ) . 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 PART 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 R A PY ROUTI N E S BY BODY REGION

.. .. .. ....
.... . ..... . . . . ...... . .. . . .. . .. . ...
TRIGGER POINT ACTi VATION
. . . . . .

Typing on a keyboard that is too high


This muscle is very likely to receive forceful impacts d irectly Driving a car with hands at the top of the steering
against the underlying humerus. The anterior part can be wheel
traumatized by a repeated recoil of a rifle when shooting or Swimming w i th the freestyle stroke
reaching out to a railing to catch oneself from falling. This
part may be overloaded by using heavy power tools at shoul PRECAUTIONS
der height or sorting mail into shoulder-height boxes for Areas of hardness may be felt under the deltoid. This
long periods of t ime. may be attachments of other muscle groups. If tender,
The posterior part is easily overloaded by over exercise treat these attachments using moderate pressure
using weights, or using ski poles for long periods of time. through the deltoid
This is also a site for intramuscular injections of medica The subdeltoid bursa near the greater tubercle of the
t ions. If the needle is placed into a latent trigger point, it is humerus may be inflamed and can cause true bursitis
likely to activate it. The anterior portion does not usually
develop trigger points alone as a result of activity, but usu
MASS'AGE'THERA'Py 'cois'I'DERATi6Ns" " " " " " " " " "
Trigger points in any or all of the three parts of the
ally in association with trigger points in other muscles.
deltoid may refer pain sensation to the subacromial
The middle part is less v ulnerable to overload than are
area and, therefore, be overlooked. According to
the other two parts. Trigger points will set in, however, if
Travell and Simons, often this will mistakenly be diag
there is repetitive, jerky abduction of the arm. Also, satellite
nosed as subdeltoid bursitis. If treated as though it were
trigger points are likely to set in here because of key trigger
subdeltoid bursitis, it will be injected at the bursa and
points in the infraspinatus.
will have a poor therapeutic result consequently
A person may feel symptoms after impact trauma to this
muscle during sports or an injury of some sort. The com The tendon attaching to the deltoid tuberosity may be
plaint will be of pain upon movement of the shoulder and ischemic
possibly upon rest as well. There will be d ifficulty in raising Pain upon flex ion of the arm may indicate trigger
the arm into the horizontal position as well as in bringing points in the anterior fibers
the hand to the mouth. If there is limited but pain-free range of motion, the
. . . .. .. . . . . . deltoid may be treated w ith the person seated, leaning
STRESSORS AND PERPETUATiNG FACTORS
. . . . . . . . . . . . . . . . . . . . .

forward onto the massage table with the arm resting


I ntramuscular injections such as B vitamins, penicil overhead
lin, and influenza vaccine Many other muscles are likely to refer sensation into
Overhead repetitive strain during prolonged lifting the deltoid muscle
CHAPTER 6 I UPPER TORSO 123

Serratus Posterior Superior: Cryptic, Deep, U pper Back Pain

This muscle is labeled the "cryptic, deep, upper back pain" rience painful sensation intensely over the posterior border
because of having very annoying trigger points with very of the deltoid and the long head of the triceps brachii, with
painful referrals, such as a very deep ache under the upper numbness into the hand.
portion of the scapula.
TRIGGER POINT ACTIVATION
ORIGIN Trigger points here are activated by overloading the tho
Spinous processes of C 7 through T 2 o r T3 racic respiratory effort because of coughing (pneumonia,
asthma, chronic emphysema ) , or paradoxical breathing
INSERTION ( using the diaphragm and abdominal muscles out of phase ) .
Superior borders of ribs 2 through 5
STRESSORS AND PERPETUATING FACTORS
ACTION Chronic or long-standing coughing
Raises ribs 2 through 5 to assist inspiration Paradoxical breathing
Smoking cigarettes
TRIGGER POI NTS AND REFERRAL ZONES
Writing at a desk or table that is too high
Sensation from trigger points in this muscle refers strongly
Scoliosis
directly around the trigger points as well as to the posterior
part of the deltoid, the elbow, both po terior and anterior sides PRECAUTIONS
of the wrist, and the radial side of the hand. There may be Rhomboids, which are superficial to serratus posterior
spillover sensation into the chest and between all of the strong superior, must be cleared before working on this muscle
referrals, as well. The person will report a steady, deep ache at
rest, with it increasing by lifting an object with outstretched MASSAGE THERAPY CONSIDERATIONS
hands or lying on the same side as the aching ( Fig. 6-2 5 ) . To palpate its insertion, the scapula must be abducted
Clients will likely identify the painful area a s being under Remember to work d irectly on the ribs, not between
the upper portion of the scapula. They will also likely expe- them

FIGURE 6-25 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 PART I I I M U S C L E S A N D N E U RO 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

Thoraco l u m ba r Pa raspinals: Lumbago spinalis, longissimus, and iliocostalis. Of the three muscles
Generally referred to as the throacolumbar paraspinals, making up this superficial group, it is the longissimus thora
these muscles may be categorized as superficial and deep. cis and iliocostalis thoracis that are most likely to develop
They all appear within the lamina groove. trigger points. Hypercontracted erector spinae muscles cause
a sway-backed condition called hyperkyphosis in the tho
Superficial Muscles: Erector Spinae racic area, whereas hypercontraction of one side only causes
The uperficial paraspinal musculature consists of a superfi scoliosis.
c ial group of longitudinal, long-fibered muscles. They are

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)
- Spinalis
IttrM"<;J"'--
TRIGGER POI NTS AND REFERRAL ZONES
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.
FIGURE 6-26 Attachment sites for the spinalis. ( Reprinted with per

STRESSORS AND PERPETUATING FACTORS mission from Moore KL, Ag u r A. Essential Clinical A natomy. 2nd ed.
Philadelphia, PA: Lippi ncott Williams & Wilkins; 2002.)
Protracted head syndrome and/or excessive neck
hyperextension
Dowager's hump and protruding vertebrae at C7 and T I
Scoliosis
CHAPTER 6 / UPPER TORSO 1 25

When using the elbow to perform deep effleurage, be


PRECAUTIONS

sure to stop at the sacrum when moving in an inferior


A person may need special bolstering and support sys
direction, as this may cause trauma to the tissues over
tems if he or she has scoliosis and/or "roto-scoliosis"
lying the sharp, bony protrusions there
With the above conditions, a person may be uncom
fortable lying prone for prolonged periods of time MASSAGE THERAPY CONSIDERATIONS
When performing deep effleurage with an elbow, do The erector spinae muscles act as flexors of the trunk/
not rotate while exerting deep pressure, as this may spine when standing. This involves eccentric contrac
torque the superficial fascia and cause bruising t ion
Be sure the elbow does not intrude on the spinous It is not uncommon to find the erector spinae muscles
processes, as they are sharp. Avoid traumatizing the weak and fatigued once released
supraspinous ligament and interspinalis muscles attach Good cl ient follow - up practices should include
ing to them strengthening techniques
126 PA R T I I / M U S C L E S A N D N E U RO M U S C U LA R T H E R A PY ROUT I N E S BY BODY R E G I O N

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 FIGURE 6-27 Attachment sites for the longissimlls. ( Reprinted with
tion will begin unilaterally and then, left untreated, become permission from Moore KL, Agur A. Essential Clinical A natomy. 2nd ed.
bilateral as muscles on both s ides become involved ( Fig. Philadelphia, PA: Lippi ncott Williams & Wilkins; 2002.

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 STRESSORS AND PERPETUATING FACTORS
points. This could be a specific activity or a traumatic event. Hyperlordosis and hyperkyphosis, which crete fat igue
A lso repetitive movement over a period of time may acti and ischemia
vate trigger po ints here. Any quick awkward movement, Twisting and lifting at the same t ime. Often occupa
such as a combination of bending and twisting of the back, tional injuries occur because of the employee lifting an
especially when the muscle is fatigued or chilled, will likely object on the floor off to the side without turning first
activate trigger points. to face the object
CHAPTER 6 / 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
FIGURE 6-28 Trigger points and referral zones for the longissimus.

MASSAGE THERAPY CONSIDERATIONS (Reprinted with permission from Simons DG, Travell JG, Simons LS.
Upper Half of Body. 2nd ed. Baltimore, M D: Lippincott Williams &
Longissimus, along with the other erector muscles, will
Wilkins, 1 999. Travell & Simons' Myofascial Pain and Dysfunction: The
respond well to longitudinal friction, which helps Trigger Point Manual; vol 1 . p. 91 5, Fig. 4B. 1 D.)
lengthen muscle fibers
128 PART I I / M U S C L E S A N D N E U RO M U S C U LA R TH E RA P Y ROUTI N E S BY BODY R E G I O N

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 FIGURE 6-29 Attachment sites for the il iocostalis. (Reprinted with
vate trigger points here. Any quick, awkward movement, permission from Hendrickson T. Massage for Orthopedic Conditions.
Baltimore, MD: Lippi ncott Williams & Wilkins; 2003; Fig. 4-46.)
such as a combination of bending and twisting of the back,
especially when the muscle is fatigued or chilled, will likely
activate trigger points.
PRECAUTIONS
STRESSORS AND PERPETUATING FACTORS Chronic pain that does not respond to treatment may
Leaning into a side bend, then quickly twisting into a indicate other structural involvement
forward bend without straightening first If there is a chronic condition, the person may feel
Prolonged sitting in car seats or chairs without support discomfort upon initial compression of this muscle. Be
Whiplash injuries, which can strain this muscle careful here of using any twisting movements
CHAPTER 6 / 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 When perfor m i ng deep effle urage w i th an elbow,
processes, as they are sharp. Avoid traumatizing the do not rotate while exerting deep pressure, as this
supraspinous ligament and interspinalis muscles attach m a y torque t h e superfi c i a l fasc i a and cause
ing to them bru ising
When using the elbow to perform deep effleurage, be
sure to stop at the sacrum when moving in an inferior MASSAGE THERAPY CONSIDERATIONS
direction, as this may cause trauma to the tissues over The lower r i b attachments are often sites of pain, espe
lying the sharp, bony protrusions there cially when a person has an exaggerated lordotic curve
130 PA R T I I / M U SCLES A N D N E U RO M U S C U L A R T H E R A P Y ROUTI N E S BY BODY REGION

Deep Paraspinal Muscles: Lumbago the fibers o f these three deep paraspinal muscles become
The deep paraspinal muscles consist of semispinalis, multi deeper, they also become progressively shorter and more
fidus, and rotatores. The entire group of these deep paraspi horizontal and also become more of a rotator of the spine
nal muscles i s also called "the transversospinalis group." A s 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 FIGURE 6-31 Attachment sites for the semispinalis. (Repri nted with
permission from Hendrickson T. Massage for Orthopedic Conditions .
movement that combines bending, lifting, and twisting of
Baltimore, MD: Lippincott Williams & Wilkins; 2003; Fig. 4-40A.
the back when the muscles are fat igued will most likely acti
vate a trigger point.

STRESSORS AND PERPETUATING FACTORS MASSAGE THERAPY CONSI DERATIONS


Work the lateral aspect of the spinous processes using
Scoliosis
deep transverse friction
Chronic holding or twisting patterns, such as when a
This muscle responds well to longitudinal forearm
person sits on one leg w ith his trunk twisted
lengthening, getting deeper incrementally
Anterior pelvic tilt ( too much pelvic flexion)
You may lengthen this muscle using the forearm "from
Subluxation of vertebrae
distal to proximal and/or the reverse
PRECAUTIONS Chronically tight or painful fibers may feel like wire
Avoid gouging the t issue when applying friction strings or small cables
CHAPTER 6 / 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 FIGURE 6-32 Attachment sites for the multifidus. (Reprinted with
movement that combines bending, lifting, and twisting of permission from Hendrickson T. Massage for Orthopedic Conditions.
the back when the muscles are fatigued will most likely acti Baltimore, M D: Lippi ncott Williams & Wilkins; 2003; Fig. 4-40B.

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
132 PART I I / M US C L E S AND N E U R O M U SC U LA R TH ERAPY ROUTI N E S B Y BODY REGION

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 Unilateral contraction of the tissues of the lamina


Avoid gouging the tissue when applying friction groove can contribute to scoliosis. Bilateral contrac
tions can contribute to a hyperlordotic curve. Small
MASSAGE THERAPY CONSIDERATIONS localized areas of contraction can be responsible
Work the lateral aspect of the spinous processes using for isolated subluxations-partial dislocations of a
deep transverse friction joint-of the spinal vertebrae
C H A PT E R 6 / 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
Multifidus --+-"':"-b---1.-fIj,.::.J
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.

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.)
1 34 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

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)
" ,:
J ft
Subluxation of vertebrae

PRECAUTIONS
. -. :--
Avoid gouging the tissue when applying friction .J - ::
v

MASSAGE TH ERAPY CONSIDERATIONS v


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

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.)
CHAPTER 6 / UPPER TORSO 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, ACTION


bulk, attachments, and innervation. It may occur bilaterally, No skeletal movement is attributed
but more often unilaterally: either side could be missing. I t The reason for contraction of this muscle remains a
i s reported t o b e present in 1 o f 20 individuals. If bilateral, it mystery
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 TRIGGER POINTS AND REFERRAL ZONES
Find ings from these studies also showed that this muscle Trigger points are most often found t o the left o f the midline
may be as thick as X inches over the sternum. This text cites at the midsternal level, with a possibility of another located
the usual attachments. close to the lower attachment in the muscle belly. Referral
sensation is strongly felt covering the majority of the ster
ORIGIN num, with a possibility of spillover across the chest j ust
Sternum under the clavicle and down the anteromedial aspect of the
Fascia over either pectoralis major or sternocleido forearm to the elbow ( Fig. 6-3 6 ) . The sensation felt from
mastoid, possibly forming a continuation of those trigger point activity in this muscle will most likely be
muscles intense, deep substernal pain. Occasionally, a person will
also complain of soreness over the sternum.
INSERTION
3rd through 7th costal cartilages TRIGGER POINT ACTIVATION
Fascia covering pectoralis major Activation is likely to occur upon acute heart attack or
Possibly the sheath of rectus abdominis 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 .)
136 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 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

event that set i t in. Trigger points are also l ikely to occur PRECAUTIONS
as satellites from referral zones of trigger points in sterno Be sure this client has been released from the doctor's
cleidomastoid. In add i t ion, trigger points may be acti care and has this release in writing for you
vated as a resu lt of direct trau m a to the costosternal
Be sure to inform the client that he may experience
area.
similar pain as his previous heart attack or angina when
you press on the trigger points
STRESSORS AND PERPETUATING FACTORS
Forward head posture MASSAGE THERAPY CONSIDERATIONS
Rounded shoulders As this muscle has no real movement, often sternalis is
Maintaining high levels of anxiety overlooked as a source of trigger points
CHAPTER 6 / UPPER TORSO 1 37

Major:The Poor Posture and Heart Attack Muscle

The anatomy of pectoralis major is quite complex as it has ACTION


multiple overlapping layers of muscle fiber, looking simi lar Adduction, horizontal adduction, and medial rotation
to a playing card arrangement held in one's hand. Pectoralis of the humerus
major influences three joints, namely, the sternoclavicular,
Assists in protraction of the shoulder
acromioclavicu lar, and glenohumeral. This muscle is d ivided
Flexion of the humerus ( upper fibers, especially the
into four sections: clavicular, sternal, costal, and abdominal.
clavicular head)
There i a very thick musculotendinous j unction due to the
Depression of the shoulder girdle ( lower fibers)
overlapping fibers wrapping around each other as they work
Extension of the humerus from an elevated po ition
their way toward the insertion. Often, anatomists will omit
( sternal, costal, and abdominal heads)
the abdominal portion of the muscle, possibly because of it
not seeming to develop in certain individuals. There seems
TRIGGER POINTS AND REFERRAL ZONES
to be quite a bit of disagreement among anatomists as to the
Trigger points may form in pectoralis major within any o f the
attachments of this muscle, but most agree on the following
muscle bellies and are likely to develop in fi ve specific areas,
(Figs. 6-37 and 6-3 8 ) .
each with a distinct referral pattern. The sensation from
ORIGIN these trigger points is usually referred unilaterally and might
Clavicular head: medial half of the clavicle localize substernally in the area of the chest and breast,
Sternal head: sternum extending down the ulnar aspect of the arm into the fourth
Costal head: cartilage of ribs 2 through 6 or 7 and fifth fingers. There might be a trigger point in the costal
section that is somatovisceral in nature. The exact location
Abdominal: aponeuroses of the external oblique and,
is the medial right side at the level of the sixth rib. According
occasionally, rectus abdominis
to Travell and S imons, deactivation of this particular trigger
INSERTION point may terminate episodes of cardiac arrhythmia. Any or
The crest of the greater tubercle of the humerus at the all trigger points on the left side may refer sensation in the
lateral lip of the bicipital groove ( there are two d istinct form of pain patterns that are easily mistaken for the pain of
layers here, ventral and dorsal) 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.)
1 38 PART 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 R A PY ROUTI N E S BY BODY R E G I O N

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
FIGURE 6-38 Attachment sites for the pectoralis major. (Reprinted working at the computer
with permission from Life Art, Lippincott Williams & Wilkins.) Standing in a slouched, posture with collapsed chest,
protracted head syndrome, protracted/rounded shoul
ders
Lifting a heavy object with arms outstretched in front
When there is muscle fiber shortening going on to the
extent of protraction of the shoulder girdle, the person is Sustained lifting of a heavy object in a flexed position
likely to be equally aware of their secondary interscapular ( using a chain saw )
back pain within the middle trapezius and rhomboids as they I mmobi l ization of the arm in an adducted position
are of the referral sensation from trigger points in the pecto ( having the arm in a sling)
ralis major. There will be complaints of pain in the front of Overuse of arm adduction (using manual hedge clippers)
the shoulder and subclavicular area along with restricted Sustaining high levels of anxiety or the exposure of
abduction, particularly horizontal abduction. There may be a fatigued muscle fibers to cold air (sitting in the shade
sense of chest constriction along with sensation down the to dry off after a swim)
ulnar aspect of the arm into the hand. If on the left side, Sustaining an acute myocardial infarction

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 / U P P E R TO R S O 1 39

Excessive exercise such as push-ups or using weight MASSAGE THERAPY CONSIDERATIONS


machines to strengthen the pectoralis muscles A person may report intermittent chest pain, chest con
PRECAUTIONS striction, sleep d isorders, and/or breast tissue sensitivity
Pectoralis major can have a somatovisceral effect: a It may be wise to refer this person to a medical doctor
trigger point on the right side only at the medial, costal to be sure there is no sign of heart disease
section Trigger points in the sternal and costal sections have
Elimination of the above mentioned trigger point may been noted to cause pain, swelling, and disruption of
terminate episodes of cardiac arrhythmia, according to lymphatic drainage of the breast tissue. Treating these
Travell and Simons trigger points will usually bring rapid relief of swell ing
Due to the above two precautions, be sure to practice and tenderness according to Travell and Simons
within your proper scope and refer the client to a doc Pincer compression at the musculotendinous j unction
tor (or emergency room if necessary) if they have not is best used when the therapist kneels at the side to
done so on their own allow for good wrist and hand mechanics ( the wrist
Care must be taken not to compress or invade in any and hand will be on the same level plane as the muscle
way the breast tissue when examining or working on tissue this way)
this muscle
1 40 PART I I / M U S C L E S A N D N E U RO M U S C U L A R THERAPY ROUT I N E S BY BODY REGION

Pectoralis Minor: Neurovascular Entrapper

When the pectoralis minor has trigger points, the taut fibers those of pectoralis major. There may be difficulty in reach
are likely to entrap the axi llary artery along with the bra ing forward and up or in reaching backward at shoulder
chial plexus, which may mimic cervical radiculopathy. level.

ORIGIN TRIGGER POINT ACTIVATION


Anterior ribs 3 through 5 near the costal cartilage As with the pectoralis major muscle, any posture that acti
vates a trigger point and is not corrected may also perpetu
I NSERTION ate it. These trigger points here may be activated as satellite
Coracoid process trigger points because of their placement within the area of
pain caused by myocardial ischemia, or as satellites of trigger
ACTION
points in the scalene or pectoralis major muscles.
Protraction o f the scapula
Depression of the scapula STRESSORS AND PERPETUATING FACTORS
Downward rotation of the scapula A trauma such as broken ribs in the upper chest
Assists forced inspiration A whiplash accident
Severe coughing
TRIGGER POINTS AND REFERRAL ZONES
Use of crutches to walk
There are usually a couple o f trigger points found in the
belly of the musc le. The strongest referral is to the anterior Prolonged compression with a tight strap by carrying a
deltoid area. There may be spil lover to the entire chest (on heavy knapsack
the same side as the trigger point) and down the med ial Collapsed chest, respiratory problems, or prolonged
aspect of the ent ire arm into the third through fifth fingers vigorous inspiration
anteriorly. Accord ing to Travell and Simons, a trigger Hyperkyphosis, poor sitting habits, poor chair design,
point on the left side may refer a sensation that mimics muscle imbalances, poor posture in general
cardiac ischemia or angina, j ust as it can in the pectoralis Prolonged position of an arm overhead when sleeping
major ( Fig. 6-4 1 ) . The maj or complaints will be similar to or painting a ceiling

FIGURE 6-41 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 I UPPER TORSO 1 41

FIGURE 642 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.)

This person may complain of numbing and tingling or


PRECAUTIONS

The brachial plexus, axillary artery, and subc lavian other neurovascular symptoms due to entrapment of
vein all pass deep beneath this muscle the neurovascular bundle

Pectoralis minor is a major player when it comes to Symptoms will be similar to those of thoracic outlet
distortion of posture of the upper body as it pulls the syndrome
shoulder forward ( Fig. 6-42 ) Another way to access this muscle is with the person in
a side-lying position. This position allows the breast
MASSAGE THERAPY CONSIDERATIONS tissue and pectoralis major to shift medially, allowing
For comfort when working with a client in a supine pectoralis minor more superficial exposure
position, slacken the muscle and be sure the direction A thorough examinat ion of the upper 2 inches of
of the friction stroke is perpendicular to the axis of the the three tendons attaching to the coracoid process
body ( pectoralis m inor, coracobrachialis, and short head
This muscle is usually tender due to the slumping pos of b iceps brac h i i ) is necessary for all shoulder
ture patterns existing in our society problems
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 FIGURE 6-43 Attachment sites for the subclavius, also shows
t h e sternal e n d referring across t h e chest under t h e clavi pectoralis minor. (Reprinted with permission from Life Art, Lippincott
Williams & Wilkins.)
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 to shoulder
asymmetry

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
C H A PT E R 6 / UPPER TORSO 1 43

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 44 PA R T I I / 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 Repeated forceful lifting overhead while using strong
shoulder syndrome. adduction (swinging a child overhead and then down
again between the "swinger's" legs)
ORIGIN Sudden overload from the trauma of falling backward
Subscapular fossa of the scapula ( anterior surface of the
and catching oneself by reaching back
scapula)
Dislocation of the shoulder joint
INSERTION 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
ACTION hand in a slumped forward posture)
Rotator cuff function: stabilizes the head of the humerus
into the glenoid fossa
STRESSORS AND PERPETUATING FACTORS
Repeated or chronic tendonitis
Medial rotation of the humerus
Reaching into the back seat of a car to lift a heavy object
Assists adduction of the humerus
Having to use the arm overhead for prolonged periods
TRIGGER POI NTS AND REFERRAL ZONES of time (sleeping wrong or painting a ceiling)
There will be trigger points in the muscle belly as well as the Forceful med ial rotation with the arm horizontally
musculotendinous j unction. The strongest referral areas are abducted (playing tennis or weight lifting)
the posterior glenohumeral joint region and the posterior PRECAUTIONS
wrist. There may be spillover referral sensation wrapping Compression techniques applied to the scapula poste
the entire wrist, across the scapula, to the middle deltoid, riorly will affect thi muscle
and down the medial aspect of the upper arm ( Fig. 6-4 5 ) .
A person with trigger points i n this muscle may complain MASSAGE THERAPY CONSIDERATIONS
of progressively painful restriction of abduction and lateral Chronic contraction of subscapularis may mimic fro
rotation of his or her arm. This person will be unable to reach zen shoulder syndrome ( adhesive capsulitis). Th is
backward at shoulder height and, therefore, will not be able should always be checked in an individual diagnosed
to throw a ball. There may be pain both at rest and upon with "frozen shoulder"
motion, with inability to reach across to the opposite armpit. Use the lesser tubercle as a bony landmark for locating
the subscapularis tendon
TRIGGER POINT ACTIVATION Use a broad sweep to friction this tendon
Unusual repetitive exertion of forcefu l medial rotation The belly of subscapularis may be accessed directly
(pitching a baseball or swimming the crawl stroke) through the axilla

FIGURE 6-45 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.
ROUTINE 6-1
Note: Move to the head of the table.
146 PA R T I I / M U S C L E S A N D N E U RO M U S C U LA R THERAPY ROUT I N E S BY BODY R E G I O N

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 / UPPER TORSO 1 47

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
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 ROUTI NE 6-8

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.
CHAPTER 6 UPPER TORSO 1 49

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.
ROUTIN E 6-1 1
Note: Move to the side of the table.
15 0 PA R T I I I 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 / UPPER TORSO 1 51

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
1 52 PART I I I 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

TERES MAJOR 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 / UPPER TORSO 15 3

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. ROUTI N E 6-22

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.
1 54 PA RT I I / 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

SIT TENDONS
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 / UPPER TORSO 1 SS

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


ROUTI N E 6-26
through the sheet if necessary.

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
ROUTI NE 6-27
from origins on the clavicle and upper sternum toward the
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 ROUTI N E 6-28
(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.
15 6 PA R T I I / 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.

ROUTINE 6-30
SUBCLAVIUS e
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 / UPPER TORSO 1 57

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
15 8 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 BY B O DY R E G I O N

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
ROUTI NE 6-34
it in a lateral direction. This will abduct the scapula and a llow
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 I UPPER TORSO 1 59

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, your primary goals for the therapy?
all in his right shoulder. He was left with very l ittle range of
2. Which regions and m uscles would you work on?
motion in this shoulder. He had many s u rgeries to regain
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?
1 60 PART I I / M U S C L E S A N D N E U RO M U S C U LA R TH E R A PY ROUTI N E S B Y B O D Y R E G I O N

REVIEW QUESTIONS

Short Answer Questions 1 0. Eliminating trigger points in which muscle may actu
ally terminate episodes of cardiac arrhythmia?
1. What is the significance of working the lateral aspects
of the spinous processes in the thoracic spine ? What is A. Pectoralis minor
being worked on ? B. Pectoralis major
C. Anterior deltoid
2. N ame the three muscles that insert at the b ic ipital
D. Subclavius
groove of the humerus.
True/False
3. List the four muscles involved in downward rotation of
the scapula. 1 1 . Scoliosis is a lateral curve i n the spinal column: either
a "c" - or an "s" -shaped curve.
4. Which two muscles have attachments on the inferior
angle of the scapula? 1 2. Upper trapezius, levator scapulae, and serratus anterior
all contribute to elevating the shoulder.
5. Which part of the trapezius most commonly refers pain
to the head? 1 3 . Pain medial to the vertebral border of the scapula could
indicate ischemia and trigger points in rhomboids, mid
Multiple Choice Questions
dle trapezius, and levator scapulae.
6. Which two muscles act in both flexion and horizontal
14. The lower attachments of serratus anterior interdigi
adduction of the shoulder?
tate with the attachments of rectus abdominis.
A. Pectoralis minor and upper trapezius
B. Teres major and pectoralis major 1 5 . To palpate the trigger point in serratus posterior supe
C. Pectoralis major and anterior deltoid rior, the scapula must first be abducted.

D. Subclavius and pectoralis minor Matching

7. Which muscle does Travell and Simons refer to as "the 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 1 8. Which is a rotator cuff muscle?
dorsi to the spinous processes and sacru m ?
1 9. Which muscle inserts at the bicipital groove of the
A . Iliolumbar ligament
humerus ?
B. Oblique fascia
C. Palmar aponeurosis 20. The greater tubercle of the humerus is the common
D. Thoracolumbar aponeurosis insertion of which muscles?

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
CHAPTER 6 / U P P E R TORSO 1 61

REFERENCE

1 . Eisler P. Die Musckeln des Stammes. lena, Germany: Gustav


Fischer Verlag; 1 9 1 2 :470-475; Figs. 70, n.
THIS PAGE INTENTIONALLY
LEFT BLANK
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
together
the wrist
Synergistic muscles: muscles that work together to perform
Congenital: existing prior to or at birth
specific movement
Dupuytren contracture: contracture of the pal mer aponeuro
Thenar eminence: t he fleshy m ound of muscle tissue that
ses causing the ring and the little fingers to bend into the
covers the first metacarpal distal to the base of t he thumb
palm and not be extended
Thoracic outlet syndrome: a complex condition caused by condi
Electromyographic test (EMG): a test to record graphica l l y the
tions in which nerves or vessels are compressed in the neck or
contraction of a muscle using electric stimulation
axilla; also known as thoracic outlet compression syndrome
Enigmatic: puzzling
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

upper arm, then moving on to the forearm and, finally, the


OVERVIEW OF THE ARM, WRIST, hand. We will cover both the anterior and posterior por
AND HAND REGION tions of the arm. As always, our goal here is to find all
In this chapter, we will concern ourselves with the mus active, latent, and associated trigger points, and then
cles of the arm and the hand region, beginning with the deactivate them.

163
1 64 PA R T I I M U S C L E S A N D N E U RO 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

Conditions one may encounter when working with this learn to recognize possible symptoms of key conditions and
area of the body are usually caused by mechanical overload refer your client to a primary care physician if you suspect a
and repetitive strain injuries. Carefully consider each cli condition that falls outside of your scope of practice. You
ent's medical history and also be aware of symptoms of may also want to request that your client bring in a written
potentially undiagnosed conditions. Although it is not the diagnosis from his or her doctor if necessary.
massage therapist's role to diagnose conditions, you should

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
FIGURE 7-1 Attachment sites for the biceps brachii. Short head: cora
lies of this muscle. Referral sensation will be most strongly coid process of the scapulae. Long head: supraglenoid tubercle of the
felt in the long head tendon and at the insertion. There may scapulae with its tendon lying in the intertubercular (bicipital) groove
be some spillover activity between those two points, as well of the humerus. Both heads: radial tuberosity. (Reprinted with permis
sion from LifeArt, Lippincott Williams & Wilkins.)
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
C H A PT E R 7 I A R M , W R I S T , A N D H A N D 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

jC 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. Sustained elbow flexion overload (playing the violin or
The trigger points will usually set into the muscle belly closer to its guitar, using electric hedge clippers, etc.)
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
PRECAUTIONS
two points. (Reprinted with permission from Medi Clip, Lippincott
Begin work on the long head tendon gently, as it can
Williams & Wilkins.)
be quite tender.

MASSAGE THERAPY CONSI D ERATIONS


raising the arm above the shoulder level upon flexion and A good position for working the long head tendon is
abduction. They may experience diffuse aching and tender with your hand above the client's shoulder, with your
ness and inflammation over the long head bicipital tendon, thumb positioned to apply long strokes downward from
a condition known as bicipital tendonitis. proximal to distal through the intertubercular groove.
If this person presents with a sudden painful catch in the The tendon of the long head can become misplaced,
shoulder when abducting the arm, refer him or her to a doc out of the intertubercular groove; if this occurs, it will
tor to have the long head tendon checked to be sure it is not be quite sore.
being pinched between the acromion and the glenoid Remember to have the entire arm supinated to be able
labrum. This condition must be dealt with surgically. to work on the entire muscle.
1 66 PART I I I M U S C L E S A N D N E U RO M U SC U L A R T H E RAPY ROUT I N E S BY BODY R E G I O N

Coracobrachia l is: H ide a nd Go Seek

Locating trigger points in this muscle requires more skill Chances are that this feeling will even persist when at rest,
than with most muscles due to their mainly being satellites as well (Fig. 7-3).
from the anterior deltoid, the short head of biceps brachii, The primary complaint of clients with trigger points in this
and the long head of triceps brachii. region is typically upper limb pain, usually in the front of the
shoulder and posterior arm. They often describe the pain as
ORIGIN occurring when they are reaching behind the body and across
The apex of the coracoid process of the scapulae (the
the low back. This movement stresses this muscle because it
tendon blends with the short head tendon of biceps involves strong medial rotation along with extension.
brachii there)
TRIGGER POINT ACTIVATION
INSERTION These trigger points usually develop secondarily to active
Medial surface of the humerus at the midpoint of the
trigger points in related, synergetic muscles: the short head
shaft of biceps brachii and pectoralis major. Synergistic muscles are
muscles that work together to perform specific movement.
ACTION
Flexion and adduction of the arm at the glenohumeral
STRESSORS AND PERPETUATING FACTORS
joint Trigger points in its synergistic muscles
Weak assistance in returning the arm to neutral from
Keeping the arm in adduction, as when having to wear
lateral and medial rotation a sling

TRIGGER POINTS AND REFE RRAL ZONES PRECAUTIONS


Trigger points are usually found in the proximal muscle belly Positive isolation or identification is important before
just below the musculotenclonus junction of its origin but can working here due to nerve and lymphatic tissue in this
be as far distal as the middle of the muscle belly. A musculoten area
clonus junction is where a muscle and tendon join together.
Sensation is referred over the anterior deltoid region MASSAGE THERAPY CONSIDERATIONS
and inferiorly down the posterior aspect of the arm, con If trigger points are suspected here after relieving those
centrating over the triceps brachii, the dorsum of the fore found in synergistic muscles, have the person perform
arm, and the dorsum of the hand. It usually skips the elbow a back rub test to confirm by placing the posterior wrist
and wrist regions. When these trigger points are most at the small of the back and rubbing it across to the
active, the referral sensation is greater or more intense. 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 .)
C H A P T E R 7 / A R M , W RI S T , A N D H AN D 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 FIGURE 7-4 Attachment sites for the brachialis.The distal half of the
Carrying groceries anterior shaft of the humerus, coronoid process of the ulna. ( Reprinted
with permission from Life Art, Lippincott Williams & Wilkins.)
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
1 68 PA R T II / M U S C L E S A N D N EU R O MU S CU L A R T H E R A P Y R OU T I N E S B Y B O D Y R E GI O N

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. FIGURE 7-6 Attachment sites for the triceps brachii. Long head: infra
glenoid tubercle of the scapulae. Lateral head: posterior humerus
The medial head usually has two trigger point areas
above the spiral groove. Medial head: posterior humerus below the
that refer strongly to the lateral and the anteromedial spiral groove. All heads: olecranon process of the ulna. (Reprinted
elbow with spillover above and below these two points with permission from Life Art, Lippincott Williams & Wilkins.)
and possibly into the anterior surface of the mo t medial
two fingers.
The client will likely describe pain more upon forceful
The lateral head's trigger point usually strongly refers
extension at the elbow, such as when playing a racquet sport
right around itself, but could have spillover around the
or golf. Chances are that if left without seeking treatment,
strong referral area, into the posterior forearm and the pos
this client will develop serious epicondylitis either medially
terior surface of the most medial two fingers.
or laterally.
The common tendon will also have a trigger point within
it that refers very strongly into the posterior elbow (Figs. 7-7 TRIGGER POINT ACTIVATION
to 7-9 ). Trigger points in this muscle are likely to occur as a result of
A client with trigger points in this muscle will probably overload from overuse.
complain of vague, hard-to-Iocalize pain in the posterior
shoulder and upper arm. The client will likely not demon STRESSORS AND PER PETUATING FACTO RS
strate restriction of movement due to compensation by Using crutches or a cane that is too long

keeping the elbow slightly bent. You may observe the client Having the anatomical variation of a short humerus

holding the elbow away from the side, avoiding body con Straining the muscle during sports
tact due to a very sensitive medial epicondyle. Doing too many push-ups
1 70 P A R T II / MU S C L E S A N D N EU R O MU S CU L A R T H E R A P Y R OU T I N E S B Y B O D Y R E G I O N

v
v

"
v

"
v
V v
oJ oJ

v v
v

//""' v

\)

------

\)
I

FIGURE 7-7 Trigger points and referral zones for the triceps brachii, FIGURE 7-8 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 numbers 3 and 4. Number 3 trigger point sets up within the upper por
long head with strong referral to the posterior deltoid and lateral tion of the muscle belly of the medial head with strong referral around
condyle of the humerus. There could be spillover from the base of the itself. Spillover may surround the strong referral; go down the posterior
neck, across the shoulder, down the posterior upper arm and forearm forearm and into the posterior side of the ring and pinky finger.
as well. N u mber 2 trigger point will set up in the lower belly of the Number 4 trigger point sets up within the long, dense tendon above
medial head and refer strongly to the lateral condyle of the humerus the insertion and refers strongly into the olecranon process. (Reprinted
with a bit of spillover down the lateral posterior forearm. (Reprinted with permission from Medi Clip, Lippincott Williams & Wilkins.)
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
FIGURE 7-9 Trigger points and referral zones for the triceps brachii,
With chronic rotator cuff problems, the long head of tri number 5.This is a tricky trigger point that sets into the musclf belly
ceps should be checked at its attachment to the scapulae 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
Trigger points in this muscle are often overlooked
with spillover down the anterior forearm and into the anterior side of
Trigger points here increase muscular tension and the ring and pinky fingers. (Reprinted with permission from Medi Clip,
cause dysfunction as well as pain 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 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
FIGURE 7-'0 Attachment sites for the brachioradialis. Lateral supra
space. There may be spillover sensation along the length of condylar ridge of the humerus, styloid process of the radius. (Reprinted
the muscle, as well (Fig. 7- 1 1 ). with permission from Life Art, Lippincott Williams & Wilkins.)
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.
1 72 PA R T II M U S C L E S A N D N E U RO M U S C U L A R T HE R A P Y RO U T I N E S B Y BO D Y R EG IO N

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
FIGURE 7-11 Trigger points and referral zones for the brachioradialis.
sensation from a trigger point
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.)
C H A PTER 7 A R M , W R I S T, A N D H A N D 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 FIGURE 7-13 Attachment sites for the supinator: posterior view.
pattern has very little spillover. There is usually very strong Dorsal surface of the ulna, lateral and ventral ligaments of the radioul
sensation at the lateral epicondyle of the humerus on both nar joint, anterior capsule of the humeroulnar joint. These are all ori
the anterior and posterior surfaces as well as into the base of gins. (Reprinted with permission from Life Art, Lippincott Williams &
Wilkins.)
the thumb and the index finger at the web space (Fig. 7- 1 4 ).

FIGURE 7-14 Trigger points and referral zones for the supinator.
Trigger points in the muscle belly usually set in on the posterolateral
FIGURE 7-12 Attachment sites for t h e supinator: anterior view. edge of the radius with very strong referrals to the lateral epicondyle
Proximal one-third of the radius, wrapping it from lateral to medial on both the anterior and posterior sides as well as to the posterior
then attaching. This is the insertion. (Reprinted with permission from web and thumb. (Reprinted with permission from Medi Clip,
Life Art, Lippincott Williams & Wilkins.) Lippincott Williams & Wilkins.)
1 74 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 NE S B Y B O D Y R E G I O N

A client with active trigger points here will often complain hand repeatedly throughout the day. Also, trigger points
of having aching pain in either, or both, the lateral epicondyle could be activated simply by carrying a heavy briefcase or
and the dorsal surface of the web of the thumb. This pain will suitcase with the elbow straight because the supinator must
probably be experienced when the elbow is at rest after using constantly be stabilizing.
it. Travell and Simons state that it is their experience that
nearly every person with lateral epicondylar pain and tender STRESSORS AND PERPETUATING FACTORS
Stress overload (as discussed above)
ness has an active trigger point in the supinator, and this
most often contributes to the pain of tennis elbow. Opening tight jars or using a screwdriver by only using
the wrist
TRIGGER POINT ACTIVATION Turning stiff doorknobs
Trigger points will set in and become active when a racquet Wringing wet clothes when doing laundry
sports player mis-hits the ball off center, twisting the racquet Meticulous ironing
while the elbow is completely extended; usually this occurs
Walking a large dog that pulls on the leash
with a backhand stroke. The supinator is being strained
Handshaking long lines of people
with this activity because of full elbow extension. When
Raking leaves or washing walls
this is the case, the biceps brachii cannot assist to resist the
added force. Activation of trigger points here could also be PRECAUTIONS
from resisting unexpected pronation or by executing an There may be entrapment of the radial nerve which, in
extremely forceful supination. turn, may activate trigger points
Travel1 and Simons also use terms such as briefcase elbow,
door-handle elbow, and dog walker's elbow. These names MASSAGE THERAPY CONSIDERATIONS
refer to any excessive or forceful, repetitive, or sustained Access to this muscle works best when the client's elbow
supination of the forearm, especially when the elbow is is flexed with the forearm held in a neutral position
straight. Also, it could be forceful elbow flexion when the It will be important to soften brachioradialis and
forearm is held in pronation. Briefcase elbow occurs by the extensor carpi radialis longus before working with the
briefcase being flipped onto the desktop by the carrying supinator
CHAPTER 7 / A R M , W R I ST, A N D H A N D 1 75

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
FIGURE 7-15 Attachment sites for the extensor carpi radialis longus.
plaints are of dysfunction in the form of weakness and pain. Base of the 2nd metacarpal on the posterior surface, distal third of
Pain is probably the major complaint. the lateral supracondylar ridge of the humerus. (Reprinted with
permission from Life Art, Lippincott Williams & Wilkins.)
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.
1 76 PA R T I I M U S C L E S A N D N E U R O MU S C U L A R T H E R A P Y R OU T I N E S B Y B O D Y R EG I O N

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

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"
FIGURE 7-16 Trigger points and referral zones for the extensor carpi
Trigger points here can produce dysfunction in the
radialis longus.The trigger point will set up within the muscle belly
form of limited movement and/or weakness, as well as and strongly refer around itself.There may be quite a bit of spillover
pain in the posterior hand with a bit surrounding the strong referral and
Trigger points in the scalene and supraspinatus muscles then down the posterior forearm. (Reprinted with permission from
Medi Clip, Lippincott Williams & Wilkins.)
can induce satellite trigger points in this muscle
C H A P T E R 7 / A R M , W R I S T, A N D H A N D 1 77

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 FIGURE 7-17 Attachment sites for the extensor carpi radialis brevis.

the form of weakness and pain. Pain is probably the major Base of the 3rd metacarpal on the posterior surface, lateral epi
condyle of the humerus via the common extensor tendon deep to
complaint. extensor carpi radialis longus muscle belly. (Reprinted with permis
sion from Life Art, Lippincott Williams & Wilkins.)
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.

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
FIGURE 7-18 Trigger points and referral zones for the extensor carpi
radialis brevis. While the trigger points will usually be found within
MASSAGE THERAPY CONSIDERATIONS
the muscle belly, there will be strong referral to the posterior surface
This is the most common muscle involved in the con of the hand with spillover around it. (Reprinted with permiSSion from
dition of tennis elbow Medi Clip, Lippincott Williams & Wilkins.)
1 78 PA R T I I 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). FIGURE 7-1 9 Attachment sites for the extensor digitorum. Dorsal
A client with trigger points in this muscle will most likely surface of the distal phalanx of fingers no. 2-5, lateral epicondyle of
complain of either pain like that of tennis elbow or of feel the humerus via the common extensor tendon. (Reprinted with per
ing arthritis in the fingers. mission from Life Art, Lippincott Williams & Wilkins.)

TRIGGER POINT ACTIVATION


Overuse of forceful repetitive finger movements by musi
cians (mostly pianists), carpenters, or mechanics com STRESSORS AND PERPETUATING FACTORS
monly activates trigger points in this muscle. Travell and Repetitive forceful hand gripping

Simons report having seen activation by a fracture of the Playing the piano for long periods of time
forearm. Throwing a Frisbee
CHAPTER 7 A R M , W R I ST, A N D H A N D 1 79

..
" .


".

..
. ,.
""
'.

0'
"""

FIGURE 7-20 Trigger points and referral zones for the extensor FIGURE 7-21 Trigger points and referral zones for the extensor
digitorum--middle fi nger. The trigger point is usually in the upper digitorum-ring finger. Again the trigger point is in the u pper mus
muscle belly with very strong referral to the middle finger on the pos cle belly with strong referral to the ring finger. There may also be
terior surface with spillover between the actual trigger point and the strong referral to the posterolateral el bow area with spillover
strong referral. (Reprinted with permission from Medi Clip, Lippincott between the two strong referrals. (Reprinted with permission from
Williams & Wilkins.) Medi Clip, Lippincott Williams & Wilkins.)

PRECAUTIONS MASSAG E THERAPY CONS I DERATIONS


It is possible for a tendon to lose its mooring over the Travell and Simons cite a study done by Hong4 that
metacarpophalangeal joint. This displacement must be indicates key trigger points in either the scalenes or
repaired surgically the serratus posterior superior could induce satellite
If a client sleeps with his hands and fingers fully flexed, trigger points in the extensor digitorum
this muscle will be overstretched. According to Travell
and Simons, this encourages the development of a car
pal tunnel syndrome
1 80 PA R T I I M U SC L E S A N D N E U RO M U SC U L A R T H E RAPY R O U T I N E S BY BODY R E G I O N

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.
FIGURE 7-22 Attachment sites for the extensor carpi ulnaris. Base of
TRIGGER POINT ACTIVATION the 5th metacarpal on the medial surface, lateral epicondyle via the
Mostly, trigger points in this muscle are activated by force common extensor tendon. (Reprinted with permission from Life Art,
ful, repetitive hand gripping. The larger the object being Lippincott Williams & Wilkins.)

grasped is, the more likely this muscle is to develop trigger


points, just as with brachioradialis.

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 FIGURE 7-23 Trigger points and referral zones for the extensor carpi
This muscle, together with the flexor carpi ulnaris 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
muscle, strongly adducts the wrist
surrounding. (Reprinted with permission from Medi Clip, Lippincott
Williams & Wilkins.)
CHAPTER 7 A R M , W R I ST, A N D H A N D 181

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)
FIGURE 7-24 Attachment sites for the anconeus. Dorsal shaft of the
ulna, lateral side of the olecranon process, lateral epicondyle of the
TRIGGER POINTS AND REFERRAL ZON ES
humerus. (Reprinted with permission from Life Art, Lippincott Williams
Trigger points in this muscle are usually located in the mus & Wi lkins.)
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


r X(r
'.'
'.'

Trigger points may be activated in this muscle because of


overload from overuse.

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
FIGURE 7-25 Trigger points and referral zones for the anconeus. The
support 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.)
1 82 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

Vigorous repetitive extension of the elbow, usually MASSAGE THERAPY CONSIDERATIONS


accompanied by a sudden impact or vibration, for This muscle can be extremely tender and feel gritty
example, using a heavy hammer or operating motor upon palpation; be gentle
ized equipment with the arm extended and held in Using sustained pressure to this muscle while applying
front of the chest
mobilization can be effective in loosening tight bands,
for example, flexion to extension or alternating supi
PRECAUTI ONS
According to Travell and Simons, this anomalous
nation and pronation
exceptional or abnormal-muscle has been reported to
be the cause of ulnar compression neuropathy
C H A P T E R 7 / A R M , W R I ST, A N D H A N D 1 83

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
FIGURE 7-26 Attachment sites for the flexor carpi radialis. Base of
the median nerve in the wri t. second and third metacarpal, medial epicondyle via the common
flexor tendon. (Reprinted with permission from Life Art, Lippincott
TRIGGER POINT ACTIVATION Williams & Wilkins.)
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.
1 84 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

STRESSORS AND PERPETUATING FACTORS


Any prolonged, gross gripping, such as occurs when
L
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 FIGURE 7-27 Trigger points and referral zones for the flexor carpi
elbow radialis. The trigger point will set up within the muscle belly, usually
half way down the forearm, and strongly refers into the anterior wrist
Trigger finger may develop here: a condition in which
with a bit of spillover above and below the strong referral. (Reprinted
flexion or extension of a digit is arrested temporarily with permission from Medi Clip, Lippincott Williams & Wilkins.)
but finally is completed with a jerk
C H A PT E R 7 A R M , W R I S T, A N D H A N D 1 85

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 FIGURE 7-28 Attachment sites for the flexor carpi ulnaris.The origins
working with the muscles in the arm will not be sufficient. are as follows: H umeral head-medial epicondyle via the common
Thoracic outlet syndrome, also known as thoracic outlet flexor tendon. Ulnar head-medial margin of the olecranon and the
compression syndrome, is a complex condition caused by proximal two-third of the dorsal edge of the ulna.The insertion is the
pisiform. (Reprinted with permission from Life Art, Lippincott Williams
conditions in which nerves or vessels are compressed in the
& Wilkins.)
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.
1 86 PA R T I 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

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
FIGURE 7-29 Trigger points and referral zones for the flexor carpi
serves to attach muscle to bone or other tissues ulnaris. The trigger point will set up within the muscle belly, usually
Tendonitis at the origin of this muscle is called "golfer's half way down the forearm, and strongly refers into the anteromedial
wrist with a bit of spillover both above and below the strong referral.
elbow"
(Reprinted with permission from Medi Clip, Lippincott Williams &
Trigger finger may develop here Wilkins.)
CHAPTER 7 A R M , W R I ST, A N D H A N D 1 87

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 FIGURE 7-30 Attachment sites for the flexor digitorum superficialis.
what proximally while referring sensation to a distance. The origins are as follows: Ulnar head-ulnar coronoid process,
medial aspect. Humeral head-medial epicondyle via the common
Trigger points in the radial head refer strongly to the middle
flexor tendon. For the insertion, each tendon splits to encircle the ten
finger with spillover into the palm and also extending dons of profundus as they attach to the sides of the middle phalanx
beyond the fi n ger as if exploding. Trigger points in the of the medial four fingers. (Reprinted with permission from Life Art,
humeral head refer sensation strongly into the medial two Lippincott Williams & Wilkins.)
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 ical overload of the muscle. Satellite trigger points may
to those of the other finger flexors. Clients with these trigger develop from key trigger points in the pectoralis minor mus
points are likely to report having difficulty using scissors or cle. Tightly gripping an object for long periods of time may
shears when cutting heavy cloth, gardening, or snipping tin. be considered mechanical overload.
They also may have problems with doing fine movements
STRESSORS A N D PERPETUATING FACTORS
with fingers, such as placing their hair in rollers.
Any prolonged, gross gripping, such as occurs when

TRIGGER POINT ACTIVATION using hand tools, holding ski poles, or grasping a steer
Trigger point activation in this muscle, again, is identical to ing wheel for long periods of time
that of the other finger flexor muscles. Usually, trigger points Not correcting an active trigger point may also per
here become activated because of acute or chronic mechan- petuate it
1 88 PA R T I I / M U SCLES A N D N E U RO M U SC U L A R T H E RAPY R O U T I N E S BY BODY R E G I O N

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. Trigger points left in superficial is may entrap the
The origins are as follows: Profundus-proximal % of the medial and median nerve, as well
dorsal surface of the ulna, the ulnar coronoid process on the medial
aspect, the ulnar half of the interosseous membrane. The insertion is MASSAGE THERA PY CON SIDERATIONS
the base of distal phalanx of the medial four fingers. (Reprinted with
Tendonitis at the origin of this muscle is called "golfer's
permission from Life Art, Lippincott Williams & Wilkins.)
elbow. "
Trigger finger may develop here
C H A PT E R 7 / A R M , W R I ST, A N D H A N D 1 89

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
FIGURE 7-33 Attachment sites and trigger points with referral zones

I N SERTION for the palmaris longus. (Reprinted with permission from Simons DG,
Travell JG, Simons LS. Upper Halfof Body. 2nd ed. Baltimore, MD:
Palmar aponeuroses
Lippincott Williams & Wilkins, 1 999. Trave" & Simons' Myofascial Pain
Transverse carpal ligament (also called the flexor reti and Dysfunction: The Trigger Point Manual; vol 1 . p. 744, Fig. 37.1 .)

naculum)

ACTION cases will also demonstrate palmar contracture, as with


Flexes the hand at the wrist Dupuytren's contracture : a contracture of the palmer
Tenses the palmar fascia aponeuroses causing the ring finger and the little finger to
Assists pronation of the hand against resistance bend into the palm and not be able to extend.
Assists elbow flexion
TRIGGER POINT ACTIVATION
TRIGGER POI NTS AND REF E RRAL ZON ES Usually, trigger points here develop as satellites because of
With the trigger points occurring within the belly of the key trigger points in the distal medial head of triceps
muscle, referrals are strongly felt at a distance into the palm brachii, which refers sensation to the area of palmaris lon
of the hand with spillover around that area and up the gus. Direct trauma can also activate trigger points in pal
center of the forearm (Fig. 7-33). maris longus. According to Travell and Simons, people with
Clients with trigger points here often complain of pain in Dupuytren's contracture usually have one or more active
the palm of the hand as well as of difficulty in handling tools trigger points in palmaris longus, though there is no experi
due to soreness and tenderness in the palm. There may be mental data regarding the contractu res being related to
tender nodules in the palm of the hand, as wei\. Advanced trigger points.
1 90 PA R T I I M U SC L E S A N D N E U RO M U SC U L A R T H E RAPY R O U T I N E S B Y BODY R E G I O N

STRESSORS A N D PERPETUATING FACTORS PRECAUTIONS


Falling onto an outstretched hand Anatomical variations may cause median nerve entrap

Any prolonged, gross gripping, such as occurs when ment at the wrist
using hand tools, holding ski poles, or grasping a steer Anatomical variations may cause ulnar nerve entrap
ing wheel for long periods of time ment in the area of the ulnar tunnel at the wrist
Holding a racquet with the end of the handle against
MASSAGE TH ERAPY CON S I D E RATIONS
the palm
Tendonitis at the origin of this muscle is called golfer's
Leaning on a cane with an angular head pressing into
elbow
the palm
N ot correcting an active trigger point may also per
petuate it
CHAPTER 7 A R M , W R I ST, A N D H A N D 191

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
FIGURE 7-34 Attachment sites for the pronator teres. The origins are
hand.
as follows: Humeral head-proximal to the medial epicondyle. Ulnar
head-medial side of the coronoid process of the u lna. The insertion
TRIGG ER POINT ACTIVATION
is the lateral radius at the midpoint of the forearm. (Reprinted with
Trigger points here could be activated by a wrist or elbow permission from Life Art, Lippincott Williams & Wilkins.)
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.

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.)
1 92 PA R T I I M USCLES AND NEU ROMUSCULAR THERAPY ROUTI NES B Y BODY REGION

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
FIGURE 7-36 Attachment sites for the adductor and opponens polli
Opponens Pol/icis cis. Adductor pollicis origins: Oblique head-carpometacarpal region
Brings thumb across the palm toward the pads of the of the index and middle fingers. Transverse head-shaft of the 3rd
ring finger (opposing) metacarpal bone.The insertion is the base of the proximal phalanx of
the thumb. Opponens pollicis origins-trapezium bone, flexor reti
TRIGGER POI NTS A N D R E FERRAL ZON ES naculum (also known as transverse carpal ligament). The insertion is
the head of 1 st metacarpal, lateral aspect. (Reprinted with permission
Trigger points in both muscles usually occur within the mus
from Medi Clip, Lippincott Williams & Wilkins.)
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 complain of the thumb being clumsy and their handwriting
two are quite similar, with sensation sent into the anterior being illegible due to having difficulty holding a pen. They
radial aspect of the wrist, anterior thumb, and thenar emi may also have problems with fine manipulations with the
nence, and posteriorly to the base of the thumb and the thumbs, such as when buttoning clothing, sewing with a
thumb itself with some spillover. Thenar eminence is the needle, and writing and painting, due to movement that
Aeshy mound of muscle tissue that covers the first metacar requires a pincer grip using the thumb.
pal proximal to the base of the thumb (Figs. 7-37 and
7-38). TRIGGER POINT ACTIVATION
The symptom most associated with trigger points in these This is usually due to spending long periods of time .using
muscles is pain. Clients with these trigger points may also the thumb for strong grasping, as when weeding well-rooted
C H A PT E R 7 A R M , W R I S T, A N D H A N D 1 93

FIGURE 7-37 Trigger points and referral zones for the adductor poll i FIGURE 7-38 Trigger points and referral zones for the opponens pol
cis. The trigger point will usually be in the muscle belly just medial to licis.The trigger point will usually be in the muscle belly near the base
the 2nd metacarpal bone. It strongly refers to the thumb in a pattern of the thumb with strong referrals to the anterolateral wrist and ante
that wraps the entire thumb from base to tip and from the anterior rior surface of the thumb. There may be some spillover that surrounds
surface to the posterior surface. There may be some spillover that sur both of the strong referrals. (Reprinted with permission from Medi
rounds the strong referral. (Reprinted with permission from Medi Clip, Clip, Lippincott Williams & Wilkins.)
Lippincott Williams & Wilkins.)

weeds. In this situation, the person must hold strongly to the most commonly mistakenly attributed to carpal tun
weed while rotating the wrist to loosen it up before pulling nel syndrome, DeQuervain's tendosynovitis, and
it out of the ground. Any other sustained tension using a osteoarthritis.
pincer grip with the thumb opposing the fingers may also Articular dysfunctions can relate strongly to trigger
activate trigger points. points in these thumb muscles.

STRESSORS AND PERPETUATING FACTORS MASSAGE TH ERAPY CON S I D E RATIONS


Working with a small instrument held firmly between Be sure to check for trigger points if there was a previ
the thumb and fingers, such as when using a fine paint ous fracture to the hand/wrist area and the pain never
brush, sewing with a needle, or writing longhand went away
A fracture of a wrist or hand bone This area can be very tender, so be sensitive with your
Weeder's thumb syndrome work

PRECAUTIONS
According to Travel! and Simons, symptoms pro
duced by trigger points in these thumb muscles are
1 94 PA R T I I M USCLES AND NEUROMUSCULAR THERAPY ROUTI NES BY BODY REGION

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 FIGURE 7-39 Attachment sites for the flexor pollicis longus. Radius,
as placing curlers into the hair. This person's ability to do interosseous membrane, humerus (by a slip of aponeurosis), base of
gross gripping movements will most likely be compromised. 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
FIGURE 7-40 Trigger points and referral zones for the flexor pbllicis
MASSAGE THERAPY CON S I D E RATIONS longus. This trigger point is within the muscle belly, but quite distal
This area is usually quite tender; be sensitive with your from the origins with strong referral to the thumb on the anterior
work side with spillover both above and beyond the strong referral. The
referral beyond the thumb indicates an experience of the thumb
Be sure to work on the other thumb muscles, as they exploding. (Reprinted with permission from Medi Clip, Lippincott
must work together as a coordinated unit 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 95

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. FIGURE 7-41 Attachment sites for the extensor indicis. Lower '/5 of
the dorsal and lateral surface of the ulna, interosseous membrane,
STRESSORS AND PER PETUATING FACTORS head of the 2nd metacarpal bone. (Reprinted with permission from
Life Art, Lippincott Williams & Wilkins.)
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

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.)
1 96 PA R T I I I M U S C LES A N D N E U RO M U S C U LAR T H E R A P Y R O U T I N E S BY BODY R E G I O N

Interossei a n d Lu m bricals: Associates of Heberden's Nodes

The interossei lie between adjacent metacarpal bones. The phalanx of each finger but only weakly extends the two dis
lumbricals are not interosseous muscles, but they function tal phalanges. The flexor digitorum superficialis attaches to
similarly. They are unusual as they anchor to tendons of the middle phalanx, flexing the proximal and middle pha
other muscles rather than to bone. lanx. The flexor digitorum profundus attaches to the distal
phalanx, flexing it and the more proximal phalanx.
ORIGIN The four dorsal and three palmar interossei have oppos
First Interossei
ing actions in abduction, adduction, and rotation, but both
Ulnar border of the first metacarpal groups, along with the lumbricals, f l ex the fingers at the
Entire length of the radial border of the second meta metacarpophalangeal joints and extend the distal phalanx.
carpal The interossei and lumbricals extend the distal two
phalanges when there is any degree of flexion of the proxi
Three Dorsal Interossei
mal phalanx present.
Lateral aspect of the base of the second and third met
The dorsal interossei abduct away from the main ray,
acarpals
or the middle finger
Medial aspect of the base of the third and fourth meta
The palmar interossei adduct toward the main ray
carpals
TRIGG E R POI NTS A N D REFE RRAL ZON E S
Three Palmar Interossei
A s usual, trigger points set up within muscle bellies. There
Medial aspect of the base of the second, fourth, and
is strong referral down the radial or lateral aspect of the
fifth metacarpals
index and middle fingers with spillover across the dorsal
Lumbricals surface of the hand and down the little finger. There is also
The four tendons of the flexor digitorum profundus at spillover into the center of the palm and the palmar surface
mid-palm of the index finger (Fig. 7-43 ) .
Clients with trigger points i n the interosseous muscles
I N S ERTION may complain of having arthritis pain in a finger. The finger
First In terossei will be stiff enough to produce impairment of hand func
Base of the proximal phalanx of the index finger tions such as buttoning a shirt, writing with a pencil or pen,
and grasping.
Three Dorsal In terossei
This person may complain of having sore joints that are
Shaft of the proximal phalanx, lateral aspect of the swollen, as with Heberden 's nodes. Heberden's nodes,
index and middle fingers which is often identified with osteoarthritis, is a condition
Shaft of the proximal phalanx, medial aspect of the in which enlargements of soft tissue (nodes), sometimes
middle and ring fingers partly bony, occur on the dorsal surface of either side of the
terminal phalanx at the distal interphalangeal joint.
Three Palmar Interossei
According to Travell and Simons, tenderness is present in
Base of the proximal phalanx, medial aspect of the
Heberden's nodes, but no true synovial or bony swelling.
index finger
The tenderness may be referred to the joint. In time, the
Base of the proximal phalanx, lateral aspect of the ring
nodes become less tender. Travell and Simons go on to
and little fingers
explain that, clinically, it appears that trigger points in these
Lumbricals muscles can contribute to joint disease.
Radial side of the extensor aponeuroses on each of the
four fingers TRIGG E R POINT ACTIVATION
Activation of trigger points in these muscles is usually
ACTION caused by sustained or repetitive pincer grasping, as when
According to Travell and Simons, to understand the actions one is a seamstress, painter, sculptor, or mechanic whG must
of these intrinsic hand muscles, it is important to remember hold small items firmly while moving the hands and
that the extensor digitorum strongly extends the proximal fingers.
C H A PT E R 7 / A R M , W R I ST, A N D H A N D 1 97

First dorsal interosseous

)(
)(
Heberden's
nodes

Abductor digiti Second dorsal


minimi 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 MASSAGE TH E RA PY CONSIDERATIO N S


Repetitive or sustained pincer grasping Inactivation of trigger points and elimination of their
Increased strain due to abnormal hand mechanics asso perpetuating factors is important to early therapy in an
ciated with distorted joint function of arthritis effort to delay or abort the progression of some types of
osteoarthritis
PRECAUTIONS The presence of Heberden's nodes is a common finding
If Heberden's nodes are apparent, be gentle as the fin in those with trigger points in the interossei
gers will be quite sensitive
Be very careful if osteoarthritis is present
1 98 PA R T I I / M U SCLES A N D N E U RO M U S C U LAR T H E R A P Y R O U T I N E S BY BODY R E G I O N

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

Abductor digiti
TRIGGER POINTS A N D R E F ERRAL ZON ES
minimi
Trigger points may set in with the muscle belly and refer
'/.II-J.I-I-- Flexor digiti
strongly to the dorsal side of the little finger, with some minimi brevis
slight spill over into the fifth metacarpal and at the hypoth
Opponens digiti
enar eminence. The hypothenar eminence is the fleshy minimi
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.

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. 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.
STRESSORS A N D PERPETUAT I N G FACTO RS
Baltimore, MD: Lippincott Williams & Wilkins, 2004.)
Repetitive overuse of the little finger
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 FIGURE 7-45 Trigger points and referral zones for the abductor digiti
effort to delay or abort the progression of some types of minimi.The trigger point will set up in the muscle belly and refer
osteoarthritis 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 1 99

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
200 PA R T I I M U SC L E S A N D N E U RO M U SC U L A R T H E R A P Y R O UT I N E S B Y BODY R E G I O N

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 A R M , W R I S T, A N D H A N D 201

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
202 PA R T I 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 ROUTI N E S BY BODY R E G I O N

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
ROUTINE 7-9
form deep effleurage from the elbow to the midpoint of the
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 A R M , W R I S T, A N D H A N D 203

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
204 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 DY R E G I O N

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 ar