4Myofasial Trigger Point

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5/5/2012 1

Pain Reference Chart

HEADACHES• trapezius

• posterior neck muscles

• scm

CHEST PAIN• scalenus

• serratus posterior

• thoracic paraspinal

ARM PAIN

• scalenus

• serratus posterior• infraspinatus

• teres major

• latissimus dorsi

THORACIC OUTLETSYNDROME

• scalenus

5/5/2012 2

CARPAL TUNNELSYNDROME

• scalenus

• teres minor

PAIN WITH BREATHING

• serratus posterior• serratus anterior

• thoracic paraspinal

HAND & FINGER PROBLEMS

• scalenus

• teres minor

NECK PAIN (BACK)

• trapezius

• levator scapulae

• posterior neck muscles.

5/5/2012 3

FROZEN SHOULDER

• infraspinatus

• supraspinatus• teres major/minor

SIDE & STOMACH PAIN

• serratus anterior

NECK PAIN (SIDE)

• levator scapulae

• scm

SHOULDER PAIN (BACK)• trapezius

• teres major/minor

• latissimus dorsi• levator scapulae

• supraspinatus

• scalenes

5/5/2012 4

EAR & JAW PAIN

• Trapezius

• Scm

SINUS, TONGUE,THROAT,

• Scm

UPPER BACK PAIN

• Trapezius

• Teres minor

• Latissimus dorsi

• Levator scapulae

• Supraspinatus• Serratus posterior &

• Rhomboids

SHOULDER PAIN(FRONT)

• latissimus dorsi• Infraspinatus

EYE PROBLEMS

• Trapezius

• Scm

• Posterior neck

muscles

5/5/2012 5

HEAD & SCALP NUMBNESS

SHOULDER BURSITIS

• Trapezius

• Supraspinatus

DIZZINESS

• Trapezius

• Scm

TENNIS ELBOW

• Supraspinatus

BURNING BETEENSHOULDERS

• Trapezius• Rhomboids

• Thoracic paraspinal

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HEADACHES & trigger points

• trapezius

• scm

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Upper trapezius

Referral• Posterolateral neck,

mastoid process,temple and posteriorregion of the head,occiput, and angleof the jaw.

• One or more of these areas may bea site of pain

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5/5/2012 9

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Splenii

Referral

• Top of the head

• behind the eye

• to the base of the neck

• and along the

side of the neck.

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5/5/2012 12

Posterior cervical muscles

Suboccipitalmuscles

Posterior cervicalmuscles

multifidus

Semispinalis cervicis

Semispinalis capitus

5/5/2012 13

Posterior Neck Muscle Locationsand Trigger Points

5/5/2012 14

Posterior Neck Muscle Locationsand Trigger Points

• Headaches are the mosttroublesome pain experienced as aresult of Posterior Neck muscleTrigger Points.

• Migraine headaches, with paininside the head all along one sidegenerally result from Trigger Pointsin the muscles at the base of theskull.

• Headaches which feel like aconstricting band around the headare also attributed to thesemuscles. In addition, thesemuscles can be a cause of blurred

vision and pain behind the eyes

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Sternocleidomastoid (SCM) Muscle

Location and Trigger Points

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Sternocleidomastoid

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Sternocleidomastoid

• Most common areas are in and behindthe ear, around the eye, forehead,cheek, teeth, tongue, pharynx and

upper aspect of the sternum.

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Brachialgia & trigger points (Chest pain)

• Scalene muscles

• Serratus posterior superior

• Thoracic paraspinal

• Latissimus dorsi

• Serratus anterior

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Scalene Muscle Trigger Points

• The scalene muscles are

actually three musclesfound in the side of theneck. Blood vesselssupplying the arm actuallypass between thesemuscles.

• Trigger Points here can

cause chest pain similarto angina, as well asupper back pain.

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Scalenes Referred Pain Patterns

• If you’ve had difficulty finding

relief from these symptoms,

addressing the problematic Scalene muscles could provide better results. Remember, the pain location is not always the same location as the source of pain.

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Scalenes

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Serratus Posterior Superior MuscleLocation and Trigger Points

• This muscle runs underneaththe shoulder blade and attachesto multiple ribs. Its primaryfunction is to help raise theribcage when breathing in.

• Since the muscle runs under theshoulder blade, treating thismuscle requires moving theshoulder blade out of the way.When using the PressurePointer, reach the arm of theaffected side across the chest tomove the shoulder blade away.

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• Trigger Points in the Serratus

Posterior Superior cause a deepaching pain under the shoulderblade.

• Additionally, pain or numbness

can be found in the back of theshoulder, the elbow, and thepinky finger of the hand.

• Finally, the Serratus Posterior

Superior can refer pain to theback of the upper arm andforearm, as well as the pectoral,or chest, region

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• Superficial paraspinalmuscles (iliocostalis & longissimus).

– Midthoracic muscles

– Lower thoracic

muscles

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Deep paraspinal muscles (Rotators, semispinalisand multifidi)

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Latissimus Dorsi Muscle Locationand Trigger Points• The Latissimus Dorsi is a large, broad

muscle that brings the arm down andback. (“swimmer’s muscle.”)

• Trigger Points in the Latissimus Dorsicause pain in the mid back, below the

shoulder blade. They also refer pain tothe lower back and stomach.

• Additionally, they cause pain along theinside of the arm, all the way to thefourth and fifth fingers of the hand.

Pain in the fingers, with no numbness,is usually due to the Latissimus Dorsi.

• Activities which involve repetitivemotions

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Latissimus dorsi

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• Refers pain: inferior angle of scapulaand midthoracic area , can also in theposterior shoulder, posterior medial arm

and forearm, and to the ulnar hand andfingers.

• Trigger points: a couple of centimeterbelow the top of the arch of theposterior axillary fold at the midscapularlevel.

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• Activities which involve repetitive motionsof the entire arm, such as swimming,rowing, throwing, tennis, and golf, arecommon causes of Latissimus Dorsioveruse.

Latissimus Dorsi Referred Pain Patterns

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Serratus Anterior Muscle Location andTrigger Points

• The SerratusAnterior muscleattaches to the ribsand the shoulderblade.

• Its main functionsare to assist inraising the arm and

to expand the ribswhile breathing in.

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Serratus Anterior

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Serratus Anterior Referred Pain Patterns

• Trigger Points in the SerratusAnterior muscle typically referpain to the side and the lowerportion of the shoulder blade.

• When Trigger Points arepresent in this muscle,breathing in causes a sharppain in the side.

• The pain of Serratus AnteriorTrigger Points can mimic thepain of lung disease and heartattacks.

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Infraspinatus

• Refers pain in theanterior shoulder, to theanterior arm, to the wrist,and to the radial fingers.

• Occasionally to thevertebral border of thescapula and base of theskull.

• Trigger points: superior

aspect of the muscleinferior to the scapularspine.

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Infraspinatus Muscle Locationand Trigger Points

5/5/2012 36

Teres Major/Minor Muscle Locationand Trigger Points

• The Teres major and Teres minorare two muscles that are closelyrelated, and also comprise part ofthe rotator cuff muscles. Teres minorhelps rotate the arm outward, while

Teres major helps extend the armbackward and pull the arm down.

• Trigger Points in the Teres minorrefer pain to a very small andspecific area of the back of theshoulder, near the outer edge of the

shoulder blade. Numbness andtingling, but not pain, in the fourthand fifth fingers is also commonlyassociated with Teres minor

5/5/2012 37

Teres major

• Refers pain over theposterior deltoid, overthe triceps long head,and occationally into

the posterior forearm.• Trigger point: the

groove between thelateral lower edge of the scapula and theaxillary fold ispalpated.

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Teres minor

• Refers pain to the upperposterior arm, proximalto the deltoidattachment and about5cm in diameter.

• Trigger point: in themuscle bellyalong thelateral scapular borderbetween the teres

major inferiorly and theinfraspinatus superiorly.

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Teres Referred Pain Patterns

• Teres major Trigger Points

create a feeling of sharp pain inthe back of the shoulder andarm, often feeling like pain inthe Deltoid muscle.

• These muscles are small, but

important. They become easilyfatigued and affected by TriggerPoints. Using the PressurePointer to treat these musclescan help decrease thesesymptoms

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Supraspinatus Muscle Locationand Trigger Points

• Supraspinatus Trigger Points cause adeep, aching pain in the shoulder.

• It is extremely painful, if not impossible,to raise your arm above your head.

• • This interferes with many simple, daily

tasks, and makes normal life verydifficult.

• If you’ve ever been diagnosed withbursitis, it’s possible the Supraspinatusis the true source of your pain, not theshoulder bursa. In this case, the paindoes not resolve with typicallyprescribed anti-inflammatorymedications.

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Supraspinatus

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Supraspinatus

• The referred pain pattern is a deep ache that occursaround the lateral shoulder in the middle deltoid areadown to the deltoid region.the pain can also be referredto the elbow’s lateral epicondyle.

• 2-3 cm lateral to the vertebral border the trigger point is

common

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Supraspinatus Referred Pain Patterns

• Another interesting pain referrallocation of Supraspinatus TriggerPoints is the outer portion of theelbow.

– This pain is often misdiagnosed as

Lateral Epicondylitis, morecommonly known as “Tennis Elbow.”

• Working on the computer with noelbow support, carrying a heavy

purse or briefcase at your side, ormoving heavy objects canoverwhelm the Supraspinatus,causing increased incidence ofTrigger Points.

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Burning Between the shoulder blades

• Rhomboids

• Levator scapulae

• Middle trapezius

5/5/2012 45

Levator Scapula Muscle Location

• The Levator Scapula muscle’s

main function is to raise theshoulder blade.

• Stress and tension keep theshoulders raised, creatingincreased tension on this muscle.

Poor posture can also be a factor.

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Levator scapulae

5/5/2012 47

Levator Scapula Referred PainPatterns

• This muscle is typically involvedwhen you find yourself unable toturn your head. In this case, thedirection which you cannot turn isthe side that of the problematic

Trigger Point.

• Trigger Points in this muscle alsocreate pain and stiffness along theneck and the edge of the shoulder

blade.

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Rhomboid Muscle Location andTrigger Points

• The Rhomboids are very thinmuscles which have thetremendous responsibility for

much of the movement of theshoulder blades.

• Due to the enormous amount

the shoulder blades are useddaily, the Rhomboids areoften overworked and overtired, leading to chronicTrigger Points.

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Rhomboids

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Rhomboid Referred Pain Patterns

• The pain is generally extends from theedge of the shoulder blades to thespine.

• Since the Rhomboids on both sidesare almost always affected, this is aprimary source of mid back tightnessor aching between the shoulderblades.

• This pain is felt when the muscles arein use, but also at rest. Snapping orcrunching noises when moving theshoulder can also be traced to theRhomboid muscles.

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Back pain & trigger points

• Quadratus lumborum

• Multifidus

• Psoas major and minor

• Gluteus medius

• Rectus abdominis

Q d t l b

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Quadratus lumborum

• The superficial fibres refer

pain along the iliac crest orgreater trochanter or canwrap around outer groin(Cephalad to the iliac crest

or distal of the 12th

• The deep fibres refer down

to the sacroiliac joint orlower buttock (just lateralto the paraspinal muscles).

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Deep paraspinal muscles

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Rectus abdominis (abdominal, low back, pelvic pain)

• Rectus abdominisoriginates on thesternum and ribcageand inserts on thepubis. Its primary

function is flexion of thetrunk.

• Trigger points in rectusabdominis typically refer

to the abdomen, lowback, middle back,groin and pelvis.

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Iliopsoas (low back, abdomen, groin, pelvic pain)

D i t B i th

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ILiopsoas• During wt. Bearing the

pain is noticed andreleived in non wt.

Bearing.• Referral: throughout the

lumbar paraspinal regionon the same side or into

the anterior thigh andgroin.

• Proximal trigger point: just behind the ASIS andinside the rim of the iliaccrest.

• Distal trigger point: onthe lateral wall of thefemoral triangle

Gl t di

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Gluteus medius

• Pain is aggravated with walking,lying supine,

side lying on the affected side, or sitting in aslouched position.

• Point: down the sacrum, along the posterioriliac crest,lateral posterior gluteal area.

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• This medium-sized butt musclelies under the biggest buttmuscle, and over the smallestbutt muscle.

• It attaches along the upperedge of the back of the pelvis,and to a sheet of connectivetissue that spreads from thebutt up over the lower back.

• It also attaches to the upperback of the hipbone (the knobat the top of the thighbone).

• One of its jobs is to help raisethe leg away from the body, butits main job is to hold the pelvis

steady, especially when the hipon its side bears your weightwhile you're walking.

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Sciatica & trigger points

• Gluteus minimus

• Piriformis

• Tibialis anterior

5/5/2012 61

Glueteus minimus

• Pain occurs whilegetting out of chair.

• Referral: lower lateralbuttock, down thelateral thigh, lateral leg

to the ankle for anteriortrigger points. Locateddistal to the ASIS

• Referral:lower posteriorback, posterior thigh

and proximal posteriorcalf for posterior triggerpoints.located abovethe piriformis.

5/5/2012 62

Gluteus Minimus

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Piriformis

• Refers pain into thesacroiliac area andposterior hip.

• A line from the

greater trochanterto the superiorborder of the sciaticforamen is the

course of themuscle.

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Piriformis (low back, hip, sciatic, legpain) • Piriformis originates on the

sacrum and inserts on the

medial surface of the headof the femur.

• It is the principal lateralrotator of the hip.

• The sciatic nerve may passunder or through thepiriformis, causingentrapment.

• Much sciatic pain is causedby the piriformis, as well as

restless leg syndrome. Itstrigger points typically referinto the leg, the hip, and thelow back.

Its main job is to rotate the leg

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• Its main job is to rotate the legoutward, but it also helps to holdthe hip in joint when it's bearingweight.

• Sciatic nerve, which is the nervethat goes down the back of yourleg, passes under or through thismuscle, so tightness in thepiriformis can cause sciatica,

which is pain down the back of the leg.

• It can also cause what's called"restless leg syndrome." Trigger

points in this muscle can causepain in the back of the leg, thehip, and the low back.

Thi h i (A i & l l)

5/5/2012 66

Thigh pain (Anterior & lateral)

• Quadriceps femoris

• Hamstring

• Tensor fascia lata

• Adductors

5/5/2012 67

Quadriceps

• Trigger points in these musclescan cause pain in your knee andall along the front and outside

of your thigh as far up as yourpelvis.

• Trigger points in quadriceps areone of the chief causes of kneepain in both children and adults.

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Quadriceps

• Rectus femoris and vastus mediali into theanterior knee.

• Vastus lateralis to the posterolateral knee andlateral thigh

• Proximal thigh pain caused by VL can makeuncomfortable during sleepinf

• Rectus femoris described as a deep thighache especially at night

• Referred pain from VM sometimes causebuckling of the knee.

• VIM cause pain in the mid and upper thigh

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Quadriceps

V t l t li

5/5/2012 71

Vastus lateralis

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Hamstring

• Referred pain occursin gluteal fold andposterior knee.

• Trigger points arelocated at the middlethird of the muscles.

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• These muscle on the inner thigh have the job of pulling your legtoward the center, or pulling your legs together. At one end theyattach all along an arch of bone that goes from your pubic bone downand back to your "sitbones." At the other end, three of them attach atvarious points along the inner part of your thighbone.

• The fourth, gracilis (which means "the slender muscle"), crosses yourknee and attaches near the inner knob at the top of your lower leg.

• Trigger points in these muscles can cause pain along your inner thighs

and the fronts of your thighs.

Tenso Fascia Lata

5/5/2012 75

Tensor Fascia Lata

• Refers a deep pain inthe anterolateral hipfrom the greatertrochanter and can

extend as far as theknee.

• Trigger points: distalto the anterior

superior iliac spineand medial andproximal to thegreater trochanter

Tensor fasciae latae

5/5/2012 76

• Tensor fasciae latae originates on theouter aspect of the ilium and insertson the iliotibial band or tract, a bandof connective and contractile tissueextending down the outside of the

thigh.

• Its principal functions are stabilizationof the hip and knee joints, and

assistance in abduction of the hip.

• Its trigger points typically refer intothe hip and leg.

5/5/2012 77

• It attaches below to a band of connective tissue that runsdown the outside of your thighto the outer top of your lowerleg. It helps to lift the leg awayfrom center, and to make thehip and knee joints more stable.

• Trigger points in this musclecan cause pain in the hip and

down the outside of the thigh

Leg pain

5/5/2012 78

Leg pain

• Tibialis Anterior• Peroneus longus, brevis, tertius.

• Gastrosoleus

• Tibialis posterior• Extensor digitorum longus hallucis

longus

• Flexor digitorum longus, hallucis longus

TIBIALIS ANTERIOR

5/5/2012 79

TIBIALIS ANTERIOR

Trigger Point Examination

• Most commonly found in theupper one-third of themuscle.

• Transverse palpation will

reveal taut bands.• Digital pressure applied to an

active TrP will elicit thereferred pain in the ankle orfoot.

Tibialis anterior

5/5/2012 80

Tibialis anterior

• Refers pain to theanteromedial ankleand over the dorsaland medial big toe.

• Occationally to theanterior shin.

• Trigger pointproximal and middlethird of the anteriorextremity near thetibial ridge.

PERONEUS LONGUS BREVIS AND TERTIUS

5/5/2012 81

PERONEUS LONGUS, BREVIS AND TERTIUS

Peroneal pain

5/5/2012 82

Peroneal pain

• Pl & PB to the lateralmalleolus

• PT to the anterolateralarea.

• PL triggerpoint: 2- 4 cmdistal to the fibularhead

• PB at middle and distalthird of extremity.

• PT just anterior to thePB trigger point.

GASTROCNEMIUS

5/5/2012 83

GASTROCNEMIUS

Gastrocnemius

5/5/2012 84

Gastrocnemius

• Medial arch to the medial calf

• Close to the medial border of the MG.

• Close to the lateral border of the LG.

• Distal to the lateral head of gastrocnemius.

SOLEUS

5/5/2012 85

SOLEUS

Soleus

5/5/2012 86

Soleus

• Referral: posterior plantarheel area and in distalachilles.

• rarely into ipsilateral SI joint

TIBIALIS POSTERIOR

5/5/2012 87

TIBIALIS POSTERIOR

• Patient will usually complain of pain in the sole of the foot andachilles tendon during ambulation.

• Symptoms are exacerbated by

walking or running on unevensurfaces.

Trigger Point Examination

• TrPs lie deep to the gastrocnemiusand soleus and are only palpableindirectly.

• They can be palpated with amedial or posterior approach.

Long toe extensors

5/5/2012 88

Long toe extensors

• EDL & EHL• Cause night cramps in toes.

• Painrefers anterior ankle, dorsum of

foot and toes• EDL : 8cm distal to fibular head.

• EHL : ant. To the fibula at the juncture

of middle and distal thirds

EXTENSOR DIGITORUM LONGUS AND EXTENSOR

5/5/2012 89

EXTENSOR DIGITORUM LONGUS AND EXTENSOR HALLUCIS LONGUS

Long toe flexors

5/5/2012 90

Long toe flexors

• FDL & FHL• Pain if the feet during walking.

• FDL ; sole of the forefoot

• FHL: plantar great toe and 1st metatarsal head.

FLEXOR DIGITORUM LONGUS AND FLEXOR HALLUCIS

5/5/2012 91

LONGUS

Int insic m scles of foot

5/5/2012 93

• Intrinsic muscles of foot

• a) EDB &EHB

• b) AbDM• c) AbHB

• d) FDB

5/5/2012 94

• Extrinsic muscles of foot

• QP• FHB

• AH

• Interosseii

ABDUCTOR HALLUCIS

5/5/2012 95

ABDUCTOR HALLUCIS

EXTENSOR DIGITORUM BREVIS & EXTENSOR HALLUCIS BREVIS

5/5/2012 96

SO G O U S & SO UC S S

ABDUCTOR DIGITI MINIMI AND FLEXOR DIGITORUM BREVIS

5/5/2012 97

QUADRATUS PLANTAE

5/5/2012 98

QUADRATUS PLANTAE

ADDUCTOR HALLUCIS AND FLEXOR HALLUCIS BREVIS

5/5/2012 99

ADDUCTOR HALLUCIS AND FLEXOR HALLUCIS BREVIS

INTEROSSEI

5/5/2012 100

INTEROSSEI

References

5/5/2012 101

References

• Myofascial Release – Carol Manheim• Therapeutic exercises for

musculoskeletal injuries – Peggy A.Houglum.

Address

5/5/2012 102

Address

Physiotherapy college Raipur

Sapre School Campus

Budhapara

Raipur – 495001

Chattisgarh

• Email : rmozhi@gmail.com

• Mobile: 09893385522

4Myofasial Trigger Point

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