Trigger Point Therapy Slides

@Physiocouk #manchesterphysio facebook.com/physio

05/03/16 2
Welcome
Trigger point therapy & soft tissue release for sports
and massage therapists
With Katie Emmett & Kate Mcnally
@Physiocouk #manchesterphysio facebook.com/physiocouk

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

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Let’s connect
Website: www.physio.co.uk
Twitter: @physiocouk
Facebook: www.facebook.com/physiocouk

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

Itinerary
10.00 - 10.30 - Induction / Arrival
10.30 - 10.50 - Quiz – What do you know about trigger point
therapy
10.50 -11.30 - Theory: Trigger point therapy
11.30 -12.00 - Practical: workshop
12.00 - 12.30 - Lunch
12.30 - 13.00 - Theory: Trigger pointing technique
13.00 - 14.00 - Practical: Muscle groups
14.00 - 14.30 – Practical: Tools & other STR techniques
14.30 - 15.00 - Evidence/Case Studies/Quiz answers

Quiz…
What do you know about trigger point
therapy?

Question 1
Name a type of Trigger Point?

Question 2
How would patients describe trigger point
pain?

Question 3
Name some indications for Trigger Point
Therapy?

Question 4
Name 5 benefits of Trigger Point Therapy

Question 5
Where are the Rhomboid muscles located?

Question 6
Name the muscles in the Hamstring group

Question 7
Name 5 contraindications of Trigger point
therapy

Question 8
Name some related symptoms to trigger
points in the Sternocleomastoid muscle

Theory:
Trigger Point
Therapy

What are trigger
points?
• Trigger points are hyperirritable areas of contracted
muscle fibres that form a palatable nodule
• On a microscopic level, the contracted muscle fibres
accumulate into a small thickened area causing the
rest of the fibre to stretch
• The areas of contracted muscle restrict blood flow
within the tissue causing an accumulation of waste
products and reduced levels of nutrients available.

Brief History
• 1930s -Dr Hans Lange used sclerometer to prove that tender areas in muscles
are 50% harder than surrounding areas.
• 1940s- Janet Travell developed trigger point injection therapy and termed the
“tender areas” described by Dr Hans “Trigger points”.
• Travell's therapy called for the injection of saline (a salt solution) and procaine
(also known as Novocaine, an anesthetic) into the trigger point.
• Travell mapped what she termed the body's trigger points and the manner in
which pain radiates to the rest of the body.
• Travell's work came to national attention when she treated President John F.
Kennedy for his back pain.
• Travell co-authored several books with David Simons which are considered
the definitive reference for trigger point therapy.
• Travell & Simons' Myofascial Pain and Dysfunction: Upper half of body
• Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual
• Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 2

Brief History
• 1976- Bonnie Prudden, a physical fitness and exercise therapist
developed Travells trigger point therapy. She found that applying
sustained pressure to a trigger point using thumbs, knuckles and
elbows produced superior results to those treated with injections
when followed by corrective movements and stretching. Prudden
later went on to author two books:
• Myotherapy: Bonnie Prudden’s Complete Guide to Pain Free Living
• Pain Erasure the Bonnie Prudden Way

Different types of trigger
points
• Trigger points are described according to location, tenderness and
chronicity as central (or primary), satellite (or secondary), attachment,
diffuse, inactive (or latent) and active
• The main types of trigger points are:
 Central/ primary trigger points
 Satellite/ secondary trigger points
 Active trigger points
 Latent trigger points

Central/ primary trigger
points
• These are the most well-established and painful points
• Pain is felt by the individual when they are active, and are usually
what people refer to when they talk about trigger points
• Central trigger points exist at a neuromuscular point, which is the
meeting place of a nerve and muscle

Satellite/ secondary trigger
points
• These trigger points are “created” as a response to the central
trigger point in neighbouring muscles that lie within the referred
pain zone.
• Form in response to central trigger points within the pain referral
patterns
• The primary trigger point is still the key to trigger pointing
intervention: the satellite trigger points often resolve once the
primary point has been effectively rendered inactive.
• Satellite points may also prove resilient to treatment until the
primary central focus is weakened; such is often the case in the
paraspinal and/or abdominal muscles.

Active trigger points
• This can apply to central and satellite trigger points.
• A variety of stimulants, such as forcing muscular activity
through pain, can activate an inactive trigger point.
• This situation is common when activity is increased after trauma
i.e a road traffic accident, where multiple and diffuse trigger
points may have developed.
• This trigger point is both tender to palpation and elicits a referred
pain pattern.
• Pain can limit range of movement

Latent trigger points
• This applies to lumps and nodules that feel like trigger points. These can
develop anywhere in the body and are often secondary.
• These trigger points are not painful, and do not elicit a referred pain
pathway.
• The presence of inactive trigger points within muscles may lead to
increased muscular stiffness and tension. They can build up for years.
• It has been suggested that these points are more common in those who
live a sedentary lifestyle (Starlanyl & Copeland 2001)
• These points are “potential” trigger points and may reactivate if the
central or primary trigger point is (re)stimulated
• Reactivation may occur following trauma and injury

Symptoms of Trigger
Points
Active trigger point referral symptoms
•Dull ache
•Deep
•Pressing pain
•“Stabbing”
•Burning
•Referred pain
•Common reports of headaches, dizziness and pins and
needles

Referral Pain Guide
Sternocleomastoid and Masseter

Referral Pain Guide
Trapezuis

Referral Pain Guide
Pectorals

Referral Pain Guide
Quadratus Lumborum

Referral Pain Guide
Piriformis

Referral Pain Guide
Glute maximus, medius and minimus

Referral Pain Guide
TFL

Referral Pain Guide
Vastus Lateralis

Referral Pain Guide
Hamstrings

Other Symptoms
A sensation of:
•Numbness
•Fatigue
•Weakness
A loss of:
•Flexibility
•Range of movement
•Muscular power and strength

Why are they
present?
• Repetitive overuse injuries (using the same body parts
in the same way hundreds of times on a daily basis) from
activities such as typing/mousing, handheld electronics,
gardening, home improvement projects, work environments,
etc.
• Sustained loading e.g heavy lifting, carrying babies,
briefcases, boxes or lifting bedridden patients.

Why are they
present?
•Poor posture due to our sedentary lifestyles, de-
conditioning, poorly designed furniture and technology.
•Muscle clenching and tensing due to mental/emotional
stress.
•Direct injury such as a strain, break, twist or tear e.g car
accidents, sports injuries, falling down stairs.
•Trigger points can even develop due to inactivity such as
prolonged bed rest or sitting.

The Trigger Point
Complex
How are they formed?
• Within the muscle structure trigger points lye
within a single muscle fibre
• They are located within each sarcomere
which is where muscle contraction takes
place
• Sarcomeres often get overstimulated and
become difficult to release their contraction
• Each segment of sarcomeres becomes longer
and shorter which stretches the rest of the
fibres in the band

The Trigger Point
Complex
How are they formed?
• Multiple sarcomere knots form trigger points
• Stretched segments of fibres give increased tension to the taut band of
fibres.
• Blood flow is restricted in these fibres which reduces oxygenation and
accumulative of waste products which irritate trigger points
• The body responds by sending out pain signals
• The brain stimulates decreased movement into these muscles which
further tightens the structure

The Trigger Point
Complex
https://www.youtube.com/watch?v=sltGyJvbvWw

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

The Trigger Point
Theories
“Muscle spindle hypothesis”
•Proposes inflamed muscle spindles cause trigger points.
•Sustained muscular overload causes fatigue, muscular spasm and
restricted blood flow.
•Causes muscle spindles to be surrounded by waste products e.g.
lactic acid, potassium ions and inflammatory chemicals such as
histamine.
•This results in inflammation of the muscle spindle and spasm of
the extrafusal muscle fibres, forming the taunt band that we can
palpate.

Indications and Outcome
Measures
Indications Outcome measures
Pain VAS scale & subjective symptoms
Reduced AROM Active range of movement
High muscle tension and tone Muscle testing
Muscle tightness Palpation
Muscle weakness

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Outcome measure:
VAS/ Numeric Pain Scale
• Simple and easy
• Before, during and after massage
• Record change
• Use with patient to see reduction in pain over
the progression of treatments

Outcome measure:
Range of movement
• Pre and post measurements
• Goniometer or visual
• Standardise to produce reliable results
• Review each session
• Used to distinguish areas to treat and
techniques types
• Valuable in the success of treatment

Outcome measure:
Muscle testing
• Measure nerve conduction, muscle recruitment
to determine a deficit
• Test uninjured side for norm
• Patient will see and feel a progression
• Strengthening exercises needs to be used along
side massage

Outcome measure:
Palpation
• Use palpation as a measure
• “the four T’s”
Temperature
Tissue may be hot or cold, indicating inflammation or ischaemia
Texture
Swelling (acute-hard, chronic – “boggy”, congested)
healthy tissues should have an even texture
Adhesions feel like tissues are “stuck” and less mobile
“audible crunching”

Outcome measure:
Palpation
Tenderness
Pain can be indicated through response/ use vas scores
Structures that are too painful to palpate
Tone
Tissues may be hypertonic or hypotonic
Use to compare

Practical:
Trigger point
workshop:
Symptoms

Lunch

Theory:
Trigger Pointing
Therapy

How to treat a Trigger
Point
Assessment
•Find the most painful TP using patient response and Numeric Rating Scale or (VAS)
•Treat the highest rated point and radiate out from this point
•Once the points are found – a good amount of pressure is applied (perform with
precaution - keep communication with patient)
•Initial pain is stimulated and you hold the pressure until the pain has eased completely or
in some cases reduced slightly
•Reapply pressure onto the same point until the pain eases off quicker or it isn’t felt
anymore
•Thumbs/elbows or tools can be used

How to treat a Trigger
Point
Guidelines
Application of direct pressure onto the trigger points for around 30 seconds or until
the patient’s pain has decreased to at least 3/10 VAS score.
The applied pressure help breakup the adhesive fibre connections within the
trigger points and push out blood containing waste products and toxins.
After 30 seconds the pressure is released allowing a rush of fresh blood containing
nutrients to circulate the trigger point.
Repeat 3 times in conjunction with deep massage strokes.
• This can depend on the severity of pain/ how deep or superficial the TP is –
subjective and variable to each patient

The Benefits
• Reduced pain
• Increased range of motion
• Decreased muscle stiffness and tension
• Reduction in headaches
• Improved flexibility
• Improved circulation
• Fewer muscle spasms

Precautions
• High pain scales
• Patient Anxiety
• Acute/ Inflammatory stage of healing
• Hypersensitivity
• Pregnancy
• Epilepsy
• Asthma
• Hypertension
• Prescribed medication

Contraindications
General Local
Acute conditions requiring medical attention Acute flare-up of inflammatory arthritides
Acute pneumonia Aneurysms deemed life-threatening (may be
general contraindication depending on
location)
Advanced kidney, respiratory or liver failure Local contagious condition
Diabetes with complications such as gangrene,
advanced heart or kidney disease or very
unstable or high blood pressure
Local irritable skin condition
Hemorrhage Malignancy
Severe atherosclerosis Open wound or sore
Severe and unstable hypertension Recent burn
Shock Undiagnosed lump
Systemic contagious or infectious condition

Manual Handling and
Body Position
• Posture
– Bed height
– Stance
– Patient position
• Use different parts of your hands/ arms to apply pressure
• Keep arms straight to utilise body weight when applying
pressure/resistance.
• Move from the hips and knees as much as possible
• Oil (or cream)- only needs to be a little bit, if any.
Look after yourself before you look after the patient!

Post Treatment Irritation
Very common for people to experience irritation for up to 72
hours after treatment.
Side effects can include:
• Bruising
• Redness
• Tenderness/Increased Sensitivity
• Increased symptoms
• Aching similar to DOMS

Post Treatment Irritation
Causes
• The release of toxins/waste products from muscular tissue
• Neurological sensitisation
• Increased blood flow and micro trauma can lead to bruising and
redness
Advice
•Reassure the patient it's a normal response to be
sore after soft tissue treatment
•Recommend they drink water to keep hydrated

Practical:
Trigger pointing
muscles
• Sternocleomastoid
• UFT
• Rhomboids
• QL
• TFL
• Vastus Lateralis
• Hamstrings

Sternocleomastoid
Anatomical Highlights:
• Each SCM group has two divisions that originate off the mastoid process behind the ear.
The sternal division runs diagonally downward to attach to the sternum, while the clavicular
division attaches right behind it on the medial clavicle.
• Acting unilaterally, contraction of the SCM muscle turns the head towards the opposite
side, while bilateral contraction flexes the neck and head forward.
• The most important function of the SCM is to control and monitor the head’s position in
space. Proprioceptive feedback from the SCM is essential to being able to maintain one’s
balance, and is also important for interpreting visual information.

Sternocleomastoid Trigger
Points
• The SCM muscle group can contain a up to
seven trigger points, making it’s trigger point
density one of the highest in the body.
• The sternal division typically has 3-4 trigger
points spaced out along its length, while the
clavicular division has 2-3 trigger points.
• Trigger points typically develop in one SCM
muscle group first, but quickly spread to the
SCM on the opposite side of the neck.

Sternocleomastoid Pain
Each SCM division has a separate and distinct referred pain pattern:
• The sternal division’s referred pain is felt deep in the eye socket (behind the eye),
above the eye, in the cheek region, around the TMJ, in the upper chest, in the back
of the head, and on the top of the head.
• The clavicular division’s referred pain is felt in the forehead, deep in the ear,
behind the ear, and in the molar teeth on the same side.
Related symptoms
• Sore Neck
• Tension Headaches
• Migraine
• Dizziness

RX: Sternocleomastoid
• Locating and releasing these trigger points can be complicated due to their
proximity to many blood vessels and nerves in the neck region.
• Because of this, the application of direct pressure is limited to the superior
trigger point only, with the rest of the trigger points released with a specific
squeezing-type of technique.

Upper Fiber Traps
The trapezius is not one, but three separate
muscles:
•The upper trapezius
•The middle trapezius
•The lower trapezius
All three trapezius muscles originate along the
spine and extend laterally to attach to the
shoulder girdle, but each muscle has a different
fiber direction and pull.

Upper Fiber Traps
The whole trapezius muscle creates various movements of the shoulder blade, neck,
and head.
An example, the simple act of flexing the head to the right requires:
•Contraction of the lower trapezius on the right side to fix the right shoulder blade in
place.
•Contraction of the right upper trapezius to pull the neck and head to the right.
•Relaxation of the left lower trapezius to allow the left shoulder blade to rise.
•Relaxation of the left upper trapezius to allow the neck and head to move to the right.
This type of complexity makes it easy for trigger point activity to spread quickly
through the muscle group as a whole.

UFT Trigger Points
Four primary trigger points in the
trapezius muscle group; two trigger
points in the upper fibers, and one each
in the middle and lower fibers.
• The anterior trapezius trigger point
• The upper trapezius trigger point
• The middle trapezius trigger point
• The lower trapezius trigger point

UFT Pain
• “Pain in the neck”
• The mental and emotional stress of modern day life often takes physical form as trigger
points in the lower and upper trapezius muscles.
• The lower trapezius trigger point is the most sensitive to psychological and projects
pain and tenderness upward into the neck and shoulder region.
• The anterior trigger point refers pain to the side of the neck, jaw, and face, but it is
notorious for producing a throbbing headache in the temple region. This headache
pain may also be described as “behind the eye.”
• Middle trapezius trigger point, which produces a localised burning-type pain along the
spine. It will often recruit the rhomboid trigger points as they share a similar intra-
scapular pain pattern.

RX: UFT
• The anterior trapezius trigger point
• The upper trapezius trigger point
• The middle trapezius trigger point
• The lower trapezius trigger point

Rhomboids
“That Nagging Pain Between the Shoulder Blades”
• Location: The rhomboid muscle group is found between the spine and the scapula
in the mid- back region. It lies deep to the Trapezius muscle and is composed of
the rhomboid major and rhomboid minor muscles.
• Structure: The rhomboid minor is smaller than and lies above (superior to) the
rhomboid major. Both muscles originate along the thoracic spine with their fibers
running diagonally downward and outward to attach along the inside border of the
scapula.
• Function: In everyday life, the rhomboid muscles function to position the scapula
during various movements of the shoulder and arm.

Rhomboids
“That Nagging Pain Between the Shoulder Blades”
•The rhomboid minor originates on the spinous processes of C7 and T1 and attaches to
the medial border of the scapula near the root of scapular spine.
•The rhomboid major originates from the spinous processes of T2 to T5 and attaches
along the lower half of the scapular border.

Rhomboid Trigger
Points
3 primary trigger points
• The rhomboid minor trigger point lies just medial to the inside edge of the scapula,
level with the scapular spine.
• The rhomboid major trigger points lie one above the other, along the lower part of the
scapular border.
It should be noted that all three of the rhomboid trigger points lie beneath the trapezius muscle and
may be difficult to palpate if there is tension or trigger point activity in the trapezius.

Rhomboid Pain
Referred Pain: The pain concentrates in the region between the spine and the shoulder
blade. It may also extend to the region above the shoulder blade as well.
The rhomboid and levator scapulae trigger point pain patterns are very similar except
that the rhomboid pattern does not involve the neck.
Symptoms/ Clinical Findings
•Pain Between the Shoulder Blades: an aching (but not deep) pain that is felt along the
inside of the shoulder blade.
•Pain is usually felt at rest and not typically affected my movement.
•A patient will typically present with rounded-shoulder, sunken chest posture where tight
pectoralis muscles pull the shoulder forward, producing a chronic strain and stretch on
the rhomboids and middle trapezius muscles.
•Rhomboid weakness
•Patients may hear snapping or grinding noises from the region around the shoulder
blade during movements of the arm.

RX: Rhomboids
• Make sure that you have released any trapezius trigger points first.
• If you don’t, you will never be able to accurately locate the rhomboid
trigger points by palpation. Even with a relaxed trapezius muscles, these
trigger points will feel rather deep to your touch (even though they really
aren’t that deep)
Positions:
• Side-lying position to allow more forward movement of their shoulder
• Prone to allow more pressure to be applied

RX: Rhomboids

Have a go!

QL – Quadratus Lumborum
• A small and hidden muscle that plays a prominent role in normal body mechanics
that without its functioning, the upright posture of the human being is impossible to
maintain.
This muscle group has three subsections that each have a distinct fiber direction:
• The Iliocostal fibers (shown in the following picture as blue) attach on the Iliac Crest
and run vertically upward to attach to the 12th rib.
• The iliolumbar fibers (shown in the following picture as green) attach on the Iliac Crest
and run diagonally upward and medially to attach to the transverse processes of the
lumbar vertebrae (L1 > L4)
• The lumbocostal fibers (shown in the following picture as red) attach on the lumbar
vertebrae and run diagnonally upward and laterally to attach to the twelfth (lowest) rib

QL – Quadratus Lumborum

QL Trigger points
• The primary antagonist to each QL muscle is the opposing QL muscle on the
other side of the body.
• If one muscle develops trigger point activity, the muscle on the other side will
become overloaded and develop trigger points as well.
• From a clinical perspective, you should always address the trigger points in both
the left and right QL muscles, even if the pain is limited only to one side.

QL Trigger points
There are four potential trigger points in the
QL muscle:
• The upper QL trigger point is found just
lateral to where the lumbar paraspinal muscles
and the twelfth rib meet.
•The lower QL trigger point lies deep in the
region where the paraspinal muscles meet the
hip crest (iliac crest).
•The middle or deep QL trigger points lie
closer to the spine than the superior or lower
trigger points, next to the third and fourth
lumbar vertebrae.

QL Pain
• Usually described as an intense, deep ache but occasionally can initiate a sharp,
knifelike symptom, particularly during movement.
The distribution of the referred pain from each TP is:
• The upper trigger point refers pain to the flank region of the low back, along the
crest of the hip, and around the front to the upper groin region.
• The lower trigger point refers pain and tenderness to the hip joint region, making
laying on that side too painful during sleep.
• The middle trigger points refer pain and tenderness strongly to the S.I. joint and
lower buttock regions. Occasionally, these trigger points may refer a sharp,
“lightening bolt” of pain to the front of the thigh.

QL Pain

RX: QL
• The first step in the effective treatment
of the QL trigger points is being able to
accurately locate and contact the
trigger points.
• Prone position
• Extended side-lying position

TFL - Tensor Fasciae Latae
Location:
•A small muscle found on the side of the pelvis and runs downward in front of the hip
joint to blend with the iliotibial tract just below the hip joint.
Function:
• Its function is primarily to control movement of the leg during the stance phase of
walking.
• It also works to keep the pelvis level when the opposite leg is raised off the ground
during walking (assisting the gluteus medius and gluteus minimus muscles).
•It may also help to stabilise the knee joint during weight bearing activity.

TFL - Tensor Fasciae Latae
Muscle Structure:
•The upper attachment of the TFL originates along the outer aspect
of the Iliac Crest (of the pelvis) and Anterior Superior Iliac Spine
(A.S.I.S).
•Two functionally distinct sections, the anterior and posterior
fibers.
•The anterior fibers become tendinous as they run down the
outside of the thigh and attach to the connective tissue
encapsulating the knee joint.
•The posterior fibers join the iliotibial tract (a central thickening of
the large fascial sheath covering the outside thigh) and attach to
the lateral tubercle of the tibia leg bone.

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

TFL Pain
• The referred pain pattern associated with this trigger point covers the entire
hip joint and extends down the outside aspect of the thigh, sometimes nearly
to the knee joint. Tenderness to touch may also be prominent in the hip joint
and down the thigh
Symptoms/Clinical Findings
• Pain and/or soreness in the hip joint (greater trochanter) and down the outside
thigh during movement of the hip.
• Pain prevents them from walking quickly.
• Unable to sit in a deep (or low) chair or flex their hip more than 90°.
• Unable to lie on the affected hip during sleep and unable to lie on the unaffected
side during sleep without a pillow between their knees.
• Adduction of the thigh at the hip is limited to 15° or less.
• Swinging the leg on the affected side up and to the side (hip abduction) may be
painful.

RX: TFL

Vastus Lateralis
Location: The quadriceps femoris muscle group
form the thigh musculature found on the front of
the upper leg. The group is comprised of four
muscles:
• The Vastus Lateralis
• The Rectus Femoris
• The Vastus Medialis
• The Vastus Intermedius

Vastus Lateralis
Function
•The quadricep muscle group as a whole functions to allow a person to squat, bend
backwards, walk up or down stairs, and move from a standing to a seated position (or vice-
versa).
•These muscles are not active while standing with the knees locked, but become active
during the heel-strike and toe-off phases of walking.
Muscle Structure and Actions
•The vastus lateralis is the largest muscle in the group.
•It originates along the posterior-lateral aspect of the femur bone and runs down the
outside of the thigh to attach to the lateral aspect of the patella bone.
•Contraction of this muscle produces extension of the lower leg at the knee.

Vastus Lateralis Trigger
Points
There are two sets of trigger points in the vastus lateralis muscle:
• The upper vastus lateralis trigger points are located in mid-thigh region on the
outside aspect of the leg.
• They refer pain all along the outside of the thigh and knee, from the pelvic crest
down to the lower leg region just below the knee.
• The lower vastus lateralis trigger points are found just above and to the outside of
the knee joint. They refer pain around the outside aspect of the knee joint and below
it, sometimes extending up into the lower lateral thigh region.
• The pain may also be experienced as going “through the knee” and into the back of
the knee, especially if it occurs in children.

Vastus Lateralis Trigger
Points

RX: Vastus Lateralis

Hamstrings
Muscle Structure & Attachments: The four components of the hamstring muscle group
are detailed below:
The semitendinosus
•Medial aspect of the posterior thigh
•Originates on the ischial tuberosity of the pelvis and runs down the leg to attach below
the medial condyle on the tibia.
•The belly of this muscle is found in the top portion of the posterior thigh.
The semimembranosus
•Also lies on the medial aspect of the posterior thigh
•It attaches to the ischial tuberosity of the pelvis and runs deep to the other hamstring
muscles to attach to the medial condyle of the tibia just below the knee joint capsule.

Hamstrings
The bicep femoris
• It has two heads that lie on the lateral aspect of the posterior thigh; the long
head and the short head.
•The long head of the biceps femoris attaches to the ischial tuberosity and runs
diagonally downward and laterally to attach to the head of the fibula bone.
•The short head of the biceps femoris attaches along the linea aspera on the
shaft of femur bone and runs diagonally outward to join the tendon of the long
head as it attaches to the head of the fibula.

Hamstring Trigger
Points
The hamstring muscle group
contains two clusters of trigger
points:
• The medial cluster can
contain up to 5 trigger points
that are located about mid-
thigh, along the inside of the
leg.
• The lateral cluster can
contain up to 4 trigger points
that are located about mid-
thigh along the outside aspect
of the leg.

Hamstring Pain
• The medial cluster trigger point(s) refer pain strongly upward to the gluteal
fold/upper posterior thigh region and down the back of the thigh to the medial calf
region.
• The lateral cluster trigger points refer pain primarily to the back of the knee, with
some spillover referral to the back of the thigh.
Symptoms/Clinical Findings of active hamstring
• Posterior thigh or posterior knee pain, worse when walking, often causes a limp.
• Pain in buttocks, back of the thigh and/or knee while sitting
• Leg pain that disturbs sleep
• Quadriceps femoris trigger point symptoms due to the prominent antagonistic
relationship between these muscle groups.

RX: Hamstring
+ Active Release Technique

The use of other STR
•Helps warm up an area
•Removes waste products
•Increases oxygenation
•Increases new blood flow
•Further breaks down collagen
•Helps sooth an area after deep pressure has been applied
•Nice, relaxing end to a treatment

Effleurage
• Technique used to warm up or warm down the tissues
• Tensile force, works as a mechanical pump
• Increases fluid flow encourages venous and lymphatic return
• Increases tissue mobility
• Dilation of capillaries
• Can increase or decrease tone depending upon speed

Petrissage
• Examples of petrissage- Kneading, wringing & skin rolling
• A group of techniques that are applied with pressure and
are deep and compress the underlying muscles
• Movements should be slow and repetitive with pressure in
order to loosen the muscles and increase blood flow to the
area
• Promotes relaxation
• Increases fluid flow
• Increases mobility of fibrous tissue
• Decreases tone

Why should you stretch post-massage?
• Excessive tension may still remain post-massage.
• It takes up to two days post-massage to experience full effects.
• Essential to use other techniques to restore good functioning
and reduce tension.
• need to stretch the collagen fibres that have been “knotted” to
allow them to regain their full length.

Post treatment stretches
Passive static stretching
•Involves taking the muscle belly to its outer range until you can feel a
gentle stretch.
•Static stretches are usually held for at least 30 pain free seconds.
•Research suggests static stretches should be repeated from 2 to 4 times.
As further repetitions do not promote any further muscle elongation
(Bandy, 1997).

Practical:
Tool and other STR
techniques

Supporting
Evidence

Myofascial trigger points in subjects presenting with
mechanical neck pain: a blinded, controlled study
Fernandez-de-las-penas, 2006
•Aim: To highlight the presence of trigger points in subjects complaining of
mechanical neck pain within the upper trapezius, sternocleidomastoid, levator
scapulae and suboccipital muscles.
•Method: 20 subjects with mechanical neck pain matched with 20 healthy
subjects. TrPs were identified, by an assessor blinded to the subjects' condition,
when there was a hypersensible tender spot in a palpable taut band, local twitch
response elicited by the snapping palpation of the taut band, and reproduction of
the referred pain typical of each TrP.
•Results: the mean number of TrPs present on each neck pain patient was 4.3
(SD: 0.9), of which 2.5 (SD: 1.3) were latent and 1.8 (SD: 0.8) were active TrPs. All
the examined muscles evoked referred pain patterns contributing to patients'
symptoms. Active TrPs were more frequent in patients presenting with mechanical
neck pain than in healthy subjects.
•Link: http://www.manualtherapyjournal.com/article/S1356-689X(06)00031-
2/fulltext?refuid=S1479-2354(07)00108-3&refissn=1479-2354

Effectiveness of Myofascial Trigger Point Manual Therapy Combined
With a Self-Stretching Protocol for the Management of Plantar Heel Pain:
A Randomized Controlled Trial
Renan-Ordine et al, (2011)
•Aim: to assess the effect of trigger point therapy and stretching or stretching alone in the treatment
for plantar heel pain.
•Method: 60 patients with plantar heel pain were divided into 2 groups a)self-stretching b) self-
stretching and trigger point therapy.
•Outcome measures: assessed at baseline and at a 1-month follow up.
– Physical function and bodily pains assessed through a quality of life questionnaire.
– pressure pain thresholds were assessed over affected gastroc, soleus muscles and over the
calcaneus using a mechanical pressure algometer.
•Results: trigger point therapy and self-stretching is superior to stretching alone in the treatment of
patients with plantar heel pain.
•Link: http://www.jospt.org/doi/full/10.2519/jospt.2011.3504

Comparative study on effects of manipulation treatment and
transcutaneous electrical nerve stimulation on patients with cervicogenic
headache
Li et al, (2007)
•Aim: To compare the effects of trigger pointing and transcutaneous electrical nerve
stimulation (TENS) on patients with cervicogenic headache.
•Method: 70 patients with cervicoigenic headaches were randomly allocated to receive
trigger pointing or TENS every other day for 40 days.
•Outcome measures: taken 2 weeks pre-treatment and 4 weeks post-treatment.
– headache degree, frequency and lasting time using a numeric rating scale
– ROM of cervical spine.
•Results: Trigger pointing was superior to TENS in headache frequency, lasting time and
ROM scores. Response rate of trigger pointing treatment was 94.5%, significantly higher
than 64.5% of TENS treatment.
•Link: http://europepmc.org/abstract/med/17631795

Immediate effect of activator trigger point therapy and myofascial band
therapy on non-specific neck pain in patients with upper trapezius trigger
points compared to sham ultrasound: A randomised controlled trial
Blikstad and Gemmell, (2007)
•Aim: To determine the immediate effect of activator trigger point therapy and myofascial
band therapy compared to sham ultrasound on non-specific neck pain
•Method: 45 patients with non-specific neck pain of at least 4 on an 11-point numerical
rating scale and upper trap trigger points, decreased cervical lateral flexion away from the
active trigger points participated. Participants were assigned to one of three treatment
groups; trigger point therapy, myofascial band therapy or sham ultrasound.
•Outcome measures: assessed before and 5 min after treatment
– pain levels assessed using numerical scale
– cervical ROM using goniometer
– pain perceived thresholds using pain pressure algometer.
•Results: For the primary outcome measure of pain reduction the odds of a patient
improving with activator trigger point therapy was 7 times higher than a patient treated with
myofascial band therapy or sham ultrasound.
•Link: http://www.sciencedirect.com/science/article/pii/S1479235407001083

Cervicogenic headache caused by myofascial trigger points in the
sternocleidomastoid: a case report
Case report:
•45 year old male patient with 25 year history of chronic headaches and neck pain.
•Patient had seen many medical specialists and had received multiple facet
blocks, radiofrequency ablation, selective C2 nerve blocks, occipital nerve blocks,
multiple pharmacological regimes and behavioural therapy. All producing no
change in symptoms.
•Patient was referred back to physical therapy to assess musculoskeletal
contributions to head pain.
•Patient reports 5/5 pain scale, had a slumped sitting posture, restricted right
cervical rotation, extension and muscular tightness in right pectoral muscles and
active trigger points in sternocleidomastoid muscle which on palpation reproduced
the patients pain.
•Patient given treatment including kinesiology taping, trigger point therapy and
postural training.
•After 4 weeks he reported pain reduction of 70%.
•6 months after being discharged from 16 sessions he reported being pain free
approximately half of the time with only mild discomfort the rest.
•Link: https://deepblue.lib.umich.edu/bitstream/handle/2027.42/74754/j.1468-
2982.2007?sequence=1

Supporting
Evidence:
Other STR techniques

Therapeutic evaluation of lumbar tender point deep
massage for chronic non-specific low back pain
Zheng et al, 2012
•Aim: To investigate the effects of lumber traction along and in combination with
deep tissue massage in patients with chronic low back pain.
•Method: 64 patients with LBP were divided to two groups A) lumber traction and
deep tissue massage or B) lumber traction who both received treatment twice a
week for 3 weeks.
•Outcome measures: tissue hardness meter/algometer and VAS pain scores.
•Results: Patients receiving deep tissue massage and traction experienced
significant decreases in muscle hardness and pain intensity when compared to
those who received lumber traction alone.
•Link: http://www.sciencedirect.com/science/article/pii/S0254627213600667

Massage therapy as an effective treatment for carpal
tunnel syndrome
Elliott and Burkett, 2013
•Aim: To investigate the effects of massage therapy as the
treatment for carpal tunnel syndrome.
•Method: 21 participants received 30 min of massage
including trigger point therapy twice a week for 6 weeks.
•Outcome measures: Carpel tunnel questionnaires, Phalen
and Tinel test assessment.
•Results: Participants experienced a significant reduction in
symptom severity and improvements in physical function.
•Link:
http://www.sciencedirect.com/science/article/pii/S1360859212002434

Case Studies

Case Study: Shoulder
pain
PC/HPC -21 year old female with an gradual onset of ache pain in shoulders over
past 1/12 rating 4/10 on VAS scale. The pain is aggravated by sitting at a desk for
long hours and eased with the application of heat.
SH- final year art student with a sudden increase in workload as final project is
due in 2/12. Carry heavy art portfolio to and from university. Attends a LBP class
at the gym 1 x a month.
PMH- nil to note
DH- paracetamol when needed

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

pain

Case Study: Buttock
pain
PC/HPC- 25 year old male 5/10 pain in L buttock. 1/12 ago increased pain
following legs gym session, gradually worsening since. Aggravated by
climbing multiple flights of stairs at work. Eased by resting.
SH- Started going to the gym 1/12 ago after a 5 year break. Doesn’t do any
stretching because he doesn’t know how to. Works on the 8th
floor of a
office building.
PMH- over pronate both feet, especially bad in L side.
DH- nil to note

Case Study: Buttock
pain
Objective signs
•Over pronation in L > R foot
•Valgus position of knees
•Poor hamstring flexibility on 90/90 test in L>R legs
•No neurological symptoms during SLR
•PALP: tension L>R hamstring, glutes and piriformis
•Very tender on PALP of piriformis

Case Study: Buttock
pain
Diagnosis?
How would treat this?

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

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

pain

Case Study: Calf pain
PC/HPC – 35 year old male runner. Felt a 6/10 sharp pain in R calf towards
the end of a 5K run 2/52 ago. Had to stop running. No swelling or bruising
was present. Pain reduced since 3/10 ache pain, tried running again but still
feels painful.
SH- work in a warehouse, on feet all day up and down ladders.
PMH- prev R lateral ankle sprain 12/12 ago
DH-nil to note

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

Quiz…
Answers

Question 1
• Central/ Primary
• Satellite/Secondary
• Active
• Latent/potential

Question 2
• Dull ache
• Deep
• Sharp
• Pressing pain
• Stabbing
• Burning
• Travelling pain
• Head pain

Question 3
• Pain
• Reduced AROM
• High muscle tension or tone
• Muscle tightness

Question 4
• Reduced pain
• Increased range of motion
• Decreased muscle stiffness and tension
• Reduction in headaches
• Improved flexibility
• Improved circulation
• Fewer muscle spasms

Question 5
• The rhomboid muscle group is found between the spine and the scapula in the
mid- back region. It lies deep to the Trapezius muscle and is composed of
the rhomboid major and rhomboid minor muscles.
• The rhomboid minor originates on the spinous processes of C7 and T1 and
attaches to the medial border of the scapula near the root of scapular spine.
• The rhomboid major originates from the spinous processes of T2 to T5 and
attaches along the lower half of the scapular border

Question 6
The semitendinosus
•Medial aspect of the posterior thigh
•Originates on the ischial tuberosity of the pelvis and runs down the leg to attach below the
medial condyle on the tibia.
•The belly of this muscle is found in the top portion of the posterior thigh.
The semimembranosus
•Also lies on the medial aspect of the posterior thigh
•It attaches to the ischial tuberosity of the pelvis and runs deep to the other hamstring muscles to
attach to the medial condyle of the tibia just below the knee joint capsule.
• The long head of the biceps femoris attaches to the ischial tuberosity and runs diagonally
downward and laterally to attach to the head of the fibula bone.
• The short head of the biceps femoris attaches along the linea aspera on the shaft of femur
bone and runs diagonally outward to join the tendon of the long head as it attaches to the head
of the fibula.

Question 7
General Local
Acute conditions requiring medical attention Acute flare-up of inflammatory arthritides
Acute pneumonia Aneurysms deemed life-threatening (may be general
contraindication depending on location)
Advanced kidney, respiratory or liver failure Local contagious condition
Diabetes with complications such as gangrene,
advanced heart or kidney disease or very unstable or
high blood pressure
Local irritable skin condition
Hemorrhage Malignancy
Severe atherosclerosis Open wound or sore
Severe and unstable hypertension Recent burn
Shock Undiagnosed lump
Systemic contagious or infectious condition

Question 8
• The sternal division’s referred pain is felt deep in the eye socket (behind the eye),
above the eye, in the cheek region, around the TMJ, in the upper chest, in the back
of the head, and on the top of the head.
• The clavicular division’s referred pain is felt in the forehead, deep in the ear,
behind the ear, and in the molar teeth on the same side.
Related symptoms
• Sore Neck
• Tension Headaches
• Migraine
• Dizziness

138
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