Myofascial Release &

Trigger Point Therapy

Modern Manual Therapy I
KNR 494

Fascia
3D network of connective tissue from head to
toe
Contains
-

Vascular structures
Adipose cells
Sensory receptors

Myofascial tissue?

(Manheim, 2001)

(Marieb, 2004)

Myofascial Tissue

Myofascial Pain
Originates in both muscle & fascia
Symptoms
- Deep, sharp, burning, dull, diffuse, heavy,
squeezing

Needs to be treated quickly

- Why?

What is Myofascial Release

(MFR)?
Interactive stretching technique that uses
manual pressure to facilitate maximum
relaxation of tight or restricted tissues
- Direction
- Force
- Duration
(Manheim, 2001; Ferguson & Gerwin)

Fixes/Anchors

Forearm
Elbow
Fist
Palm
Grip
Reinforced thumbs
Finger(s)
Knuckle(s)
External devices

(Manheim, 2001)

Direction of Stretch

Horizontal
Diagonal
Perpendicular
Vertical

Why not just use a gross

stretch?

Benefits of MFR over GT

Less expensive
Patient ease
Less invasive
Self-treat
Tightness vs. restrictions
Difficult to evaluate some areas with GT

General Indications
Myofascial restrictions
Pain has not been alleviated by other
treatments
Pain is complex, global, or specific pain
Underlying chronic condition causing tightness
and restrictions
Complex postural asymmetries
Athlete needs stretching to increase
performance and prevent injury
(Manheim, 2001)

Precautions/Contraindications
Myofascial Restrictions

Inflammation
Patient uncomfortable with touch
Dermatitis
Contagious/infectious disease
Fractures/open wounds
Circulatory problems
Taking blood clotting medicine
Osteoporosis
(Manheim, 2001)

MFR Treatment Steps

1. Gross stretch of entire body area
2. Focused stretch of muscles in same
body area
3. Finish with gross stretch of entire
muscle

Focused Stretch
One hand, finger or body
weight acts as anchor
Use broad surface to apply
stretch if possible for large
muscles
For smaller muscles use 1 or
2 fingers

Focused Stretch

1-2 fingers of each hand

1 or both hands may move
Distance between fingers may be several
millimeters/inches

Levels of MFR
1. No stretch/pre-tension
2. Pre-tension (stripping)
3. Moderate passive stretch
4. Active MFR
(Leahy & Mock)

Common Mistakes
Too much pressure
Too long of stretch
Too many applications

Myofascial Trigger Points

Myofascial Trigger Points (TP)

A hyperirritable spot located within a
taut band of skeletal muscle or its fascia
- Active
- Latent
(Travell & Simons, 1983)

(Marieb, 2004)

Overloading
Stretch/shortening
Micro/macro
trauma

Loss of flexibility
Local pain, muscle guarding &
REFERRED PAIN

Destruction of
sarcolema & SR

Release of nociceptive
substances

Release of Ca2+

Trigger point
formation/activation

Sustained muscle
contraction
Ischemia, hypoxia,
metabolic waste
(Kostopoulos & Rizopoulos, 2001)

How can TP therapy alleviate

this pathologic cycle?

Considering Fibromyalgia
Trigger Points
No gender bias
Can be sudden &
related to specific
movements
Often have taut
bands and twitch
responses

Fibromyalgia

General Indications
Myofascial Trigger Points
Frequently complaints of
referred pain
Autonomic &
proprioceptive disturbances
Taut band
Tender and painful nodules
Local twitch response
Limited ROM
Muscle weakness

(Kostopoulos & Rizopoulos, 2001)

Precautions/Contraindications
Trigger Points

Inflammation
Patient uncomfortable with touch
Dermatitis
Contagious/infectious disease
Fractures/open wounds
Circulatory problems
Taking blood clotting medicine
Osteoporosis
(Manheim, 2001)

Trigger Point Therapy

Progressive pressure technique/Ischemic
Compression
Use pain as guide
- Varying pressure (light pressure/stretching,
heavy pressure)

10 seconds to 2 minutes
Follow with myofascial stretching
Positive stretch sign
(Kostopoulos & Rizopoulos, 2001)

Trigger Point Therapy: Self

Treatment

Trigger Point Therapy

Positional Release Therapy/StrainCounterstrain
Trigger points are addressed while body is
a position of comfort
(DAmbrogio & Roth, 1997)

Physiologic basis?
Reduce muscle spindle input

Trigger Point Therapy

Ice-and-stretch
Apply ice in sweeping motion
Slow continual passive stretch is applied at same time as
ice application
Can also add contraction of antagonist
Can repeat for several cycles

Trigger Point Therapy

Stripping Massage
Deep-stroking massage applied with minimal
lubrication on the fingertips
Increase pressure with each successive pass
along muscle
Both stripping and ischemic compression are
believed to cause a reflexive hyperemia that
returns the site to a normal condition

Myofascial & Trigger

Point Treatments:
Upper Extremities

Gross Stretch of Upper Quarter

Arm Pull
Supine
Stretch parallel to floor
Hold for release and repeat
Caution
ATC must be relaxed
Elbow flex contracture
Hypermobile elbow

Gross Stretch of Upper Quarter

Bilateral Arm Pull
Supine/prone
Stretch parallel to floor
Hold for release and
repeat

Posterior Cervical: TP
Suboccipitals

Splenius capitus

Posterior Cervical

Make sure you know

pathologies associated
with muscles

Posterior Cervical

Posterior Cervical

Scalenes: TP

Pathology
Combine with joint
mobilization
Intercostals

Upper Trapezius: TP

Upper Trapezius

Upper Trapezius (Active MFR)

(Johnson, 2009)

Sternocleidomastoid: TP

Subacromial Impingement:
Forward Head
Causes:
- Stretch of levator scapulae

Decreases scapular:
- Posterior tilt
- Upward rotation
(Ludewig et al, 1996)

Levator Scapulae: TP

Levator Scapulae (Active MFR)

(Johnson, 2009)

Acromioclavicular Ligament:
Release

Subacromial Impingement:
Rounded Shoulders
Causes:
- Tight serratus anterior &
pectoralis minor & major
(Kendall, 2005)

Increases scapular:
- Protraction

Pectoralis Major: TP

Pectoralis Major

Pectoralis Major: Release

Pectoralis Major: Traction Release

Scapular Release:
Protraction

Scapular Release:
Protraction

Scapular Release
Translate scapula toward spine
-

Superiorly
Inferiorly

Scapular Release with Pectoral

Stretch

Scapular Release

Side lying
Push scapula superiorly
Pull humerus inferiorly

Pathology?

Anterior Capsule Release

Effective for adhesive capsulitis

Pectoralis Minor: TP

Pectoralis Minor

Perctoralis Minor
Supine

Pectoralis Minor

Deltoids: TP

Deltoids

Latissimus Dorsi: TP

Latissimus Dorsi

Latissimus Dorsi

Prayer position

Middle/Lower Trapezius: TP

Lower/Middle Trapezius

Middle Trapezius

Lower Trapezius

Rhomboids: TP

Rhomboids

Teres Major: TP

Teres Major

Serratus Anterior: TP

Serratus Anterior

Side lying with arm behind back

Subscapularis: TP

Focused Stretch: Subscapularis

Subscapularis Release

Subscapularis Release

Supraspinatus: TP

Supraspinatus

GIRD

Infraspinatus: TP

Infraspinatus

Infraspinatus (Passive MFR)

Teres Minor: TP

Teres Minor

Additional stretch
- Place patients arm in internal rotation

Teres Minor (Passive MFR)

Posterior Capsule (Passive MFR)

Biceps Brachii: TP

Biceps Brachii

Triceps: TP

Supinator: TP

Supinator: TP

Extensor Carpi Radialis

(Longus & Brevis): TP

Pronator Teres: TP

Carpal Tunnel Syndrome

Flexor Carpi Ulnaris: TP

Flexor Mass