TriggerPointTherapyforMyofascialPainThePracticeofInformedTouch

DONNAFINANDO,L.AC.,L.M.T.AND

STEVENFINANDO,PH.D.,L.AC.

HealingArtsPressRochester,Vermont

Toourpatients,fromwhomwehavelearnedmuchaboutthenature

ofpainandhowtotreatit.Andtoourstudents,whorequiredus

tothinkabout,order,andcommunicatewhatwepractice.

ACKNOWLEDGMENTS

JanetTravell,M.D.,whoselifeworkinclarifyingandorderingmyofascialpainsyndromes has provided the reality base that has eluded somany others. Herwork has demonstrated beyond any doubt that pain results from musculardysfunction. So many in the medical community have, until very recently,disregarded themusculature as a source of pain and suffering. Through JanetTravell’slifelongwork—hersystematiceffortstoidentifyandchartpainpatternsassociated with muscular trigger points and the various means with which toeliminate them—we have been given the basis for treatment of chronic painsufferedbysomanyforsolong.MarkSeem,Ph.D.,whohasstrivedtoevolvetheapplicationofDr.Travell’s

work to the field of acupuncture. Understanding the value of acupuncture asphysicalmedicine in the treatment and resolutionof pain,Markhas dedicatedhis efforts to bringing acupuncture into the forefront ofAmerican health care.WewouldalsoliketothankMarkforcoiningthephraseinformedtouch,whichsoclearlydescribeswhatweseektoaccomplishthroughourwork.Arya Niellsen, L.Ac., Steven Rosenblatt, M.D., and Robert Ruffalo, D.C.,

whose feedback has helped in making this book most useful for Eastern andWesternpractitionersalike.Jane Waski, whose skillful drawings demonstrate stretches that are so

beautifullyrenderedthatwecanfeelandsensethestretchofthemuscleaswelookatthem.SusanBubenasand the staffatPolanandWaski,whosegraphiccapabilities

havebeencriticalintheproductionofillustrationsthatsoclearlyidentifymuscleandtriggerpoint.SusanDavidsonofHealingArtsPress,whohashelpedusclarify,order,and

evolvethiswork.Herhelp,herencouragement,hercarefulandcriticaleditor’seye,herpatience,andherdedicationtothisprojecthavebeeninvaluabletotheevolutionofthismanual.

CONTENTS

ACKNOWLEDGMENTS

INTRODUCTIONAGATHERINGOFFORCES:TowardanEraofInterdisciplinaryCooperationintheTreatmentofPain

CHAPTER1THENATUREOFMUSCLESANDTRIGGERPOINTSCHAPTER2QI,MOVEMENT,ANDHEALTHCHAPTER3INFORMEDTOUCHCHAPTER4DIAGNOSISANDTREATMENTCHAPTER5HOWTOUSETHISMANUAL

MusclesoftheHead,Neck,andFace

STERNOCLEIDOMASTOIDSCALENESSPLENIUSCAPITISSPLENIUSCERVICISPOSTERIORCERVICALSTEMPORALISMASSETERPTERYGOIDS

MusclesoftheShoulderGirdle

TRAPEZIUSLEVATORSCAPULAERHOMBOIDSSERRATUSANTERIORPECTORALISMINOR

MusclesoftheUpperLimb

PECTORALISMAJORDELTOIDLATISSIMUSDORSITERESMAJORSUPRASPINATUSINFRASPINATUSTERESMINORSUBSCAPULARISBICEPSBRACHIITRICEPSBRACHIIBRACHIALISBRACHIORADIALISHANDANDFINGEREXTENSORSHANDANDFINGERFLEXORS

MusclesoftheTorso

ERECTORSPINAEQUADRATUSLUMBORUMILIOPSOASRECTUSABDOMINISABDOMINALS

MusclesoftheLowerLimb

GLUTEUSMAXIMUSGLUTEUSMEDIUS

GLUTEUSMINIMUSTENSORFASCIAELATAEPIRIFORMISHAMSTRINGSQUADRICEPSADDUCTORSPECTINEUSGRACILISSARTORIUS

POPLITEUSGASTROCNEMIUSSOLEUSTIBIALISPOSTERIORTIBIALISANTERIORPERONEALMUSCLESLONGEXTENSORSOFTHETOESLONGFLEXORSOFTHETOES

APPENDIX1MERIDIANPATHWAYSAPPENDIX2ONCUTANEOUSZONESAPPENDIX3COMMONLYUSEDACUPOINTS

FOOTNOTESBIBLIOGRAPHYAOUTTHEAUTHORSABOUTTHEINNERTRADITIONSBOOKSOFRELATEDINTERESTCOPYRIGHT

INTRODUCTION

AGATHERINGOFFORCESTowardanEraofInterdisciplinaryCooperationintheTreatmentof

Pain

The field of painmanagement, specifically the treatment ofmyofascial painsyndromes, has become a meeting ground for health professionals.Acupuncturists, medical doctors, and practitioners of various manual andphysical therapies who previously had little to say to one another are nowcollaborating inways thatareunprecedented in thehistoryofAmericanhealthcare.Thereasonforthedevelopmentofsuchinterdisciplinarycommunicationisthe growing recognition that myofascial syndromes are the basis of a hugesegmentofpatientcomplaint,andassociatedallocationofresources,withinourhealthcaresystem.Patients with myofascial pain syndromes are seeking the help of family

physicians, internists, orthopedists, neurologists, rheumatologists, osteopaths,physiatrists,psychiatrists,andanesthesiologists.Dentists,particularlyspecialistsin temporomandibular joint syndrome, regularly see patients presenting withmyofascial pain. In addition, acupuncturists, chiropractors, physical therapists,occupational therapists, massage therapists, and psychotherapists are allencounteringpatients inpain.Conferencesonpain treatmenthave increasinglybecomepolyprofessionalexperiences.It is possible that, through health professionals’ mutual interest in the

treatment of myofascial pain syndromes, true complementary medicine mayemergeasarealityintheUnitedStates.ComplementarymedicineherereferstotheuseofconventionalmedicalpracticesinconjunctionwithrecentlyemergingOrientalandotherbody-therapyapproaches,providingacoordinated treatmentstrategy that is best for the patient. This differs from the alternative medicalmodel, which tends toward a competitive concept of health care, ultimatelyforcing a division between itself and conventionalmedical practices thatmaynot, in the long run, beof thegreatest benefit topatients.At this point inour

medical history the fact is that health professionals from widely varyingdisciplinesaretalkingtoeachotherwithanewfoundrespect,andtheresultmaybethefosteringofacooperativespiritthatwillhelpmillionsofpeoplewhoareinpain.Thisbook,afieldmanualforanyhealthprofessionaldealingwithmyofascial

syndromes,thereforeservesavitalpurpose.Itsaimistosimplifyandorderthevast amounts of information related to the evaluation and treatment ofmyofascial pain.Utilizingourmanyyearsof clinical and teachingexperience,wehaveendeavoredtoaddresstheconcernsanddesiresofhealthcareprovidersfor a manual that can assist in evaluating a patient, defining the presentingcondition,andguidingtreatmentofthatcondition.Itisassumedthatthereaderhas some knowledge ofmyology; therefore no effort ismade to replicate theextensive background and theoretical discussion found in seminal works onmyofascial pain, such as those of Janet Travell and David Simons and P. E.Baldry.1 Instead, in addition to the technical core of the manual, introductorychapters discuss topics that will facilitate communication among the manyprofessionsconcernedwiththisareaofstudy.Webeginwithadiscussiononthenatureofmusclesandtriggerpoints,useful

as review for those who treat primarily from this perspective and a goodintroductionforthoseenteringthefield.Wethenexaminethephenomenologyofqi,thatelusiveconceptof“energy”thatisthefoundationofallOrientalmedicalpractices.Qiisexaminedfromtheperspectiveofmyofascialsyndromes,makingitamoreaccessibleandusefulmetaphorforallhealthprofessionals.Itishopedthatanexpandedviewoftheconceptofqiwillhelpfacilitate,ratherthanhinder,communicationbetweenpractitionersofEasternandWesternmedicine.Since muscle-palpation skills are at the center of effective evaluation and

treatment, we next discuss the nature and process of palpation. Because arelative few practitioners are adept in this type of palpation, some guidingprinciplesareofferedtohelpthosewhoareevolvingpalpationskills.Achapteroutliningthefundamentalapproachestoevaluationandtreatmentofmyofascialpainsyndromeshelpsestablishcommongroundamonghealthprofessionals,inthe realization that there are behavioral elements in treatment that are shared,independent of one’s particular training or orientation.Thus the acupuncturist,neurologist, and physical therapist, while differing in perspective regardingmyofascialpainsyndromes,allultimatelysharesimilarbehaviorsinevaluationandtreatment.Abriefoverviewofhowtousetheclinicalbodyofthemanual,with a description of the information provided for each muscle, finishes theintroduction.In the final analysis, since this is amanual for the health professionalwho

encounters patients presenting with pain on a daily basis, the approach ispragmaticandbehavioral.Intheinterestofexpandingourscientificknowledge,it is enticing todetermineunderlyingmechanisms for pain that strengthenourtheoreticalunderstanding.However,itisfarmoreimportantthatthepractitionerinthefieldascertainwhathelpspatients,andlearnshowtoeffectthathelp.Thisbookisabouthow,notwhy.

CHAPTER1

THENATUREOFMUSCLESANDTRIGGERPOINTS

Movement is a fundamental characteristic of life, and themusculature playsthemajorroleinthatactivity.Motion,bothgrossandsubtle,isanessentialbodyfunctionresultingfromthecontractionandrelaxationofmuscles.Inhumansthemusculatureconstitutes40 to50percentof totalbodyweight.Consideredasasingle entity, the musculature can be regarded as the body’s largest internalorgan.Therearethreeprimaryfunctionsofthemuscles.First,theycontributetothe

supportofthebodyandcontainmentoftheinternalorgans.Second,theyallowmovement of the body as a whole, as well as movements of the organs andsubstructures.Manykindsofmotionrelyontheintegratedfunctioningofbones,joints, tendons, ligaments, muscles, and fascia. Both the maintenance of ourupright posture as well as all body movements—walking, sitting, writing,chewing,breathing,andsoforth—takeplaceasaresultofappropriatemuscularactivity. Internal, organic movement that is the hallmark of life relies onappropriate muscular activity: the beating of the heart and the movement ofbloodthroughoutthearterialvessels;digestion,peristalsis,andelimination;theemptying of the bladder; the very ability to draw a breath. Finally, thismovement produces heat and therefore contributes to the regulation of bodytemperature,thethirdprimaryfunctionofthemuscles.The three types of muscle—skeletal muscle, visceral muscle, and cardiac

muscle—provide these functions. Each of these tissues exhibits four principalcharacteristics:

1. Excitability (irritability)—theability to receiveand respond to stimulivianerveimpulse

2. Contractility—the ability to shortenwhen a sufficient internal or externalstimulusisreceived

3. Extensibility—theabilitytobestretched4. Elasticity—the ability to return to normal shape after contraction or

extension

The focus of this manual is the contractile, voluntary skeletal muscle tissue.There are two types of skeletalmuscle: phasicmuscles andpostural, or tonic,muscles.Phasicmusclesproduceacontractionknownasaphasiccontraction.Aphasic

contractionissufficientforthemuscletoproducemovementofitsattachments.Phasic muscles are mainly comprised of fast-twitch fibers, which tend toproducerapidcontractionsandthereforefunctiontoproducerapidmovements.Thereisagenerallylowcapillarysupplytophasicmusclesand,asaresult,thesemuscles tend to fatigue quickly. Phasic muscles tend toward the rapidaccumulationoflacticacid.Whenthereismusculardysfunction,phasicmusclestendtowardweakening.Those that are generally considered to be phasic muscles include the

midthoracicportionoftheerectorspinae;therhomboids;thelowerandmiddletrapezius; the abdominal portion of pectoralis major; triceps brachii; vastusmedialis and vastus lateralis; gluteus maximus, gluteus medius, and gluteusminimus;rectusabdominis;andtheexternalandinternalobliques.Postural, or tonic, muscles produce a sustained partial contraction of the

muscleknownasa toniccontraction.Witha toniccontractionaportionof themuscle cells in the muscle are contracted at any given time while others arerelaxed.Thiscausessomecontractionofthemuscle;however,becauseenoughfibersarenotcontractedat the samemoment in time,a toniccontractiondoesnotproducemovementoftheskeletalattachments.During a tonic contraction an individual motor unit does not function

continuously; rather, individual motor units within the muscle fireasynchronously, thereby relieving one another in a smooth and continuousmanner.Theresult isamusclecontractionthatcanbeheldfor longperiodsoftime. As the name implies, these postural, or tonic, muscles act in themaintenanceofuprightposture;theyareconsideredtobe“antigravity”muscles.Posturalmuscles tend to be comprisedmainly of slow-twitch fibers. There isgenerally ahighcapillary supply to thesemuscles, andas a result theydonottend to fatigue rapidly. Lactic acid production is minimal. When there ismusculardisturbance,posturalmusclestendtowardshortening.Those that are generally considered to be postural muscles include the

scalenes,sternocleidomastoid,levatorscapulae,pectoralismajor,bicepsbrachii,the cervical and lumbar portions of the erector spinae, quadratus lumborum,

iliopsoas, the hamstring group (biceps femoris, semitendinosus,semimembranosus), rectus femoris, tensor fasciae latae, the adductor group(adductor magnus, longus, and brevis), pectineus, gracilis, piriformis,gastrocnemius,andsoleus.Skeletal muscles, both phasic and tonic, are extremely vulnerable to injury

duetooveruseandthewearandtearofdailylife,yetthismusculatureisoftenoverlookedasamajorsourceofphysicalpainanddysfunction.Inorder to clearlyunderstand thenatureof an injuredmusclewemust first

understand thequalitiesofnormalmuscle.Normal,healthymuscle tissuefeelssuppleandelastic.Theunderlyingstructures—bones, joints,andviscera—maybeeasilypalpatedthroughtheskeletalmuscle.Thereisuniformconsistencyandplasticitywithinanormalmuscle,anditisnottenderwhenpalpated.Ahealthymuscle will contract in response to nervous impulse, returning to its normalshapeaftercontraction.Individualbundlesofmusclefibers(fascicles)cannotbedifferentiatedwhilepalpatingnormalmuscle.Adysfunctionalmusclewillcontract,butitwillnotreturntoitsnormalshape

followingcontraction. Itwill instead remain fixed ina shortenedposition,onethatoftenresultsinlocalreductionofbloodflow,lymphdrainage,andrangeofmotion.Over timeachronicallycontractedmusclecanundergochanges in thetissue, either throughout the functional unit or within individual bands. Thesechangesareoftencharacterizedbyanincreaseinmuscletone,greaterresistancetopalpation,anddecreasedsuppleness.Contractedmusculatureisnolongerableto perform its activities optimally. Being shortened, it cannot perform its fullrange of contraction and release. Its range ofmotion is impaired, resulting inweakenedfunctioning.Taut bands, individualized bundles of muscle fiber, may be differentiated

duringpalpationofacontractedmuscle.Themusclemayharborropelikeareas,cordlikebandsthatcanvaryinthicknessfromthinstringstocablesasmuchasafew centimeters thick. (Generally, bands formed in smallmuscles feel stringywhile bands formed in larger, thicker muscles feel “ropy,” or like cables.)Contracted muscle is generally reported to feel tender when mild pressure isapplied.Underlying structuresmaybemore difficult to palpate clearly, and incases of very strong contraction, underlying structures may be completelyobscuredtopalpation.All of us harbor areas of constrictedmuscle, contracted in varying degrees,

that maintain holding patterns in tight, chronically utilized muscles. Thesepatterns can be seen in such commonpostural habits as holding the shoulderselevated,thechestconstrictedanddropped,theupperbackrounded,orthelowerbackstronglyarched.Whetherduetoemotionalorphysicalpatternsofoveruse,

ourposture,ourabilitytomove,andourabilitytooperateinaphysiologicallyoptimal manner are all affected by holding patterns of muscular constriction.Whentheconstrictionischronic,otheraspectsofourphysiology,suchasbloodflow, lymphatic drainage, and nervous innervation, are eventually affected aswell.Ouroverallhealthisthereforeintimatelyrelatedtoourmuscularhealth.Oneofthemanyfactorsthatmaycontributetothepainanddysfunctionofa

muscleisthedevelopmentoftriggerpointswithinit.Inherencyclopedicworkon trigger point therapy, Dr. Janet Travell defines a trigger point as “ahyperirritable locus within a taut band of skeletal muscle, located in themusculartissueand/oritsassociatedfascia.”1Myofascialtriggerpoints—thatis,thosethatarelocatedinmuscle(generally,skeletalmuscle)ormusclefascia—aremostprevalentandsymptomatic;however,triggerpointscanalsobepresentincutaneous,ligamentous,periosteal,andnonmuscularfascialtissuesaswell.Amyofascial trigger point is that area, that point, along a tautmuscular band inwhich the tenderness reaches its maximum. The patient will feel the greatestdegree of sensitivity at the trigger point; the practitionerwill feel that area tohavethegreatestresistancetopalpation(thatis,itwillfeellikethehardestareaonthetautband).Atriggerpointispainfuluponcompression.Itcangiverisetoreferredpain,tenderness,andautonomicphenomenasuchasvisualdisturbances,redness and tearing of the eyes, vestibular disturbances, space-perceptiondisturbances, coryza (mucous membrane inflammation), reduction in localvascular activity, and skin temperature changes. The implications of suchextensive effects are important in regard to the examination and treatment ofmany disorders that are generally not considered to be related to muscularproblems.The size of the muscle is not the characteristic that defines the degree,

severity,andextentofpaincausedbyatriggerpointwithinthatmuscle.Rather,itisthedegreeofhyperirritabilityofthetriggerpointthatdefinesthedegreeofpain. Themore hyperirritable the trigger point, the greater the degree of painthroughoutthecourseofthereferredpainpattern.A triggerpointmaybeginwithmuscular strainoroveruse thatbecomes the

site of sensitized nerves, increased cellular metabolism, and decreasedcirculation. From an anatomic perspective, areas that tend to develop triggerpoints are generally areas in which increased mechanical strain or impairedcirculation are likely to develop due to physical activities or postural stresses.Trigger points most frequently develop in the sternocleidomastoid, uppertrapezius, levator scapulae, infraspinatus, thoracolumbar paraspinals, quadratuslumborum, gluteus medius, and gluteus minimus; however, trigger points candevelopwithinanyfascicleinanymuscleofthebody.

Triggerpointscanbelatentoractive.Bothwillcausestiffnessandweaknessof the affected muscle and restrict the muscle’s full range of movement.(Stiffnessismostnotableafterperiodsofinactivity,whileweaknesstendstobemorevariable.)Bothactiveandlatenttriggerpointsaretendertopalpation.Active triggerpointsaredifferentiatedfromlatent triggerpoints in that they

producepain.Therefore,active triggerpointsaregenerallyconsidered tobeofgreater clinical significance. This pain tends to be referred away from theaffected muscle in a characteristic pain pattern; the relationship between anactive trigger point and its characteristic pain pattern has been extensivelyresearched by Travell and Simons. There may be an abrupt onset of pain ordysfunction, whereby a specific incident is noted to be the cause of themyofascial difficulty, or the onset may be gradual, the muscle having beenoverloaded for some period of time.Myofascial painmay be characterized assteady, deep, dull, and aching; it is rarely describedby the patient as burning,throbbing, tingly, or numb. Pain varies in intensity from low-grade to quitesevere,anditmayoccuratrestorinmotion.Tenderness in response to palpation can occur within the pain pattern of a

trigger point even if pain is not experienced in the point’s referral zone. Thistenderness will dissipate after the trigger point is reduced. Pain or tendernesswillgenerally increasewithuseof themuscle, stretchingof themuscle,directpressuretothetriggerpoint,shorteningofthemuscleforanextendedperiodoftime,sustainedrepetitivecontractionofthemuscle,coldordampweather,viralinfections, and stress. Symptoms will decrease after short periods of lightactivity followed by rest, and slow, steady, passive stretching of the muscle,especiallywiththeapplicationofmoistheattothemuscle.Latent triggerpointsare farmorefrequent thanactive triggerpointsandare

commonly found in patterns of muscular constriction that frequently define aperson’s “normal” posture. Latent trigger points can become active through anumber of circumstances. Activation of a trigger point can occur directlythrough acute overload of a particular muscle, chronic overload or overworkfatiguecausedbyexcessiveorrepetitiveactionsorsustainedcontractionofthemuscle,traumatothemuscle,orcompressionorchillingofthemuscle.Indirectactivationcanoccurasa resultof leavingamuscle inashortenedpositionforextended periods of time, as in sleeping or sitting for extended periods orholdingaphonebetween theear and the shoulder. Indirect activationcanalsoresult from visceral disease, viral disease, emotional stresses, or the chronicmuscularstrainoftryingtostabilizearthriticjoints,orifthelatenttriggerpointsliewithinthepainpatternproducedbyother,activetriggerpoints.Generallythedegreeof conditioningof themuscle is the factor thatmost defineswhether a

latent trigger point will become active. The greater the degree of muscleconditioning, the lower the susceptibility to trigger point activation.However,whileanactivetriggerpointwillfrequentlyreverttolatencywithsufficientrest,triggerpointswillnotbefullyreducedwithoutclinicalintervention.Onlyadequate,focused,specificpalpationtechniquesallowthepractitionerto

identify trigger points within a muscle. Through palpation we identifygeneralized tightness of the musculature within the vicinity of the suspectedtriggerpoint.Aswepalpatewelocatethespecificmusclethatisshortenedandthen locate thespecificbandwithin themuscle that is taut.Continued focusedpalpationwillrevealanareaalongthebandthatisparticularlytightandthenapointwithintheareathatisexquisitelytender.Herewehavelocatedthetriggerpoint.Directmanualpressure to that triggerpoint elicitswhatTravell calledalocal twitch response—that is, a literal twitch of themuscle that is sometimesvisible(dependingontheplacementofthemuscle)andisoftenexperiencedbythepatient.2Inaddition,theremaybea“patientjumpsign”—thatis,thepatientjumpsorcriesout inpain.3Thepain that thepatientexpresses isoftengreaterthan the practitioner may expect given the degree of pressure applied. Withextendedpressuretothetriggerpoint,thereferredpainpatternmaybefeltinitsentiretybythepatient.Once located, the trigger point must be reduced. This is accomplished

primarilythroughneedlingorthroughischemiccompression.Dependingonthespecialtyof thepractitioner,needlingmayincludeacupunctureneedlingordryneedling, or trigger point reduction techniques developed within the medicalcommunitywiththeuseofanalgesicoranesthetic injection,or theinjectionofsaline.Ischemiccompressionrequirescompressingthetriggerpointfor15to20seconds,followedbymanipulationofthesurroundingbandsofmuscletissuetoreduce local constrictions and taut muscular bands. Spray-and-stretchtechniques, that is, theapplicationofcoldwhilestretchingthemuscle, isoftenhelpful as follow-up to needling or ischemic compression. Treatment iscompleted through the application ofmoist heat to increase circulation to theaffectedmuscle.Once there is sufficient reduction of the trigger points and associated

constrictions, the patient is instructed in stretching techniques specific to theinvolvedmuscles.Thestretchesareaimedatkeepingthemusclefromreturningtotheshortenedstate.Repeatedstretchingthroughoutthedayisunquestionablyone of the most important aspects of treatment. Finally, depending upon thedegreeofweaknessofthemuscle,afteritisclearthatthemuscleisnotreadilyreturningtoacontractedstatethepatientisinstructedonspecificstrengtheningexercisestohelphimreturntooptimalactivitylevelsandtopreventthemuscle

fromtendingtoreturntoastateofdisability.It is important to note that the conditioning of a muscle is ultimately

dependent upon the conditioning of thewhole body. It is vitally important tohelpeachpatientattainanoptimumlevelofhealthwithaprogramthatincludesexercises that will generally strengthen both the musculature and thecardiovascular system.Everypart is only asviable as thewhole.Toviewandtreat a single muscle or muscle group without consideration of the whole isinsufficienttreatment.Anexpansiveviewofthewholebodymustbeintegratedintothecareofeachpatient.

CHAPTER2

QI,MOVEMENT,ANDHEALTH

AsacupuncturistsandpractitionersofOrientalmanipulationtherapiesforovertwenty-fiveyears,ourintroductiontopatientevaluationandtreatmenthasbeenthrough the perspective ofOrientalmedicine.UnlikemodernWesternmedicalarts, Oriental medicine was developed at a time when it had neither theadvantage of extensive knowledge regarding anatomy and physiology nor theburden of understanding underlying physiological mechanisms of disease andtreatment. The result was a very practical medicine, refined by millennia ofexperience.Years of study of Eastern philosophies have shown us how, in the ancient

Orient,metaphorwasusedtodescribethenatureoftheworld.Oneofthegreatmistakes made by modern students of Oriental medicine and body therapies,bothintheEastandWest,isthinkingthatOrientalmedicalprinciplesareactualdescriptors of a physical reality rather than ideas or metaphors that serve toguide treatment. In keepingwith themost ancient roots ofOrientalmedicine,thisbookaddresseswhatwe,aspractitioners,dobehaviorallytoeffectchangeinthemusclesandfascia,andtoultimatelyreduceor terminate theexperienceofpain for our patients. Thus, in part this manual is designed to address thefollowingquestions:Howdoweapproachapatientwho isexperiencingpain?What dowe look for?Where dowe touch?How dowe untie themyofascialGordianknotthatissooftenthephysicalrealityofonewhohasbeeninpainforanextendedperiodoftime?Thesearethequestionsthatguideourapproachtoourpatients.Perhaps no area of Western medicine so parallels the pragmatic Eastern

approach as the treatment of myofascial pain. Dr. Janet Travell, the brilliantphysicianwhomadealife’sworkofstudyingtriggerpointsandthemyofascia,was an extremely pragmatic and behaviorally oriented individual. Her carefuldocumentation of myofascial pain patterns and associated causes andperpetuating factors represents decades of clinical experience. Without any

knowledge of Oriental medicine she discovered meridian therapy in Westernterms. Thiswas amonumental feat of careful clinical observation, integratingthediverseexperiencesofpatientsinpain.HerworkwithDr.DavidSimons,alandmark in the field, is ultimately decidedly behavioral and pragmatic inapproach.1On several occasions between 1991 and 1994 we had the remarkable

experienceofobservingDr.Travellatwork;itwastheopportunitytoobserveamasterpractitioner.WatchingDr.Travelltreatpatientswasajoy.Sheunderstoodwhattodo,wheretotouch,howtomove,howtofeel;andsheultimatelyhelpedherpatients.Sheunderstoodwhatwasofbenefit andhypothesizedaboutwhy.The concepts and approaches that she utilized simplywork; they help changelivesandalleviatesuffering.InourworkwithDr.Travellitbecamecleartousthatthefieldofpainmanagementisoneinwhichpracticesthatbenefitpatientsare shared between Eastern and Western approaches. It is curious to note,however, thatpractitionersofbothofthesesystemsdon’treallyunderstandthenatureofthatwhichunitesthem.During our first fifteen years in practice we studied and utilized both

traditional Chinese medicine (TCM) and an ancient style of acupuncture thatactually represents a group of methods collectively known as meridianacupuncture. Traditional Chinese medicine, primarily based upon an internalmedical model, considers the practices of acupuncture and herbology to beinseparable. TCM emphasizes assessment through the evaluation of signs andsymptoms, including the evaluation of pulse and tongue characteristics, in anefforttodiagnosesomeinternalcondition.2All acupuncturists study the meridians. However, unlike the practitioner of

TCM, the practitioner of meridian acupuncture utilizes needles first andforemosttoopenconstrictionsalongthepathwaysofthemeridians.Hegenerallyreliesonpalpation skills to locate constriction, sets needles related to areasofconstriction, and often identifies distal constrictions related to local ones. Inpractice,however,wefoundthat theuseofacupuncturetechniques,boththoseoutlined inTCM aswell as those employed bymeridian acupuncturists,werelimited in their ability to aid patients suffering from either chronic or acutemyofascial pain, regardless of the location of that pain. Neither the TCMtreatments utilizing the internal medical model nor the treatments utilizingtechniques based on meridian acupuncture were sufficient to completelyalleviate thatpain.Somethingwasmissing.Whenweencountered theworkofDr. Janet Travell we discovered what was clearly needed. Since that firstintroduction we began evolving a practice that utilizes both the Easternperspectiveofmeridiantherapeuticsandthemyofascialperspectiveoutlinedso

extensivelybyTravellandSimons.Indevelopingthispracticeweperceivedandtreated our patients through two “lenses,” and so began to see the realsimilaritiesbetweenthepatternsofpainresultantfrommyofascialtriggerpointsascataloguedbyTravellandthepathwaysofthemeridiansastheyliealongthelimbsandtorso.3Bydirectlytreatingthesourceofthepain—thespecificmuscleharboring trigger points as identified through palpation—and then supportingthatwithtreatmentalongrelatedmeridianpathways,wefoundthatwewereabletogreatlyalterourpatients’conditions,allowingthemfargreaterfreedomfrompain.EmployingthisintegrationofEasternandWesternperspectives,theworkwe have developed is called myofascial meridian therapy. This merging ofEasternandWesternpointsofviewisuseful:simplyput,itworks.In observing the fields of acupuncture and Oriental medicine over the past

decade,wehaveseenunprecedentedgrowthinthenumbersofpeoplewhowishto learn about its principles and practices. These numbers include physicians,dentists,chiropractors,osteopaths,physicaltherapists,andmassagepractitionerswho are seeking out additional, and perhapsmore effective,means of treatingtheirpatients;aswellaspeoplewhohavepersonallybenefitedfromacupunctureandwhowish tochange theircareer,perhaps tohelpothersas theyhavebeenhelped.Insomany(ifnotall)cases,thesepeopleareinterestedincaringforthewhole person, no longer satisfied with the focused specialization within themedical community inwhich a patient is defined by his presenting condition.Health care practitioners of all types are embracing a newfound, but old-fashioned, respect for the individual, holding a view in which a physicalconditionrepresentsdysfunctionwithin thewholeand isconsideredwithin thecontextofitseffectsonthewhole.Myofascial meridian therapy is a form of treatment in which addressing a

patient’spain isdonewithin thecontextof treating thewholeperson.Becausemyofascial meridian therapy utilizes aspects of both Eastern and Westernapproaches to patient care, it can provide the basis of treatment—themeetingpoint—forthosewhoseorientationliesineitherOrientalmedicineorallopathicmedicine. Those whose background is Oriental medicine can broaden theirapproachtopatientcareandthetreatmentofpainbydelvingmoredeeplyintothe study of themyofascia, increasing their understanding of themusculatureandthefasciaandthecomplexrolethoseplayinhumanhealthandwell-being.Just so, thosewhose background is in theWestern perspectives of health carecanbroadentheirperspectiveofthehumanexperiencebyembracingsomebasicconceptsutilizedinthepracticeofOrientalmedicine.One of the most basic of those Oriental medicine concepts is that of qi,

popularlyconceivedofas“lifeforce.”Itisintheconsiderationofqi,redefined

inWesternterms,thatweonceagainfindameetingplaceforboththeEasternand Western perspectives. However, in order for qi to be considered as aunifying principle for guiding treatment, its definition must be expanded andrefined.It is important to preface this discussion with the statement that Chinese

philosophicalconceptsareextremelyfluid:ideaschangerelativetotheircontextandapplication.Thepointhere is toprovideaway inwhich theconceptofqimay be particularly useful to the practitioner of myofascial meridian therapy,regardlessoforientation.Hopefullytheresultwillsimultaneouslyelevateqitoamorecomplexconceptwhilemaking its application inmeridian therapies, andpainmanagementspecifically,farmorepragmatic.

PerhapsthemostintriguingandpowerfulaspectofOrientalmedicineisitsdirectconnection to universal principles. The Taoist application of cosmology tohuman health—the view of the human being as a part of a much broaderuniversal system—is foundational to understanding the ancient Orientalapproachtohealthcare.Seeingthehumanbeingasamicrosystemthatispartofa macrosystem is intrinsic to understanding how to treat health problems.Indeed, the principles used by acupuncturists are not so much acupunctureprinciplesastheyareuniversaltenetsappliedtoacupuncture.LetusconsideruniversalprinciplesasdescribedinTaoistcosmologies.Taoist

cosmologybeginswith the ideaofWuQi, sometimesdescribedasEmptiness,the Void, or Nothingness. This is the universe a priori to existence. Think ofwhat an extraordinary idea this is: it is the concept of some “thing” beforeanythingexists.ThisistheideaoftheunmanifestGod,theAbsolute,Unity,orNirgunaBrahman (inHinduism),which refers toGodwithout attributes. It isperhapsmoreaccuratelydiscussedasadynamicthatisinperfectbalance.Whenthereisachangeinthisdelicatebalance,somemovementoccurs.Movementisarelative concept—it only exists in relation to something else; therefore,movement implies duality. This is the beginning of existence, the Tai Qi, theYin/Yang,aconceptsimilartothebigbangtheoryofcreation.AndsowehavetheWuQi, movement as potential only, giving rise to the Tai Qi, movementmademanifestintheformofduality.Now consider the idea that, following this first movement, everything that

subsequently comes into existence can only function under this universalprinciple of duality, Yin/Yang. All that exists is a function of, and thereforereflects, this first principle, this first movement, the beginning of duality.Existence can be viewed as a continuum of energy, starting with the highestenergeticleveloftheTaiQiandmovingoutward,slowingdown,andbecoming

more material. The Tai Qi pervades everything, including its ultimatemanifestation as the “ten thousand things,” the Chinese euphemism for thematerialworld.Applyingthisideatoourwork,wecanthereforeseethattheconceptofqithat

isparticularlyusefultomyofascialmeridiantherapistsisthisnotionofimpetustoward movement. Organic life exists as a particular vibration, or level ofmovement,onthisuniversalcontinuumofenergy;healthisintimatelyconnectedwiththismovement.Wearenotreferringheretothemovementofqibutrathertomovement itself,withqibeing thesourceofsuchmovement.Qias impetustowardmovementmaybeequated, then,with theTao, the“wayofall things.”AstheTaoteChingbegins:“TheTaothatcanbenamedisnottheeternalTao.”4

Ifwe try to name qiwe have begun to bring the concept down and, in somesense,makeitmore“material.”Viewedfromthisperspective,qiisametaphysical—ratherthanaphysical—

concept; it thus cannot be understood in physical terms or through customarylanguage. Because language is generally developed in the context of physicalreality,weareinalinguisticquandrywhenweentertheworldofmetaconcepts.Considered in thisway, however, qi cannot be described or held to a specificdefinition, though it can be alluded to through metaphor, parable, or similarconstructs.Unfortunately it is thehistoryof such ideas tobe reduced,broughtdown to the way we, as human beings, easily understand, and made intosomethingphysicalratherthanmetaphysical.Whiletheideathatqiissomesortofinvisible“stuff”flowingthroughthemeridianscanhaveitsuses,itshouldbeunderstoodthatthisisamaterializedconceptofqi.The fundamental characteristic of energy ismovement, and the quality and

nature of this movement defines the continuum of energy and matter. Thiscontinuumcanbeobservedbylookingatwater,thatremarkablesubstancethatisboththebasisandthereflectionoflife.Initsmostenergeticstatewaterexistsassteam; in its least energetic and most material state it exists as ice. Themetaphors of qi applied in a number of Oriental medical contexts—such asimmune,muscular,andsoft-tissuefunctions(weiqi);nutritivefunctions(kuqi);orgeneticpredispositions (yuanqi)—are all about harmoniousmovement: lifeconnectedtobalancedactivity;open,flowingmovement.Itisnowonderthatqiisoftenconnectedtowatermetaphors(sea,river,spring,andsoforth).Conceptualizingqiintermsofmovementratherthansubstancemarriesitinto

aphilosophyoflifeandhealthheldbyallmedicalsystems.ConsiderthewordsofreknownedosteopathandeducatorJohnMcMillanMennel inhisdiscussionofthemusculoskeletalsystem:

Themusculoskeletal system has two equally important functions. The first ismovement, and thesecondissupport(orcontainment).Themostimportantpartofitsmovementfunctionisperhapsthatits absence is associated with death (emphasis ours). As movement becomes more and moreimpaired,thefunctionsofthesystemsthatthemusculoskeletalsystemisdesignedtocontaincannotbemaintained,andtheseotherstructuresthemselvesbecomedysfunctional.Thisinitselfcontributestoandmayhastenthefinallossoffunctionofthecontainedsystems.5

Health requires movement; when movement ceases, life ceases. When thehuman organic system is functioning properly, things move well and in acoordinated, homeodynamic manner. Blood moves in a steady tidal flow,connectedtosuchdiverseandchangingconditionsasmuscularcontractionandrelease,digestion, andmentation.Nerves signal throughelectrochemical flowsin a coordinated system of activity; endocrine glands provide well-timedsecretionsrelatedtotherequirementsofthewhole.Muscles,fascia,tendons,andligamentsdirect lubricated joints throughcomplexmovements.Therespiratorysystemmovesgasesincoordinatedquantities,whileciliaandmucusprovidethefirst line of defense against pathogens. Digestive enzymes are secreted, andharmonious peristaltic action allows for the transformation of materials intoenergy.Lymphispumpedandcirculatedasthebodymoves.Allofthisistakingplaceinaninteractivesymphonythatwecalllife,fromthecellularleveltothecosmologicallevel.Acentralprincipleof taiqiquanholdsthat theuniverse is thisall-pervasive

movement, or activity, and it is that movement which we experience as ourhuman bodies. Human beings are loci of this activity; the more a person iscapableofrelaxing,bothphysicallyandpsychologically,themorehebecomesalocus through which more of this movement can take place. The moreconstrictedapersonis(bothphysicallyandpsychologically—whichare,infact,interdependent), the more movement is impeded. Such impediments produceconsequences that affect health andwell-being.Consider thewords of a greattaijiquanmaster,Dr.JwingMingYang,ashediscussesthefactthatmanyqigongpractitionersmistakenlytakethefeelingofheatthattheyexperienceasqi:

Actually, warmth is an indication of the existence of Qi, but it is not Qi itself. This is just likeelectricityinawire.Withoutameter,youcannottellthereisanelectriccurrentinawireunlessyousensesomephenomenonsuchasheatormagneticforce.Neitherheatnormagneticforceiselectriccurrent;rathertheyareindicationsoftheexistenceofthiscurrent.Inthesameway,youcannotfeelQidirectly,butcansensethepresenceofQifromthesymptomsofyourbody’sreactiontoit,suchaswarmthortingling[emphasisours].6

Onceagainweseethestruggletodealwithanexperiencethatisbothphysicalandmetaphysical.TheassociatedwarmthtowhichDr.Yangrefersisconnectedtoincreasedcirculationofbloodandlymphandincreasednerveconductionthatoccurasaresultofthereleasethattakesplaceduringthepracticeoftaiqiquan;

thatis,totheeffectsofimprovedmovement.GiovanniMaciocia,authorofTheFoundationsofChineseMedicine,correctly

identifies the enormous difficulty in defining qi, which he describes assomethingthatismaterialandimmaterialatthesametime.Oneinterpretationheoffersis“movingpower.”7He,likemanyotherswhohavecloselyexaminedtheidea,decidestoleavethetermqiuntranslated.Asimilarproblemofdefinitionoccurswhenweconsiderothermetaconcepts,

such as the idea of higher dimensions of space. Concepts such as a fourth-orfifth-dimensional spacecanbe representedmathematicallyorcanbediscussedinmetaphor(seeAbbott’sFlatlandorBragdon’sAPrimerofHigherSpace8),buttheycannotbeimagedordescribed.Trytopictureadirectionperpendiculartoall three spatial dimensions (that is, image the fourth dimension), and youconfront thedifficulty.Qi, likeothermetaconcepts, is in the same categoryofdefinitionalcomplexity.However,oncewerelatetheconceptofqitomovement,weholdaratherelegantideathatbridgesEasternandWesternviewsoflifeandhealth.Myofascial meridian therapy operates from this simple unifying construct.

Movement, harmonious activity, unimpeded flow of bodily fluids, unimpairednerve transmission, and the free rangeofmotionofmuscles and joints are allconnectedtohealthandlife: thismovementcanbecollectivelydescribedasqimanifesting. Constriction, impingement, entrapment, ischemia, and excessivetightness, all associated with dysfunction and pain, can thus be considered interms of some reduction in movement. Be it of an organ, muscle, fluid, orelectrochemical impulse,with pathology there is some interferencewith flow,withmovement,withqi.Deathistheresultofitsultimatewithdrawal.Given the functional definition of qi as movement, myofascial meridian

therapy is concerned not with “moving” some substance called qi, but ratherwithremovingorminimizingdisruptionstomovementitself.Ourinclinationistotrust the inherent wisdom of the body; we endeavor to provide an optimumenvironment inwhich the body can heal itself. Therefore it is the role of themyofascialmeridian therapist to releaseconstrictionsandpromote flow.Whilethefundamentalapproachismyofascial,thebroadconceptsandpatternsofthemeridian system are also embraced. The successful release of myofascialconstriction comes from applying knowledge and understanding of thesemeridian patterns in conjunction with the ability to palpate and releaseconstrictionswithinthemuscularandfascialsystems.Diagnosis, therefore, is intimately associated with treatment, since the

diagnosis isneitherof internaldiseasesorpatternsofdisharmonyas theorizedfromanEasternperspectivenortheexpressionofWesternmedicalpathologies.

Rather, to diagnose from a myofascial meridian perspective the practitionerpalpatesthebodytolocatepatternsofconstrictionandthenusesacupunctureormanualtechniquestoreleasetheseconstrictions.PrinciplesofOrientalmedicineguidethedirectionofcare.Myofascialmeridian therapy is concernedwith constriction not only in the

muscles but also in the fascia. The fascia is unique in human physiology,existing as a single continuous sheath that extends from the head to the toes,encasing every organ,muscle, andmuscle fiber as itwinds through the body.ConsiderthedefinitionoffasciaasproposedbyDr.WilliamHenryHollinshead:

Whenthenormalconnectivetissuesofthebodyarearrangedintheformofenvelopingsheaths,theyareusuallyknownas fasciae (fasciameans abandageor band, and thus connotes a layer bindingtogetherother structures).Thus, thesubcutaneous tissueor tela subcutanea is frequentlycalled thesuperficialfascia.Numerousexamplesofwelldeveloped,tough,deepfasciaeoccur,especiallyinthelimbs,wherefasciaformsheavymembranessurroundingtheentirelimb.Individualmusclesarealsosurroundedbythinfasciacalledperimysiumandareseparatedfromeachotherbylooserconnectivetissue. . . .Fromthefasciasurroundingamuscle,connective tissueseptapass into themuscleandsubdivideitintobundles;thesesepta,inturn,divideuntildelicateconnectivetissuefiberssurroundeachmusclefiberwithinamuscle.9

Thesuperficialfasciacoverstheentirebodysubcutaneously.Itiscomposedoftwolayers:theouterlayercontainsfat;theinnerlayeristhinandelastic.Lyingbetween the layers of superficial fascia are the arteries, veins, lymphatics,mammaryglands, and facialmuscles.Thedeep fascia lines thebodywall andtheextremities;itholdsthemusclestogetherandseparatesthemintofunctionalgroups.Deep fascia allows for themovement ofmuscles. It assists in supportand stabilization, aiding in the maintenance of balance. It carries nerves andblood vessels, fills spaces between the muscles, and sometimes providesattachments for muscles. Fascia facilitates circulation of the lymphatic andvenoussystems.Differentiationofthedeepfasciabeginswiththeenvelopmentof the individualmuscle by the epimysium, the external sheath of connectivetissue.Theepimysiumfurtherdifferentiatesintotheperimysium,thefasciathatwrapsbundlesofmusclefibers(fascicles),andthisfurtherdifferentiatesintotheendomysium, which penetrates the interior of each fascicle to enwrap eachmusclecell.Thissystemiscontinuouswiththestructureoftendonsthatattachmuscletootherstructures.Doctor of osteopathy JohnUpledger describes the fascia as “amazewhich

allows travel from any one place in the body to any other placewithout everleavingthefascia.”10Fascia’spervasive,continuousnaturemayexplainmanyofthe distal effects of acupuncture or other meridian-based forms of bodywork.Paula Scariati,D.O., observes that changes in the fascia due to age or trauma“set off chain reactions thatmay compromise the vasculature, nervous system

andmuscleaswellaschangethemovementofbodyfluidsthroughthefascia.”11

Itlogicallyfollows,then,thatifconstrictionoffasciacanproducedysfunction,thereleaseofconstrictionwithinthefasciacanleadtoareturnoffunction.There has been much speculation on the functional mechanism of

acupuncture; much has been made about the activation of betaendorphins, apowerful pain supressant, resulting from acupuncture treatment. Actually, theexperienceofanysystematicminorpainwillgiverisetotheinhibitoryresponseof endorphins—pinching the skin anywhere will produce endorphins. It isconceivablethatendorphinactivityisapleasantsecondaryeffectofacupuncturetreatment and is unrelated to themechanism that underlies its more powerfuleffects.Itismoreprobablethattheanswerstothequestionofhowacupunctureworks

lieinthestudyofthelittleunderstoodandcomplexmechanismsthatgovernthefascia, muscles, skin, and adipose tissue of the body. The fact that dramaticreleases of muscular constriction can be affected by surface needling is welldocumentedbyTravellandSimonsonamuscle-by-musclebasis.Suchreleaseisalso capable of exerting powerful visceral effects. The probability ofunderstandingacupuncture lies in the realityofwhat is actuallybeingdone tothe patient: a needle is being inserted into tissue, and such insertions andmanipulationshaveextensivelocalanddistaleffects.Ultimately we should consider the simple fact that, in the realm of

acupuncture treatment and bodywork, practitioners insert needles or applymanual-therapy techniques to skin, adipose tissue, fascia, and muscle.Significanteffectsareexertedbysuchtreatment.Practitionerscansaytheyaremanipulatingqiby treatingpointson themeridians,but theycannotdeny thattheyarealsomanipulatingskin,adiposetissue,fascia,andmuscle.What is the difference? Why make an issue about qi? Consider this

perspective:Rather thanmovingsome invisible,untouchable“substance” (thatis, qi), treatment tissue opens constrictions and promotes themovement of allbodilyfunctionsandactivities.Thepointistofocusourattention,andthereforeoftheskin,muscle,fascia,andadiposetofocusourskills,onwhatwedefinitelycananddoaffect:physicalstructures,suchasthemusclesandfascia.Justasqicannot be experienced directly, in a model where qi cannot be manipulateddirectlytheincreaseinmovement,orflow,occursasaconsequenceofreleasingmyofascialconstrictions.Theeasingofmyofascialrestrictionthereforeresultsinimproved circulation, lymphatic drainage, and nerve conduction. Additionalresults may include improved organ function (such as lung tidal volume,digestive activity, oruterine function), dependingupon the locationof release.Such focus onmyofascial constriction, instead of on qi, allows for a shift of

perception to a readily identified source of pain or pathology, which, whenreleased,resultsinimprovementofthecondition.Thesebasictenetsofsuchaphysicalmedicineunderlietreatmenteffectsthat

go beyond pain management. This is best understood by considering thesomatovisceralandviscerosomaticreflexconnections—thatis,therelationshipsbetweenthesoma(themusculature)andtheviscera(theorgans),aphenomenonrecognized by the fields of osteopathy and chiropractic and utilized in theirdiagnoses and treatments. The somatovisceral reflex connection is defined asmusculardisruptions thatalter theabilityof relatedvisceralorgans to functionproperly.Thesearesituationsinwhichmyofascialconstrictiondirectlyresultsinvisceralsymptomssuchastachycardia,anginapectoris,diarrhea,vomiting,foodintolerance, and dysmenorrhea. (The phenomenon of somatovisceral effects isalsodiscussedindetailbyTravellandSimons.)Conversely,theviscerosomaticreflex connection is defined as dysfunction of the myofascia resulting fromdisease or dysfunction of a related visceral organ. When applying the basicprinciple of myofascial meridian therapy, the identification and release ofpatternsofmyofascial constriction includesbut isnot limited to the releaseoftrigger points in individualmuscles.Myofascialmeridian therapy involves thereleaseofaregion,aquadrant,andultimatelythecompletebody.Thisleadstofreedomofmovementthroughouttheorganismonmultiplelevels,superficiallyas well as deeply, directly or indirectly affecting the viscera and resulting inimprovedhealth.Clearly this physical approach to diagnosis and treatment differs from the

traditionalChinesemedicalmodel in that the prominent use of herbs parallelstheuseofpharmaceuticalsinWesternconventionalmedicine;neitherhasprovento be markedly effective in treating chronic and acute myofascial pain. Thisfailureliesintheinabilityofsuchmedications,EasternorWestern,tofocusonthecentralissueofthesepatternsofpain.Acupunctureandassociatedbodyworktherapies,whenutilizedasmyofascialmeridiantherapies,doinfactfocusonthecentral issuesofmovementandconstriction,andasaresulthavedemonstratedthattheirgreatestpowerliesintheirspecificallyphysicalapproach.Many within the conventional medical establishment have noted the often

remarkable effects of acupuncture and bodywork therapies on patients whosuffer from chronic pain. Herein lies the source of increased communicationamongpractitioners.Medicaldoctorsarebeginningtorecognizethedifficultiesin themedical/surgical approach to treatmentof chronicpainandareviewing,withgreaterrespect,meridianacupunctureandbodyworktherapiesaseffectivephysicaltreatmentmethodologies.Meridian therapies are based upon the palpatory experience. The exacting

natureofmyofascialmeridiantherapyrequiresenormousemphasisonpalpation,with the therapist evolving great skill in identifying myofascial constrictions.The charts of meridians and acupuncture points are used as general maps ofareas where specific loci may be identified. Locating acupuncture points istherebynotafunctionofmeasurementbutratherofpalpation,connectedtotheskillofthepractitioner’shands.Thepointsaremovingrealitiesthatshiftonthebodylandscape.Everythingaboutourbodiesisdynamic,moving,changing;inthesameway,acupuncturepointsexistasdynamicratherthanstaticentities.Thefocus is therefore on constriction, on the real and present reality—treatmentdecisions are based not on cerebral or intellectual construction but on thepractitioner’s palpatory experience. Because a fundamental component in theevolutionofpalpation skill is the ability tovisualize andunderstandwhatyouare feeling with your hands, a working knowledge of the meridian system isnecessary and a careful study of anatomical structure, with an emphasis onmyology,becomescrucial.In the practice of myofascial meridian therapy, assessment and treatment

happen differently than they dowithin theWesternmedicalmodel. Treatmentwithintheconventionalmedicalmodelfocusesontheadministrationofadrugtoeffectachangeinthesymptomsexperiencedbythepatient,withoutregardformyofascialconstrictionsthatmayaccompanythesymptoms.Forexample, it isnotuncommonforapatientwhoissufferingwithadigestivedisorder,suchasesophageal reflux, irritable bowel syndrome, or chronic constipation, to beprescribedamedicationwithoutattentionbeinggiventoconcurrentmyofascialconstrictions.Thisisnottosuggestthatmedicationsareunnecessary;however,it is becoming increasingly clear thatmedications areoftenoverutilized to theexclusion of other treatment methodologies from which the patient may alsobenefit. Using the myofascial meridian therapy model, diagnosis follows notonlyfromthedescriptionofthepathologyasexperiencedbythepatient,butalsofromthepractitioner identifyingassociatedmyofascialconstrictions.Treatmentis focused on releasing those myofascial constrictions through needling orthroughmanualtechniques.Successfultreatmentofapatientwhopresentswithirritablebowelsyndrome

will thus involve the therapist releasing areas of muscle and fascia thatcommonlyrelatetosuchbowelsymptoms,andmayinfactbereflectionsofthebowel symptoms—these areas include the rectus abdominis and externalobliques. Utilizing principles rooted in the ancient Oriental texts, treatmentmight also include needling or massaging areas of the Hand Tai Yang SmallIntestineandHandYangMingColonmeridians,whichpassalongtheposterioraspect of the shoulder and thus coincide with the infraspinatus and posterior

deltoid. Palpation of this region may identify constrictions within localmusculature,whichwould thenbe treatedwithneedlingormanual techniques.This approach to irritable bowel syndrome might therefore also result inimprovedmovementoftheshoulderandarm.Additionally, inassessingthepatientthetherapistmightnotea“tautness”or

“fullness”associatedwiththetissuesoverlyingthetibialisanteriormuscledistaltotheknee,whichcoincideswiththepathwayoftheFootYangMingStomachregion that is associated with its Hand YangMing Colon pair. Treatment byneedlingormanualtechniquestotheseareaswillresultinreductionoffullnessorasofteningofthetautness.Theresultofthistreatmentwilllikelybeadeeper,more complete release of tissues leading to an improvement in the patient’soverallcondition.Thetherapistisguidedbysuchrelationships.Myofascial meridian therapy embraces the concept of qi in a manner that

focusesonaclearandpresentpalpablereality:IfQiislifeforceandlifeforceismovement, thenQi ismovement.Thismodelofqiandhow it relates tohealthhasanumberofdistinctadvantagesoveranherbalizedacupunctureorbodyworkthatfirstandforemostregardspathologyfromaninternalmedicalmodel.First,thismodelofqiisclearlyunderstandabletobothpatientsandotherhealthcarepractitioners. The focus of treatment is on myofascial release by extremelyeffectivemeans;andwhilethemechanismmaynotbefullycomprehended,theconcepts of somatovisceral effects and referred pain patterns can be readilyunderstood,particularlyonce thepathwaysof thepainpatternsarepointedouton pain pattern charts. The effects of this approach are also easily explained,sincetherapidmyofascialreleaseproducedbyaneedlecontactingthefasciaortrigger points is well documented by Travell and others, as are the effects ofischemicpressure.Throughexperience in treatment theeffectsarealsoclearlyobservable,topatientandpractitioneralike.It is also important to recognize that this model falls well within a

complementarymedicalmodel rather thananalternativemedicalapproach.Byand largemyofascialmeridian therapy is complementary toWesternmedicine,which does not focus on myofascial problems and associated release ofconstrictions; often the medical approaches to myofascial constriction, whichinclude medications or surgical intervention, produce unsatisfactory results.Herbalmedicine,likeWesternmedicine,isanotherformofinternalmedicine.Itis alternative to the conventional Western medical model, rather thancomplementary.Certainly regarding qi as movement is not the only way to conceive of qi

within the framework of Oriental medicine. The fluidity and relativity of thephilosophicalconstructs thatunderlieOrientalmedicinerequire that ideassuch

as this one be examined in relation to their applications. Acupuncture andassociatedbodyworkmethodshaveenormouspowertohealinamannerthatisdistinct and separate from internal medicine applications—this is observedrepeatedlyinaclinicalsetting.Thispowercanbeactualizedwithinanapproachthatlooksatqiinawaythatisusefulandpractical.Modelsare ideas thathelp to framereality inacomplexworld,and thereby

allowsomeeffectiveactiontobetaken.TheyarenottheTruth,butatruththatguidesactivity.

CHAPTER3

INFORMEDTOUCH

It is currently estimated that at some point in their lives approximately 90percent of all Americanswill experience some sort ofmyofascial pain—backpain, shoulder pain, neck pain, elbow pain—that has its roots in somedysfunctionofthemusculoskeletalsystem.Regardlessofmethod, the successful treatmentofmyofascialpaindisorders

ultimately rests on a singular skill.This is the ability to palpate, the ability todiscernourpatients’needsthroughtouch.Sincetheriseofmoderntechnologicalhealthcare,surfacepalpationhasbeen

theskillmostoverlookedinthetrainingofhealthprofessionals.Palpationofthemusculature—assessmentthroughtouchofthemuscles,tendons,andfascia—isafineanddiscerningart,onethatisbecominglostinthemorassoftechnologiesnowappliedtohealthcare.Thehealthprofessionshavegenerallyforgottentheeffectiveness of touch in both determining the extent of patients’ pains anddisabilitiesand in the treatmentand resolutionof thatpain.Throughpalpationwe can discriminate normal, supple musculature from musculature that isconstrictedorcontainstriggerpoints;palpationcanalsoassistindiscerningthesourceofmyofascialpain.Ourhands tellusabout thealignmentof the joints,about skin and body temperature, and about the flow of life on the body’ssurface.Whentrainedwell,ourhandscan“see”thestructuresthatunderlietheskin: themuscles,skeletalstructure,andorgans. Inmyofascialwork thehandsareourgreatesttool,aslongaswetrainthemtothenuancesoftouchperceptionandlearntousethemproperly.Training of the hands begins with bringing awareness to them. Practice

placing your awareness in your hands. The ongoing effort to intentionallyconnect yourmind to your hands is thekey to successful training.This is notonly truewhen touching the body, but when touching anything, all day long.Touch with attention—all touch explorations begin with this new focus. Forspecific exercises in palpation see Leon Chaitow’s Palpatory Literacy (see

bibliography).Thesecondessential requirement for thedevelopmentofexcellentpalpation

skills is thepresenceof a clearmental imageof the structuresbeingpalpated.This requirement cannot be emphasized enough. You must be able to clearlyvisualizetheanatomicstructuresofthehumanformasyoutrytopalpatethem;itis therefore necessary to study the anatomy of themusculoskeletal system.Akeen knowledge of skeletal structure and the attachments, fiber direction, andfunction of eachmuscle is essential. Beginwith knowledge, the idea, and theimage,andthentrainyourhandsto“see”whatyouknowisthere.It is important to recognize that the qualities of musculature exist on a

continuum.Hypotonicor flaccidmuscle, that is,muscle thathas reduced tone,liesononeendofthiscontinuum;hypertonicorexcessivelyconstrictedmusclelies on the other. What you feel within any given muscle will fall anywherewithin this continuum. Healthy muscle tissue is soft, supple, and resilient topressure. The underlying structures are easily palpated through such muscle.Muscletissuethatishealthyispain-freewhenpalpated.As you move through the continuum you will encounter muscle that is

somewhattight,notasresilienttothetouchassupplemuscle.Thistissuefeelsharderandtougherthansurroundingmusculature,andastronger,firmertouchisrequiredtopalpatetheunderlyingstructures.Firmpalpationmayproducesomediscomfortinthepatient.Thistypeofmusclewecallconstrictedmuscle.Thedegreeofconstrictionisdependentuponthemuscle’sstateofcontraction.

When amuscle is held in a partially contractedposition, groups of fibers thatform themusclemaybe identified anddiscerned.Theremaybe tautbandsoftissuewithinsuchmuscle.These tautbandsmayfeel threadyor ropelike—notunlike a small cable; they can feel resistant to pressure and be somewhatuncomfortable to the patientwhen pressed. In addition, through palpation youmight identify a particular region within the taut band that the patientexperiencesasparticularlysoretothetouch.Tothepractitionerthisregionfeelsmore constricted, harder, than the areas immediately adjacent to it along theband.ThisregioncharacterizeswhatTravellandSimonshavetermedatriggerpoint.Whenatriggerpointispalpateditcancausesignificantlocaldiscomfortin the patient. In addition, pressure to the point can initiate the characteristicradiatingpainpatternchartedbyTravellandSimonsandothers.Thisradiatingpain is the distinguishing characteristic of trigger point activity within themyofascia.In contrast to the partially contracted muscle just described, a deeply

contracted muscle is one that remains in the muscle’s extreme contractedposition.Thiscontracturemaybetheresultofneurologicaldysfunction,chronic

structural imbalances, trauma, or extreme repetitive strain. In cases ofcontracture, circulation to the muscle is reduced, and as a result the musclebecomes more fibrous, losing its elasticity. The muscle becomes fixed in ashortened position. Trigger points may or may not be present; pain anddysfunction will more likely be due to loss of full range of movement. Theconditionwillbechronicandcompleterecovery improbable.Withpractice thepractitionercandiscernthesevariouscharacteristicsofthemusculature.Whenpalpating it isessential to identifyanddifferentiateskeletal structures

underyourhand.Thisabilityisanessentialprerequisitetomuscularpalpation.Locating and differentiating the bony structure will provide the structuralawareness to image, first with your mind and then with your hands, theattachmentsofmusclestobepalpated.The ability to clearly identify a muscle under one’s hand (for example,

differentiating the deep thoracic paraspinalmuscles from themore superficialtrapezius and rhomboids) is often contingent upon the practitioner’s ability tofollowthecourseofthemuscularfibers.Hereinliesanotherreasonforknowingbony landmarks by touch—it is difficult to feel for fibers and fiber directionswhenthereisnoawarenessofwherethemusclesattach.Anawarenessoffiberdirection inbothsuperficialandunderlyingmusculature isnecessary toevolvetheskillofdifferentiatingmuscularlayers.Inaddition,itisimportanttohaveaworking knowledge of other structures that might be within the region beingpalpated,suchaslymphnodesintheanteriorandposteriortrianglesoftheneckandinthefemoraltriangle.Attentivepracticewillprovideyouwith theskill that isdesired—andthat is

truly required—to understand the dysfunctions causing pain and discomfort toyourpatients.Skilledhandsnotonlycanascertainthemuscleormusclesthatareinvolved,butasyou followconstrictedmuscle fibers through theircourseyoucanarriveatanimageofthehabitualphysicalposturesyourpatientassumesthatcould be the source of themyofascial problem. For example, in palpating hisneck and shoulders you may “see” with your hands that the left side isconsiderably more relaxed than the right: the right sternocleidomastoid iscontracted, the right trapezius is contracted, and the right levator scapulae iscontracted.Whatposture could this personbe taking toproduce thismuscularconfiguration? He might possibly be sitting in front of a computer with themonitorofftotheleftinsteadofdirectlyinfrontofhim.Perhapsheelevateshisright shoulder in directing his cursor around the computer screen.Maybe histelevisionathomesitstotheleftofhisfavoritechair.Atleastyouhaveamentalimage, an initial clue, a place fromwhich to questionyour patient to findoutwhathishabitualactivitiesmightbe.Knowingthemuscularaction,knowingthe

postural habits and feeling the muscular configurations, allows you to doeffectivedetectivework.Youarethenabletohelpyourpatientchangehishabitsin order to alleviate perpetuating factors giving rise to his difficulties. Thisdiscernmentisessentialtohelpingthepatientrectifythemuscularproblem.Topalpatemosteffectively,thefollowingbasicprinciplesshouldbeembraced

andpracticed:

1.Clearlyimagetheareatobepalpated.2. Softenand relaxyour fingers,hands,andarms inorder tomake full,firmcontactwiththeareaunderpalpation.3. Asyoupalpate,useasbroadasurfaceareaofyourhandaspossible.Palpation, as a method of gathering information, is far more effective ifpracticedusingthepalmarsurfacesofthehandsratherthanthetipsofthefingers. In using a broad hand you cover more “ground” and can thusevolveaclearermentalimageoftheareaunderpalpation.4.Identifypertinentbonystructuresintheregion.5.Palpateeachmuscleinatleasttwodirections:

• along the muscle fiber, from its proximal to its distalattachment, to locate themuscleand identify its sizeandshape;and• across themuscle fibers, to isolate areas of constriction, tautbands,andtriggerpoints.

6. Limit pressure to the point ofmuscle resistance.When you feel themuscle providing some resistance to pressure, keep your contact at thatlevel of pressure. Deep, excessive pressure that causes some pain willproduce an automatic tightening of the body and will prevent you fromclearly identifyingunderlyingstructures;pressure that is too lightwillnotallowyou tocontact themuscleproperly, andagreatdealof informationwillbeoverlookedasaresult.7. Palpate each muscle bilaterally to provide direct comparison.Remember thatbilateralmusculatureshouldoptimallybeequallysoftandsupple and have the same shape and form. By comparing sides you caneasilynoteareasofconstrictionthatmayexistinonesideandnottheother.

In summary, palpation is an essential diagnostic and treatment tool thatrequires attentive practice, an ability to clearly visualize musculoskeletalanatomy, and a state of relaxation that helps maximize information gatheringskills.Itisthroughextensiveclinicalpracticethatonecanevolveaclearsenseof the continuum of myofascial states and an understanding of the habits of

actionthatarethesourceofanenormouspercentageofpainsyndromes.Itisimportanttorememberthatwhenapatientexperiencingpainistouched

by a practitioner in the “right” places, a level of trust develops immediately,alleviating a great deal of the patient’s fears and tension. This alone providesenormoustherapeuticbenefit.Itbeginswithunderstandinghands,withinformedtouch.

CHAPTER4

DIAGNOSISANDTREATMENT

Itisassumedthatthereaderofthisbookhassomeexperienceinworkingwithmyofascialpain.However,afewbasicideas,perhapsknowninsomedisciplinesbutnotinothers,mayserveascommongroundindelineatingabroadprotocolforthediagnosisandtreatmentofmyofascialdisorders.Spendsometimelookingatthepatient.Observehowheorshewalks,stands,sits,breathes,holdshishands,crosseshislegs,readsintakeforms,rubshisneck,carries a purse, backpack, or briefcase. These and myriad other behaviorsprovide clues regarding the nature of his condition.While some patients willhave difficulty identifying the sites or patterns of their pain, the observantcliniciancanlearnagreatdealbypayingcloseattentiontothispersonwhohascomeforhelp.Itisrarethatmuscularconstrictionsandtriggerpointsexistinanisolated,singlemuscle.Carefulattentioncanrevealagreatdealabouttheuniqueandoftencomplexpatternpresentedbyeachpatient.Watchinghowthepatientrisesfromachair,getsonoroffatreatmenttable,removesacoat,orwearsouthisshoescanprovidevaluableinformationleadingtotheeffectivetreatmentofhiscomplaint.Asinmanymedicaltherapiestheclinicianmustbepartdetective,developinganabilitytopickupontheseclues,sincetheycanbeasimportantasanydiagnostictestingprocedure.WehadtheprivilegeofwatchingDr.JanetTravelltreatanumberofpatients.

Shebegan formulatingher treatment themoment shesaw thepatiententer theroom.Shetooknoteoftheperson’sshape,size,asymmetries,gait,posture,andthe many ways he was holding himself, particularly when in pain.When thepatientpointedouthisproblem,Dr.Travellwasalreadyawareofthemuscularpatterns involved—the history expanded the data she had already collectedthrough observation. Before Dr. Travell touched the patient she knew a greatdeal about him; in fact, after fifty years of clinical experience she was sointegratedinherawarenessthatsheoftensawtheprobleminseconds.Dr.Travell trainedherselfasabetterclinicianwitheachpatientshe treated,

whichleftuswithanothertenetforgoodpractice:Donotassumethatyouknowanything.Beit throughpalpationorquestioning,ineverytreatmentwitheverypatient always seek more information about the problem (and the person) athand.

Evolve palpation skills. Through touch the patient discoversmuch about thenatureofthepractitioner.Thatfirsttouchtellsthepatientwhetheryouaregentleorrough,respectfulorinvasive,carefulorcareless,andmostimportantly,ifyouknowwhatyouaredoing. It is agood idea to firstpalpate theareawhere thepatientiscomplainingofpain,sinceitdemonstrates,inamatterofseconds,thatyouunderstandthatheorshehaspainandthatthepainisthere,whereyouarepalpating.Sooftenpatientswillexclaim,“That’sit,”andwiththosetwowordsthey have begun to accept and trust you as a practitioner. As the practitionerexploresrelatedareasthepatientwilloftenrememberpainsorinjuriesthatwerenotmentionedinhismedicalhistory.Itisasifthepalpationexaminationopensnewdoorsinthepatient’sunderstandingofhisownproblemandencourageshimtocometosomeinsightregardingthedirectionoftreatment.Palpation is an art and a skill. It requires work, practice, and the constant

awarenessthatyouaretouchingaperson,notjustamuscle.Asmostmyofascialproblems involve sequences of numerous associated muscles, effectiveexaminationwillgenerallyinvolveextensivepalpationaroundtheareaofmostacute presentation. In acupuncture, a common assessment principle has thepractitionerexamineleftandright,upanddown,andfrontandbackrelativetothepresentingregion.Thissimplymeansthatifapatientiscomplainingofpainintheleftlumbarregion,examinationshouldincludetherightlumbarregion,theupperbackandshoulders, thebuttocksand legs, and theabdomen.Suchwideexaminationnotonlyrenderssignificantinformationbutalsorespectsthepatientasawholeperson.Learningtotouchanotherpersonincludesawarenessthatthebodywilloften

tenseto“guard”itselfagainstinvasivetouch,particularlyinpainfulareas.Suchresponses mitigate effective palpation, so the practitioner must learn how totouch,graduallyapplyingpressureandearningthetrustofhispatientstoallowforaccuratepalpation.Regardlessoftheparticularmethodoftreatmentemployed,skillfulpalpation

is the defining factor differentiating highly successful practitioners from thosewhoobtainerraticresults.Regardlessoftheory,method,oramountoftreatment,skillfulpalpationiswithoutquestionthesingularmostimportantcomponentoftreatment.

Listen closely. First, the patient has direct experience of the problem. Hisdescriptions of what he feels and when and how he feels it are extremelyimportantpiecesofdata.Second,manypatientswithchronicpainhavesufferedtheexperienceofbeingtoldthatthepainis“intheirhead”or“isn’treal.”Theywill often feel they have to convince you of the reality of their experience.Listening and confirming their reality is important in developing the trustnecessaryfortreatment.Educatingpatientsaboutthenatureofmyofascialpainsyndromes,showing themwallchartsofpainpatterns,describingposturesandmovements that can trigger pain patterns as well as what kinds of organicdysfunctionsmight be associatedwith such syndromes is important.We haveseenpatientslosetheirtensionandanxietyassoonastheysawtheirpatternonawall chart;many have exclaimed, “I’m not crazy!” This kind of confirmationand education goes a long way in establishing a relationship that leads toeffectivetreatment.Additionally,itisimportanttorememberandrespectthesubjectivenatureof

theexperienceofpain.Whatmightseemtobeamildlyconstrictedareatoyourtouchcaninfactbeasourceofconsiderablepaintothepatient.Asyoulistentoyourpatient,hearhimandembracehisreality.

Treatwithprecisionandattention.Thefollowingapproach topatientcare isdesignedtohelptofocusinontheproblemathandanditsresolution.

1. Clearly define the areas of pain and restrictions of movement that thepatientisexperiencing.Havehimdelineate,andperhapsdraw,theareasofthebodythatfeelpainful.Havehimdemonstratethemovementsthatcausepain.Becertainthatyouunderstand,tothebestofyourability,whatheisexperiencing.

2. Determine the variousmuscles thatmight be the source of your patient’spain and restriction. Utilizing the pain pattern and symptom indices (seepages229–242)willbeusefulinthisdetermination.

3. Palpateforconstrictionsandtautbandsintheindividualmusclesthatyouhavehypothesizedtobethesourceofthedifficulty.

4. Palpateassociatedregionsforadditionalconstrictionsandtautbands.It isimportant to palpate the entire body, anterior and posterior, to determineassociated constrictions. Additionally, awareness of the pathways ofmeridians and cutaneous zones will provide a guide for identifyingrestrictionsthatmightlieoutsideoftheaffectedquadrant.

5. Locate individual tautbands in the involvedmuscles. “Capture” theband

with precise palpation and compression. Define the specific trigger pointalongthetautbandthroughfocusedpalpation.

6. Applytreatmenttothetriggerpoints.Oncethebandsandtriggerpointsarecaptured,maintain pressure through ischemic compression until softeningofthepointoccurs.Thiscanbeusedfortreatmentinandofitself;however,if acupuncture needling is used, lightly peck the point until you feel asoftening of the band under the hand that is compressing the muscle.Palpationoftheregionaftertreatmentwillprovidefeedbackastowhetherornottherehasbeenacompletereleaseofthemuscle. Repeat thisprocessof treatmentwitheachareaofconstriction ineachregion that you identified as having restrictions. This is an essentialcomponentinobtainingcompleterelease.

7. Applymoistheat.Whether in theofficeorathome,moistheatshouldbeapplied to the treated regions to increase blood flow to the areas. Thisshould be done for at least twenty minutes each day for three daysfollowingtreatment.

8. Provideastretchingprogram.Oncethepatienthashadmoderatereleaseofmuscular constrictions, instruct him in appropriate stretching exercises tomaintain the releaseof themuscle.These shouldbedone several times aday.Performanceofthestretchshouldnotproducepain.

9. Provideastrengtheningprogram.When thepatienthasbeenpainfree forseventotendays,instructhiminappropriatestrengtheningactivities,ifthemuscleneedsreconditioning.

10. Teachyourpatienthowtobreathe.

Poorbreathingpatternsconnectedtostress,muscularproblems,orrespiratorytrauma can directly affectmyofascial problems.The single biggest offender isparadoxicalbreathing,aphenomenoninwhichthemovementsoppositetothoserequired for a full, relaxed breath occur. Instead of the abdominal musclesrelaxing in order for the contracted diaphragm to fully enlarge the thoraciccavity,theabdominalscontractandthechestlifts,inhibitingthetidalvolumeofthelungs.Watchapatientbreatheandyoumaynoticearaisingofthechestandpullinginoftheabdomen.Manypeoplereflexivelydothiswhentheytrytoholdthe breath. It is simply incorrect breathing and often nothingmore than a badhabit.Sinceitcanbeaperpetuatingfactorforanumberofpainsyndromes,aswell

aspartandparcelofmanystress-relateddisorders,thistypeofbreathingshouldbecorrected.1Thefollowingexercisecanhelpretrainbreathingpatterns.

1. Direct the patient to sit or stand with the body naturally erect and yetrelaxed. Keep the spine elongated and allow the musculature and thesurroundingbonystructure—theshouldersandribcage—torelaxanddropdowntowardthepelvicregion.Allowthechesttorelax;letthemusclesoftheabdomenandstomachrelax.Letthebuttocksandlowerabdomenrelax.

2. Takeaslowbreath,allowingthemusculatureofthestomachandabdomento expand somewhat with the breath. Breathe in this way for a fewmoments,allowingthebreathtomovedownintothelowerportionsofthethorax.Asconstrictionsofabdominaland/orthoracicmusculaturearefelt,intentionally relax thearea. If thechestorshoulders riseup, return to thefocusofdroppingthebreathintothelowerareasofthebody.

3. Now inhale deeply.Allow themusculature of the thorax to relax.As themusculaturerelaxesthechestwillexpandslightlyinananteriordirection,inalateraldirection,andinaposteriordirection.Thiswillhappennaturallyin the relaxed body. Sense that a container is being filled: first the lowerportionfills,thentheupperportion.

4. Nowexhale, emptying theupperportion first and then the lowerportion.Allow the body to deflate as a balloon deflates; it will do so evenly—anteriorly,posteriorly,andlaterally.

5. Relax the breath and continue to breathe fully and completely, payingattention to thepitfalls: the shouldersmaywant to riseup, theabdominalmusclesmaytighten.Keepthemrelaxed.

6. Instruct the patient to practice in front of amirror at first. The reflectionmightdemonstratewhatisnotyetfelt—thechestrising,notdropping;theabdomenpullingin,notrelaxingout.

7. Practice.Learningrequiressuccessfulrepetitionovertime.

Extend treatment beyond the office. Your job goes beyond releasingmyofascialconstrictionsandtriggerpoints.Thetreatmentofmyofascialpainismultifacetedand includes involving thepatient inhomecare,suchasapplyingmoist heat; attending to postural, visual, work habit, or sleeping corrections;addressing stressmanagement and nutritional considerations; correcting sportsmovements; or even suggesting new arrangements for furniture and computerstations.Weoftenhaveaskedpatientstobringtheirbicyclesortennisracquetsto the office if we suspected such activities were directly connected to thegeneration of their pain. The clinician as detective, one who sorts out andidentifiestheperpetuatingfactorsassociatedwiththepatient’scondition,isonly

oneoftheroleswemustassume.Wemustalsobeeducators,proddingparents,or sometimes simply friendswho care about the fact that a person is in pain.Familiaritywithsimpleexercises,nutritionalconsiderations,stressmanagementtechniques, breathing exercises, methods of changing eye-dominance, andfurniture and exercise-equipment ergonomics is part of the diverse knowledgenecessaryfortreatingmyofascialpaininacompletesense.Soften thedichotomybetween treatmentandexamination.From theoutsetthe practitioner should view examination as treatment and treatment asexamination.Failingtorecognizetheongoingfeedbackinvolvedinthisprocesscan result in the loss of important information.As you gather information bypalpating themyofascialconstriction,youareengagedin treatment.Justso,asyouseektoreleasemyofascialconstrictions,youareengagedinevaluation.Theactoftreatmentcanshowyouthecorrectnessofyourpalpation,thereactivityofthemuscle, the extent of the problem, andpossibly the approximate length oftimethismusclehasexperienceddistress.Further,eachreleasecanguideyoutoassociatedareasofconstriction.Watchingtheskinsurfaceandcarefullyfeelingfor the type and direction of the release provides evaluative information thatdirectsthecourseoftreatment.Thepatientwilloftendescribelociofpainthatare experienced at the time of palpation or treatment that correlate with thereferred pain pattern, though he might also describe a distal location,demonstrating additional muscular constriction. Evaluation, treatment, andtreatment planning are processes that occur simultaneously in working withmyofascial pain syndromes. Therefore a certain mental framework—a diffusestate of attention coupled with a constant vigilance that records cues andtransformsthemintotreatmentmodifications—iscentraltothisapproach.Suchactivitybecomespartofapracticedprocessthatiscarriedoutintreatment.While a diagnosis is made after the history is taken, the examination is

finished,testsarereviewed,andpalpationiscompleted,itshouldbeconsideredpreliminary. The treatment of myofascial pain problems is also diagnosis.Whether you are injecting trigger points, releasing tender points withacupuncture, applying ischemic pressure, or performing a spray-and-stretchtechnique, all procedures reveal further information about the patient’scondition.Attention tohow themuscles respond,how thepain isexperienced,thenatureofthefasciculations,andhowthepatientrespondstotreatmentareallpointingtothenextstepsoftreatment.Tomakeafirmdiagnosisandcarryoutarigid treatment plan is contradictory to the experience of interacting withmyofascialproblems.Thisisaworldwhereasmusclefibersreleaseothersmayconstrict;wheresimplemovementscoulddrasticallyaffecta recently released,

buthighlyreactive,muscle.Itisaworldthatissointerconnecteditisimpossibleto understand one muscle in isolation from the whole body. The successfulpractitioner understands this deeply and engages in a practice that involves akindofpassivevigilanceandfluidityofthoughtthatallowsforconstantchange.The idea thatX,andXalone, is theproblemand thatYwill fix it isaclassicerrorcommon inhealthcarebutdisastrous in theworldof treatingmyofascialpain.JohnUpledgerhasreferredtothefasciaas“asingleandcontinuouslaminated

sheetofconnectivetissue...[which]extendswithoutinterruptionfromthetopof the head to the tips of the toes. It contains pockets which allow for thepresence of the viscera, the visceral cavities, the muscles and skeletalstructures.”2Thecomplex,interactivenatureandhomeodynamicactivityofthissystemmustbeappreciatedandrespected.Aspractitionerswehavecometoexperienceafundamentalstateofawethat

iswithuseachdayaswe treatourpatients.Thecomplexityandbeautyof themyofascial system has led us to experience some amusement when a patient,learning of the nature of his or her condition, remarks, “You mean it’s justmuscular?”Exactly.It’sjusttheGrandCanyon.

CHAPTER5

HOWTOUSETHISMANUAL

Thismanualprovidesimportantinformationinaformatthatcanbeeasilyandquickly accessedbyboth the student and theworkinghealth care practitioner,makingitreadilyuseableintheclinicoroffice.In the technical body of the book an illustration of each muscle and the

locations of its common trigger points is accompanied by the followinginformation:

Proximal attachment: The cephalad (upper) attachment, that is, theattachmentclosesttothehead.Distalattachment:Thecaudad(lower)attachment,thatis,theattachmentfarthestawayfromthehead.1Action:Whatthemusclemoves,thepurposeofitsaction.Palpation:Specific instructionsonhow to locateandpalpate themuscle,includinganatomicallandmarksforreference.Pain pattern: An illustration of that muscle’s essential pain pattern isaccompanied by a written description that also details possible extendedpainpatterns.Symptomsproducedbythepresenceoftriggerpointsinthemusclearealsodescribed.Causative or perpetuating factors: A description of common behaviorsthateitherproduceorperpetuatethepain.Satellite trigger points: Additional muscles and muscle groups thatcommonly develop trigger points when there are trigger points in themuscle.Affectedorgansystems:Due to therelationshipbetweenskeletalmuscleandmeridianpathway,theconstrictionofeachmuscleormusclegroupwillaffect the meridian pathway traversing it. As each meridian exercisesinfluenceoveraspecificorganorsystem,thissectionmayshedadditionallightontheinteractionbetweenskeletalmuscleandviscera.

Associated zones, meridians, and points: A statement of other areaspredisposed to muscular constriction when there are trigger points in aparticularmuscle, toguidetreatmentforthosepracticingfromanOrientalmedical perspective. For a review of meridian pathways and zonedescription,seeappendices1and2.Stretch exercises: Illustrations and descriptions of stretching exercisesusefulforthatparticularmuscle.Varyinglevelsofstretchexercisesmaybeprovided to patients to accommodate their changing capacities during thehealingprocess.Strengthening exercises: A description of useful strengthening exercisesfor themuscle and associatedmuscle groups.A strengthening exercise isincluded for phasic muscles, which tend toward weakening. Tonic, orposturalmuscles, tend toward shortening,making strengthening exercisesgenerallyunnecessary.

Regardingthetriggerpointillustrations,itmustberememberedthattheyserveonlyasameanstoguidetheinitialpalpation,sincetriggerpointscanpresentatanypointinanymuscle.Mostpatientspresentwithsymptomsthatareusuallydescribedasaparticular

pattern of pain. Somepatientswill also presentwith other symptoms, such asimpairedrangeofmotion,usuallydescribedasaninabilitytoperformparticulartasks.Othersymptomsmightseemless related, suchasdizzinessormenstrualproblems.Twoindexesareprovidedinanefforttohelpthepractitionerquicklyfocus his or her attention onmuscle groups that commonly relate to the painpatternorsymptomspresentedbythepatient.ThePainPatternIndexisagraphicindexinwhichthepainpatternsforeach

muscle are illustrated. The pain patterns are grouped in terms of the areaaffected:painpatternsthataffecttheneckareshowntogether,painpatternsthataffect the anterior legs are shown together, and so on. With this informationreadycomparisonsofpatternscanbemadeand specific informationabout themusclegroupsquicklylocated.Some patientsmay be vague about their pain but clear on other symptoms.

TheSymptomIndexprovidescommonsymptomsofmyofascialsyndromesandthepagenumbersofrelatedmuscles.Using the indexes to help narrow the focus to particularmuscles involved,

then turning to the summary information for each muscle, should help guideexamination,treatment,andfollow-upwiththepatient.Thismanual is designed for quick access for use in clinical situations. The

material is meant to supplement and guide the careful taking of case history,

examination,andpalpation,nottoreplacethem.Thismanualdoesnotoutlineeachmuscleofthebody.Themusclesthathave

beenincludedarethosethatwehavefoundtobethemostclinicallysignificantinouryearsofpractice.Painexperiencedbythegreatmajorityofpatientsmaybe alleviated through the treatment of these muscle groups. For an indepthdiscussionofeachmuscleinthebody,useofMyofascialPainandDysfunction:The Trigger Point Manual (volumes I and II) by Travell and Simons isrecommended.

Sternocleidomastoidandtriggerpoints

STERNOCLEIDOMASTOID

Proximal attachment: Mastoid process and the lateral half of the superiornuchallineoftheoccipitalbone.Distalattachment:Clavicularhead: superiorborderof theanteriorsurfaceofthe medial one-third of the clavicle. Sternal head: anterior surface of themanubrium,medialandmoresuperficialthantheclavicularhead.Action:Actingunilaterally: rotationof thefacetotheoppositesideandliftingthechin;aidsinsidebendingtothesameside.Actingbilaterally:flexionofthehead and neck; checkreins backward motion of the head during chewing;auxillarymuscleofinspiration.Palpation: To locate the sternocleidomastoid (SCM), identify the followingstructures:

Mastoid process—Follow the base of the occiput toward its lateral edge.Therounded,mostlateralprominenceisthemastoidprocess.Clavicle—Follow the curved course of the clavicle, from its articulationwith the sternum to its articulation with the acromion. Medially thecontoursoftheclavicleareconvex;laterallyitscontoursareconcave.Sternoclaviculararticulation—Locatethesuprasternalnotchatthesuperioraspect of the manubrium. Move laterally to locate the sternoclaviculararticulation.Notethattheclavicleisraisedslightlyabovethemanubriumatthe articulation. By raising and lowering the shoulder as you palpate thearticulation, you can clearly distinguish between the manubrium and theclavicle.Transverse process of C1—Locate the angle of the mandible, the sharp,lateralaspectofthejawbone.Movingposteriorly,thebonyprominenceofthetransverseprocessofC1,lyingbetweentheangleofthemandibleandthemastoidprocess,maybepalpatedonsomepeople.Palpatebilaterally,gently,asthisareamaybequitetender.

To palpate the sternocleidomastoid, begin at the mastoid process with thepatientlyingsupine.LocatethethickenedproximalaspectoftheSCM.Useyourindexfingertoborderthemuscle’smedialaspectandyourringfingertoborderits lateral aspect. Place yourmiddle finger along the belly of themuscle andfollowitdowntotheattachmentsonboththemanubriumandtheclavicle.Tiltthechinuptowardtheoppositesidetodifferentiateclearlybetweenthesternalattachment—thinandcordlikeatitsinsertion—andthebroader,flatterclavicularattachmentontheuppersurfaceoftheclavicle.It is interesting to note that the SCM and the trapezius have a continuous

attachmentalong thebaseof theocciput.Thisattachmentsplitsat themastoidprocess.Theyhaveanoncontinuousattachmentalongthesuperiorborderoftheclavicle.

Sternocleidomastoidpainpattern

Painpattern:Clavicularhead:Painreferstothefrontalarea—whensevere, itextendsacross the forehead to theopposite side.Homolateralpaindeep in theear.Symptomsarefrontalheadache,dizziness,andpostural imbalance.Sternalhead:Cheek,temple,andorbitpain;painthatarchesacrossthecheekandintothe maxilla, over the supraorbital ridge. Vertex pain with scalp tenderness.Symptoms includedry cough and autonomicphenomenaof the eye, includingtearingandredness.Causative or perpetuating factors: Mechanical overload in extension orflexion; chronic rotation to one side; whiplash; compression of the neck;paradoxicalbreathingorchroniccough.Satellite trigger points: Contralateral SCM, scalenes, levator scapulae,trapezius,spleniuscervicis,sternalis,pectoralismajor.Affectedorgansystems:Respiratorysystem;eyes,ears,throat;nasalsinuses.Associatedzones,meridians,andpoints:Ventralandlateralzones;FootYangMingStomachmeridian;ST10,11,and12;CO17and18;SJ16;SI16.Stretchexercises:1. Clavicularhead: Bend head and neck backward, rotating the face to one

side. Themusclewill be stretched at the clavicular head on the oppositeside.

2. Sternalhead:Turnheadtooneside,thenatfullrotationtiltthechintowardtheshoulder.Themusclewillbestretchedatthesternalheadonthesameside.

Strengtheningexercises:Isometricagainstmildforwardresistance.

1. Placethepalmheelontheforeheadforresistance.Presstheforeheadintotheresistance.

2. Claspthehandsbehindthehead,justbelowthecrown.Presstheheadandneckposteriorly,againsttheresistance.

Stretchexercise1:Clavicularhead

Stretchexercise2:Sternalhead

Scalenesandtriggerpoints

SCALENES

Proximalattachment:TransverseprocessesofC2–C7.Distalattachment:Anteriorandmedius:firstrib.Posterior:secondrib.Action: Acting unilaterally: lateral flexion of the cervical spine. Actingbilaterally:stabilizationofthecervicalspineagainstlateralmovement;elevationofthefirstandsecondribstoassistininspiration.Palpation:Tolocatethescalenes,identifythefollowingstructures:

Thyroid cartilage—Located along the anterior midline of the neck. Thesuperiorborderof the thyroidcartilage, theAdam’sapple, liesanterior toC4;thedistalborderofthethyroidcartilageliesanteriortoC5.Thethyroidcartilagecanbeobservedmovingupanddownduringswallowing.Hyoid bone—Located above the thyroid cartilage and lying horizontally.The hyoid bone is the first bony structure to be palpated as you movedownward along themidline from themandible. It can be palpated as itmovesupanddownduringswallowing.ThehyoidboneliesanteriortoC3.Externaljugularvein—Beginsneartheangleofthemandible,crossingthesternocleidomastoidinthesuperficialfasciabeforepassingposteriortotheposterior border of themuscle, to empty into the subclavian vein. In thehealthypatient,lyingsupine,theveinisclearlyvisibleonlyashortdistanceabove the clavicle. However, with increased thoracic pressure (noted inpathologiessuchasheartfailure,enlargedsupraclavicularlymphnodes,andobstruction of the superior vena cava) the external jugular vein becomesprominentthroughoutitscourse.Sternocleidomastoidmuscle—Seemuscledescriptiononpage33.

The scalenes can be palpated when they are constricted or harbor triggerpoints. Note the location of the external jugular vein where it crosses thesternocleidomastoid: constriction of the anterior scalene can be palpated just

deep to this area.Move thepalpating finger slightlyposteriorly to this area tolocatethescalenes;theywillfeelliketautbandsiftheyareconstricted.It is essential to palpate this area with the greatest sensitivity to patient

tendernessanddiscomfort.Anextremelygentle touch is required tobeable topalpatethemusclewithoutcausingpaintothepatient.

Scalenespainpattern

Pain pattern: Persistent, aching pain that radiates anteriorly and downwardtowardthechestinfingerlikeprojectionsand/orlaterallytotheupperarm.Painmayskiptheelbowandreappearattheradialsideoftheforearm,hand,thumb,andindexfinger.Painmayradiateposteriorlyintothemidscapulararea.Causative or perpetuating factors: Paradoxical breathing; chronic cough;pullingorlifting,especiallywiththearmslevelwiththewaist;chronicrotationofthecervicalspinetooneside.Satellite triggerpoints:Sternocleidomastoid, upper trapezius, levator scapula,

spleniuscapitis,pectoralismajor,triceps.Affectedorgansystem:Respiratorysystem.Associated zones, meridians, and points: Ventral zone; Foot Yang MingStomachmeridian;SI16.Stretch exercise: Laterally bend the head and neck so that the ear of theunaffectedsidemovestowardthesameshoulder.Holdforacountoften.Then,withoutchanging thedegreeof lateral stretch, rotate theheadand face towardtheaffectedside,stretchingthecheektowardtheceiling.Holdforacountoften.Returntheheadandfacetotheinitiallateralstretchposition.Nowrotatethe

headandface,thistimeaimingthechinintowardtheclavicle.Holdforacountoften.Returntheheadandfacetotheinitiallateralstretchposition.

Stretchexercise:Scalenes

Spleniuscapitisandtriggerpoint

Spleniuscapitispainpattern

SPLENIUSCAPITIS

Proximalattachment:Mastoidprocessandadjacentoccipitalbone,deeptotheattachmentofthesternocleidomastoidmuscle.Distalattachment:FasciainthemidlineoverthespinousprocessesofC4–T4.Action: Acting unilaterally: rotation of the head and neck to the same side.Actingbilaterally:extensionoftheheadandneck.Palpation:Tolocatespleniuscapitis,identifythefollowingstructures:

Sternocleidomastoid—Seemuscledescriptiononpage33.Trapezius—Seemuscledescriptiononpage59.Levatorscapulae—Seemuscledescriptiononpage63.

Topalpatespleniuscapitis,placeyourpatient in theseatedpositionwithhisback resting on the back of the chair, or lying supine. Palpate the portion ofsplenius capitis that lies just above the angle of the neck: locate themusculartriangle that is formed by the sternocleidomastoid muscle (anteriorly), thetrapeziusmuscle(posteriorly),andthelevatorscapulae(distally).Gentlypalpatetautbandsofspleniuscapitisjustproximaltothelevatorscapulae.Painpattern:Painlocatedatthevertexofthehead.Causative or perpetuating factors: Postural stresses that overload, such asthrustingtheheadforwardtocompensateforexcessivethoracickyphosis.Satellitetriggerpoints:Levatorscapulae,upper trapezius,steocleidomastoid,spleniuscervicis.Affectedorgansystem:Vision.Associatedzones,meridians,andpoints:Dorsalzone;FootTaiYangBladdermeridian.Stretchexercise:Rotate thehead20to30degrees toward theunaffectedside.

Gentlypresstheheadforwardandtowardtheunaffectedside,stretchingslightlymoreforwardthanlaterally.Strengtheningexercise: Isometric againstmild posterior resistance.Clasp thehandsbehind theheadat the levelof thenuchal line.Press theheadandneckposteriorlyagainstthemildresistanceprovidedbytheclaspedhands.

Stretchexercise:Spleniuscapitis

Spleniuscervicisandtriggerpoint

Spleniuscervicispainpattern

SPLENIUSCERVICIS

Proximalattachment:PosteriortuberclesofthetransverseprocessesofC1–C3.Distalattachment:SpinousprocessesofT3–T6.Action: Acting unilaterally: rotation and sidebending of the neck. Actingbilaterally:extensionoftheneck.Palpation:Tolocatespleniuscervicis,identifythefollowingstructures:

Trapezius—Seemuscledescriptiononpage59.Levatorscapulae—Seemuscledescriptiononpage63.

Topalpatespleniuscervicis,placeyourpatientintheseatedpositionwithhisback resting comfortablyon thebackof the chair.Laterallybend thepatient’sheadslightlytothesidebeingpalpated,therebyrelaxingboththetrapeziusandthe levator scapulae.Palpatewithoneor two fingerson theverticalplane thatexists between the trapezius and the levator scapulae, moving the trapeziusposteromedially and the levator scapulae anterolaterally. Gently rotate thepatient’sheadslightly to theoppositeside.Palpate tautbandsverticallywithinthedefinedspace.Painpattern:Pain in theneck,cranium,andeye;patientmayexperiencestiffneck associatedwith the pain.Upper trigger point causes aching pain throughthe head to the back of the eye on the same side,with a possible blurring ofvisionin thateye.Lowertriggerpointcausespainradiatingupwardandto thebaseoftheneck.Causative or perpetuating factors: Postural stresses that overload, such asthrustingtheheadforwardtocompensateforexcessivethoracickyphosis.Satellitetriggerpoints:Levatorscapulae,uppertrapezius,sternocleidomastoid,spleniuscapitis.Affectedorgansystem:Vision.

Associatedzones,meridians,andpoints:Dorsalzone;FootTaiYangBladdermeridian.Stretchexercise:Drop thehead forward, rotating theneck30 to40degreestotheside.Gentlypresstheheaddown,moreforwardthanlateral.Themuscleontheoppositesidewillbestretched.Strengtheningexercise: Isometric againstmild posterior resistance.Clasp thehandsbehindtheheadatthelevelofthenuchalline.Directthepatienttopresstheheadandneckposteriorlyagainstthemildresistanceprovidedbytheclaspedhands.

Stretchexercise:Spleniuscervicis

Posteriorcervicalsandtriggerpoints

POSTERIORCERVICALSSEMISPINALISCAPITISANDSEMISPINALISCERVICIS

Proximalattachment:Semispinaliscapitis:ontheocciputbetweenthesuperiorandinferiornuchallines.Semispinaliscervicis:spinousprocessesofC2–C5.Distal attachment: Semispinalis capitis: transverse processes of T1–T6;articularprocessesofC3–C7.Semispinaliscervicis:transverseprocessesofT1–T6.Action:Actingunilaterally: slight rotationof theneck to thecontralateralside(semispinaliscervicis)andslightrotationoftheheadandnecktothesameside(semispinalis capitis). Acting bilaterally: extension of the neck (semispinaliscervicis)andextensionoftheheadandneck(semispinaliscapitis).Palpation: Semispinalis capitis is considered to be one of themost powerfulmusclesoftheneck.Palpatetheposteriorcervicalssimultaneously.Semispinaliscervicisliesdeeptosemispinaliscapitis.Tolocatethetheposteriorcervicals,identifythefollowingstructures:

Occiput—ThebaseoftheskullSpinousprocessesofC2–C5

Palpate semispinalis capitis through the superficialmusculatureof theneck.Withthepatient lyingsupine, locatethebaseof theocciput,supportingitwiththepalmsofyourhands.Palpatewiththepadsof thesecond, third,andfourthfingers,movingdistallyfromtheocciputtowardthelowercervicalregion.Placeyour hands with your fingers lying in the direction of the long fibers of themuscles,adjacenttothespinousprocessesofthecervicalvertebrae.Yourfingerswill be covering the region under which semispinalis capitis lies beneath themore superficial trapezius and spleniusmuscles.Deep, flat palpationwill notethickened areas of muscle approximately 2 centimeters ( inch) wide.Constrictionsmaybenotedapproximately1to2inchesbelowtheocciputandat

thelevelofC4–5.

Semispinaliscapitis

Semispinaliscervicis

Posteriorcervicalspainpattern

Painpattern:Proximaltriggerpointreferspainthatencirclesthehead,reachingits maximum intensity at the temple and forehead over the eye. Intermediatetrigger point refers pain over the occiput and toward the vertex.Distal triggerpoint(C4–5area)referspainandtendernesstothesuboccipitalregionanddownover theneckandupperpartof theshouldergirdle.Symptomsincludepain intheneck;restrictionofheadandneckflexion,withpossiblysomerestrictionofheadandneckrotationandextension;andtendernessatthebackoftheheadandneck.Causativeorperpetuatingfactors:Sustainedflexionoftheneck(semispinaliscervicis)andoftheneckandhead(semispinaliscapitis);sustainedextensionoftheneckandhead.Satellitetriggerpoints:Bilateralposteriorcervicalmuscles.

Affectedorgansystem:Vision.Associatedzones,meridians,andpoints:Dorsalzone;FootTaiYangBladdermeridian;BL10–17.Stretchexercise:Drop theheadforward,aiming thechinfor thechest.Allowtheweightofthehead,actingwithgravity,tostretchtheposteriorneckmuscles.In doing so the chin will reach the lowest possible level on the chest. It isimportanttotrytoavoidpullingthechinintowardthethroatduringthisstretch.Strengtheningexercise: Isometric againstmild posterior resistance.Clasp thehandsbehind theheadat the levelof thenuchal line.Press theheadandneckposteriorlyagainstthemildresistanceprovidedbytheclaspedhands.

Stretchexercise:Posteriorcervicals

Temporalisandtriggerpoints

Temporalispainpattern

TEMPORALIS

Proximalattachment:Lateralskullinfrontofandabovetheearinthetemporalfossa.Distalattachment:Coronoidprocessofthemandible.Action: Elevation of the mandible, closing the jaw; posterior fibers act inretractionofthemandible.Actingunilaterally:deviationofthemandibletothesameside.Palpation: To locate the temporalis, spread the fingers across themuscle justposteriortothetemplesandabovetheears.Gentlecompressionoftherearteethwillproducecontractionofthemuscle,whichwillbeeasilyexperiencedunderthepalpatinghandPalpatetemporalismovingcaudaltoitsattachmentatthecoronoidprocessof

themandible.Withthemouthrelaxedandopen,identifytriggerpointsinvariousportions of the belly of the muscle using a cross-fiber palpating technique.Trigger points that occur at the junction of the muscle fibers and its distalattachmentmaybefoundapproximately1inchabovethezygomaticarch.Painpattern: Temporal headache andmaxillary toothache. Pain extends overthe temporal region to the eyebrow, the upper teeth, and occasionally to themaxilla and the temporomandibular joint (TMJ).Triggerpoints can referpain,tenderness, and hypersensitivity of the upper teeth to hot, cold, and pressure.Patientsrarelycomplainofrestrictedjawmovement.Causativeorperpetuatingfactors:Excessiveforwardheadposture;overuseofthemuscleduetogumchewing,jawclenching,orbruxism;chronicoverusedueto an anteriorly displaced temporomandibular joint disc; direct trauma to themusclecausedfromafallorimpacttothesideofthehead;secondarytotriggerpointsinthesternocleidomastoidoruppertrapezius.Satellitetriggerpoints:Contralateraltemporalis,ipsilateralmasseter,trapezius,sternocleidomastoid.Affectedorgansystem:Digestivesystem.

Associatedzones,meridians,andpoints:Lateral zone;FootShaoYangGallBladdermeridian;GB3–7.Stretch exercise: Spread the fingers across the muscle, just posterior to thetemplesandabovetheears.Openthemouthaswideaspossibleandinhale.Ontheexhale,pressupwardalongthefibersofthemuscle.Strengthening exercise: Due to the nature of this muscle, strengtheningexercisesarenotnecessary.

Stretchexercise:Temporalis

Masseterandtriggerpoints

Masseterpainpattern

MASSETER

Proximal attachment:Superficial layer: anterior two-thirds of the zygomaticarch.Deeplayer:posteriorone-thirdofthezygomaticarch.Distal attachment: Superficial layer: external surface of the mandible at itsangle and the inferior half of the ramus of the mandible.Deep layer: lateralsurface of the coronoid process of the mandible and the superior half of theramus.Action:Elevationofthemandible,closingthejaws.Palpation: Palpatemasseterwith teeth slightly separated and the jaw relaxed.Beginningjustbelowthezygomaticarch,palpatemusclefibersdistallytowardthe angle of the mandible. Gently compressing the teeth will aid in theidentificationofmasseter;however,thepresenceoftheparotidglandmayhinderclear identificationofmuscle fibers.Palpateon the insideof the cheekwith aglovedhand.Placeonefingerwithinthemouthandanotherontheoutsideofthecheek to support the palpating thumb. Using cross-fiber palpation, locate tautbandsofmasseter.Painpattern:Superficial layer: Pain at theupper teeth and cheek, sometimesidentifiedassinuspain;painatthelowerteethandjaw,abovetheeyebrow,andat the region of the temporomandibular joint (TMJ).Deep layer: Pain in thecheekandTMJareadeep in theear;patientmayexperienceunilateral tinnitusthatisnotassociatedwithlossofhearingorvertigoand/oramarkedrestrictionof mouth opening. Unilateral trigger points produce restricted mouth openingwithdeviation to the ipsilateralside.Symptoms includesensitivity topressure,heat, and cold; restricted jaw opening. (Normal jaw opening will allow thecomfortableinsertionoftheknucklesoftwostackedfingersintothemouth.)Causative or perpetuating factors: Forward head posture; chronic mouthbreathing; acute overload from forcible contraction of the masseter as mightoccurwhilebitingsomethingquitehard;bruxism,clenching,gumchewing,nailbiting;occlusiondifficultiesthatmightberesultantfromthelossofnaturalteeth

orillfittingdentures;psychologicalstresses;overstretchingthatmightoccurwithdentalwork; trauma from a blow to the head; chronic infection; as a satellitetriggerpointtosternocleidomastoidoruppertrapezius.Satellitetriggerpoints:Temporalis,medialpterygoid,contralateralmasseter.Affectedorgansystem:Digestivesystem.Associated zones, meridians, and points: Lateral zone; Foot Yang MingStomachmeridian;ST5and6.Stretch exercise: Ask the patient to slowly open the mouth against mildresistanceplacedon the lower jaw.Holdagainst light resistanceforacountofthreetofive.Repeatthreetimes.Followingthisstretchcycle,openandclosethemouth several times without resistance. Note: This may be used as a triggerpointreleasetechniqueaswellasastretchexerciseforthepatient.Strengthening exercise: Due to the nature of this muscle, strengtheningexercisesarenotnecessary.

Stretchexercise:Masseter

Lateralpterygoidandtriggerpoints

PTERYGOIDSMEDIAL(INTERNAL)PTERYGOIDANDLATERAL(EXTERNAL)PTERYGOID

Proximalattachment:Medialpterygoid:medialsurfaceofthelateralpterygoidplate of the sphenoid bone; the maxillary tubercle. Lateral pterygoid: lateralsurfaceof the lateralpterygoidplateof thesphenoidbone; thegreaterwingofthesphenoidatthebaseoftheskull.Distalattachment:Medialpterygoid:medial (inner) surfaceof the ramusandangle of themandible.Lateralpterygoid: the neck of themandible below thecondyleandthejointcapsuleandarticulardiscofthetemporomandibularjoint.Action: Medial pterygoid: elevation of the jaw. Acting unilaterally: lateraldeviation of the mandible to the opposite side (producing grinding motion).Lateral pterygoid: draws the ipsilateral side of the mandible forward. Actingbilaterally:protractionofthejaw,amovementnecessaryforopeningthemouthwidely;lateralmovement(producinggrindingmotion).Palpation:Mostpatientswith temporomandibulardysfunctionsufferprimarilyfromamusculardisorder that includes the involvementof thepterygoids.Thismuscle is rarely involved alone and is less likely to be tender than othermasticatory muscles. The lateral pterygoid is one of the most commonlyinvolvedmusclesintemporomandibulardysfunction.Itisfrequentlyoverlookedasthesourceofthejointdysfunction.Fibers of lateral pterygoid can be indirectly palpated through the masseter.

Palpatewiththemouthheldopenapproximately1inch,orenoughtorelaxthemasseter sufficiently. Identify both the mandibular notch and the zygomaticprocess.Palpate justdistal to thezygomaticprocess to identify tenderareasoflateral pterygoid. It is frequently overlooked as the source of the jointdysfunction.Palpatetheupperfibersofmedialpterygoidusingaglovedfingerinsidethe

mouth.Slidetheindexfingerlateralandposteriortothelastmolar.Identifythebonyedgeofthemandible.Moveposteriorlyandlaterallytoidentifythemedialpterygoid.Askingthepatienttoslowlybitedownonasmallobjectheldbetween

theteethallowsforclearidentificationofthecontractingmuscle.Palpatetheinferiorfibersonthemedialsurfaceoftheangleofthemandible.

Allow thehead to rotate slightly toward the sideof thepalpation to allow theneckmusclestosoften.Reachupundertheangleofthemandibleapproximatelyinchtoidentifythefibersofmedialpterygoid.

Lateralpterygoidpainpattern

Painpattern:Medialpterygoid:Generalizedpain in themouthand theregionof the temporomandibular joint—symptoms include throat soreness, difficultyswallowing,painfulmoderaterestrictionofjawopening;lateraldeviationoftheincisalpath,generallytothecontralateralside;somelimitationoffullrangeofmotion, possibly limiting the insertion of two stacked knuckles between theteeth. Lateral pterygoid: Pain in the region of the maxilla and thetemporomandibular joint thatmight be associatedwith arthritis of the joint—symptomssuchastemporomandibularjointdisordersthatincludeclickingofthejaw, restriction of the jaw opening, distortion of the incisal path, altered

occlusionresultinginchewingdysfunction;excessivesecretionoffthemaxillarysinusmimickingsinusitis;sometimestinnitus.Note:Eliminationofthezigzagofthe incisalpathwhen the tongue isplacedon theposteriorhardpalateand themouthisopenedindicatespterygoidinvolvement.Causative orperpetuating factors:Medial pterygoid: Forward head posture,bruxism,excessivegumchewing.Medialpterygoidisrarelyinvolvedaloneandwillbeactivated secondary to lateralpterygoid.Lateralpterygoid:As satellitetrigger points to key trigger points in the neck muscles, especially thesternocleidomastoid; arthritis of the temporomandibular joint; bruxism;excessivegumchewingandnailbiting;mandibularprotrusionthatmightoccuraswhenplayingawindinstrument.Satellite trigger points: Medial pterygoid: contralateral medial pterygoid,ipsilaterallateralpterygoid,masseter.Lateralpterygoid:contralateralmedialandlateralpterygoid,masseter,ipsilateraltemporalis.Affectedorgansystems:Digestivesystem.Associatedzones,meridians,andpoints:Lateral zone;FootShaoYangGallBladder meridian, Foot YangMing Stomach meridian, Hand Tai Yang SmallIntestinemeridian;GB2,ST7,SI18and19.Stretch exercise: Ask the patient to slowly open the mouth against mildresistanceplacedon the lower jaw.Hold the jaw against light resistance for acountofthreetofive.Repeatthreetimes.Followingthisstretchcycle,openandclose themouthseveral timeswithout resistance.Note:Thismaybeusedasatriggerpointreleasetechniqueaswellasstretchexerciseforthepatient.Strengthening exercise: Due to the nature of this muscle, strengtheningexercisesarenotnecessary.

Stretchexercise:Lateralpterygoid

Trapeziusandtriggerpoints

TRAPEZIUS

Proximal attachment: External occipital protuberance, nuchal ligament,spinousprocessesofC1–T12.Distal attachment: Spine of the scapula, acromion, lateral one-third of theclavicle.Action:Upperfibers:flexionoftheheadandnecktothesameside;elevationoftheshoulderactingontheclavicleandtheacromion.Middlefibers:retractionofthescapula.Lowerfibers:depressionofthescapula,rotationoftheglenoidfossaupward.Palpation: The trapezius is the muscle most commonly found to haveconstrictions and/ or triggerpoint activity.To locate the trapezius, identify thefollowingstructures:

Clavicle—Follow the curved course of the clavicle, from its articulationwith the sternum to its articulation with the acromion. Medially thecontoursoftheclavicleareconvex;laterallyitscontoursareconcave.Spine of the scapula—Bony prominence of the upper scapula boundedlaterallybytheacromion,whichformsthelateraltipoftheshouldergirdle,andmediallybytherootofthespineofthescapula,theflattened,triangularsurfacelocatedonahorizontallinewiththespinousprocessofT3.External occipital protuberance—Locate the base of the skull at themidline,justsuperiortothecervicalspinousprocesses.Movingsuperiorlyfrom the midline onto the skull, you come to the external occipitalprotuberance. Its most prominent protrusion is called the inion, or the“bump of knowledge.” Move laterally from the external occipitalprotuberance to palpate the superior nuchal lines, short transverse ridgesthatmayormaynotbepalpable.Nuchalligament—Ifthepatientelongateshisspinebypullingthecrownoftheheadupanddroppingthechinintowardthethroat,youwillbeableto

palpate the cordlike nuchal ligament connecting the spinous processes ofeach of the cervical vertebrae. When the patient is relaxed the nuchalligamentwillnotbereadilypalpable.SpinousprocessesofC1–T12—Carefullydifferentiateeachofthecervicaland thoracic vertebrae, understanding that C1 spinous process cannot bepalpated.BeginbylocatingC7andT1,themostprominentvertebraeatthebaseoftheneck.Withthepatientseated,placethemiddlefingerofonehandonthemost prominent vertebra at the base of the neck. This is probably C7;however,itmaybeC6.Todifferentiatethetwo,placeyourindexfingeronthespinousprocessaboveyourmiddlefinger;placeyourringfingeronthespinousprocessdistaltoit.Askthepatienttoextendhishead.BydoingsoC6 will appear to move anteriorly under the palpating finger; C7 willremainfixed,aswillT1.OnceC7hasbeenclearlynoted,begincountingspinousprocessesofthecervicalvertebraesuperiorlyuntilyoureachthespinousprocessofC2;thencount the spinous processes of the thoracic vertebrae distally until youreachT12.

Topalpatethetrapeziusmuscle,beginatthesuperiornuchallineandfollowthemuscledistallytowardtheangleoftheneck.Thecontoursoftheupperfiberswilltakeyourhandsanteriorlyalongthefreeedgeofthetrapeziustothelateralone-thirdof theclavicle.Palpate for thequalityandconsistencyof themusclebetweenthelateralclavicleandthespineofthescapula,movingtowardtherootof the spineof the scapula.Continue thepalpationof themuscledistally as itnarrowstoitscharacteristictriangularapexatT12.

Trapeziuspainpattern

Pain pattern: Upper fibers: upper trigger points cause pain along theposterolateral aspect of the neck, behind the ear and possibly to the temple.Middlefibers:intermediatetriggerpointscausepaintowardthevertebrae,intheinterscapular region and the lateral aspect of the posterior shoulder. Lowerfibers: lower trigger points refer pain to the neck, suprascapular, andinterscapularregions.Painisaccompaniedbylittlerestrictionofmotion.Causative orperpetuating factors: Sustained lateral flexion of the head andneck and/or elevation of the shoulders; compression of the upper shoulders;whiplashtraumafromtheside.Satellitetriggerpoints:Supraspinatus,contralateraltrapezius,levatorscapulae.Affectedorgansystem:Respiratorysystem.Associated zones,meridians, and points: Dorsal and lateral zones; Foot TaiYangBladdermeridian(allyangmeridianspassthroughthefibersoftheupper

trapezius);SI12–15,GB20and21,SJ15,BL41–49.Stretchexercises:1. Upper trapezius: Bend the head toward the unaffected side, pressing the

head forward to lift the occiput. Lean the ear toward the homolateralshoulder.While holding this position, grasp the wrist of the arm on theaffectedsidebehindthebackandpullslightlytowardthesideofthebend.Themuscleontheaffectedsidewillreceivethestretch.

2. Middleandlowertrapezius:Sittinginachair,bendforward,headdropped.Crosseacharmoverthebodytograsptheoppositeknee.

Strengtheningexercise: Isometric againstmild resistance, the face positionedforward.

1. Placethepalmheelontheforeheadforresistance.Presstheheadforward,intotheresistance.

2. Place thepalmheel of the right handon the right temple.Press theheadtowardtheright,intotheresistance.

3. Place the palm heel of the left hand on the left temple. Press the headtowardtheleft,intotheresistance.

4. Claspthehandsbehindtheheadjustbelowthecrown.Presstheheadandneckposteriorly,intotheresistance.

Holdeachpositionforacountoffive.

Stretchexercise1:Trapezius

Stretchexercise2:Trapezius

Levatorscapulaeandtriggerpoints

LEVATORSCAPULAE

Proximalattachment:TransverseprocessesofC1–C4.Distalattachment:Medialaspectof thescapulafromitssuperiorangle to therootofthespineofthescapula.Action:Elevationofthescapula.Assistsinrotationofthenecktothesameside;canassistinsidebendingoftheneck.Palpation:Thelevatorscapulaeissecondonlytothetrapeziusintermsofthefrequency with which it is beset by muscular constrictions and trigger pointactivity.The levator scapulae lies deep to the trapezius.As itmoves from thesuperioraspectofthemedialborderofthescapulatothetransverseprocessesofthecervicalvertebrae,itbecomessuperficialatitsmiddleone-third,whichcanbepalpateddirectlyattheangleoftheneck(wherethemuscleliesbetweenthetrapezius and the sternocleidomastoid). Its distal one-third can be palpatedthrough the trapezius when the trapezius is relaxed and when the levatorscapulae harbors trigger points or is constricted. In order to differentiate thismuscle from theoverlying trapezius it isessential topaystrictattention to thedirection of the muscle fibers. The fibers of the oblique levator scapulae runverticallyandmedially,deeptothefibersofthe(alsooblique)uppertrapezius,whichrunlaterallyandhorizontally.Tolocatelevatorscapulae,identifythefollowingstructures:

Rootofthespineofthescapula—Asmall, triangular-shapedaspectofthescapula located at themedial border of the spine of the scapula. It mostcommonlyliesonahorizontallinewithT3.Transverse process of C1—Locate the angle of the mandible, the sharplateralaspectofthejawbone.Movingposteriorly,thebonyprominenceofthetransverseprocessofC1,lyingbetweentheangleofthemandibleandthemastoidprocess,maybepalpatedonsomepeople.Palpatebilaterally,gently,asthisareamaybequitetender.

Topalpatethelevatorscapulae,placeyourpatientinthepronepositionwithhisheadrestingcomfortablyinafacecradle.It isnecessaryfor theheadtobestraight, not turned to one side or another, to successfully palpate this region.Your patient’s arms should be at his sides with the palms up and the elbowsslightlybent.Withyourpalpatinghand,locatetheangleofthescapula.Imagethedirection

ofthemusclefibersastheyangletowardtheuppercervicalvertebrae.Usingacross-fiber technique,move superiorly back and forth overwhat you conceivethedirectionoffiberstobe.Levatorscapulaebecomessuperficialattheangleoftheneckanteriortothefreeborderofthetrapezius.

Levatorscapulaepainpattern

Painpattern:Painattheangleoftheneckandpossiblyattheposterioraspectof the shoulder and the midscapular region. There will be limited range ofmotiontotheaffectedside.

Causativeorperpetuatingfactors:Sustainedrotationoftheheadandnecktooneside;emotionaltension;earlystagesofanacuteupperrespiratoryinfection.Satellitetriggerpoints:Spleniuscervicis,scalenes,iliocostaliscervicis.Affectedorgansystem:Respiratorysystem.Associatedzones,meridians,andpoints:Dorsalzone;FootTaiYangBladdermeridian,HandTaiYangSmallIntestinemeridian;SI13,14,and15.Stretchexercises:

1. Bend thehead toward theunaffected side, leaning theear toward thehomolateral shoulder. Rotate the face approximately 30 degrees to theunaffected side. Flex the neck slightly, directing the stretch forward andtowardtheunaffectedside.2. Foradeeperstretch,whileholdingthispositiongraspthewristofthearmontheaffectedsidebehindthebackandpullslightly.

Strengthening exercise: Because the levator scapulae is a postural muscle,strengtheningexercisesaregenerallynotnecessary.

Stretchexercise1:Levatorscapulae

Stretchexercise2:Levatorscapulae

Rhomboidsandtriggerpoints

Rhomboidspainpattern

RHOMBOIDSRHOMBOIDMAJORANDRHOMBOIDMINOR

Proximalattachment:SpinousprocessesofC7–T5.Distalattachment:Medialborderofthescapula.Action:Elevationandretractionofthescapula.Palpation:Tolocatetherhomboids,identifythefollowingstructures:

MedialborderofthescapulaRootofthespineofthescapula—Asmall, triangular-shapedaspectofthescapula located at themedial border of the spine of the scapula. It mostcommonlyliesonahorizontallinewithT3.Inferior angle of the scapula—The sharp, triangular, distal aspect of thescapula.InmostcasestheinferiorangleofthescapulaliesonahorizontallinewithT7.SpinousprocessesofC7–T5

Position the patient prone on a treatment table with his face comfortablyrestinginafacecradle.Askthepatienttoplacehishand,palmup,atthesmallof his back.When he pushes posteriorly against resistance provided by yourhand,therhomboidsbecomevisible.Palpatetherhomboidsbetweenthespinalcolumnandthemedialborderofthe

scapula,throughthefibersofthetrapeziusmuscle.Painpattern:Painconcentratesalongthemedialborderofthescapulabutmayspread laterally over the supraspinous area of the scapula. Local, superficial,achingpainisexperiencedatrestandisnotinfluencedbymovement.Causativeorperpetuatingfactors:Chronicoverloadduetoprolongedperiodsworking in a hunched-over position; postural overload due to an overlycontractedpectoralismajor.Satellite trigger points: Levator scapulae, trapezius, infraspinatus, pectoralis

major.Affectedorgansystem:Respiratorysystem.Associatedzones,meridians,andpoints:Dorsalzone;FootTaiYangBladdermeridian;BL11–15,BL41–44.Stretchexercise: Sit in a chair.Bend forward, dropping the head.Cross eacharmoverthebodytograsptheoppositeknee.Holdthispositionforacountoffivetoten.Strengtheningexercise:Liediagonallyacrossabedortable,yourarmshangingover the edge.Bend the elbows to90degrees.Retract the scapulae.Hold thispositionforacountoften.Releaseandrepeat.

Stretchexercise:Rhomboids

Serratusanteriorandtriggerpoint

SERRATUSANTERIOR

Anterior attachment: Through slips (digitations) lying on the anterolateralaspectofrib1throughribs8or9.Posteriorattachment:Passingdeeptothescapulatoattachtothecostalsurfaceof the full length of the scapula’smedial border,with the heaviest attachmentontoitsinferiorangle.Action: Protraction of the scapula; lateral rotation of the scapula resulting inupwardrotationoftheglenoidfossa;assistsinupwardrotationandelevationofthe scapula; stabilizes the scapula against the thoracic wall during forward-pushingmovements.Palpation: Serratus anterior, lying on the lateral aspect of the thoracic wall,formsthemedialwalloftheaxilla.Atitsanteriorattachmenttothelowerribs,slipsofthismuscleinterdigitatewiththecostalattachmentofexternaloblique.Locatetheserratusanteriorwiththepatientlyingonhisside,thearmflexedandextendedbackward toward the surfaceof the table.Palpate superficiallyat themidaxillarylineatthelevelofribs5or6,onthesamehorizontallinewiththenipple.Palpatedistallytoribs8and9toidentifyslipsoftheloweraspectoftheserratusanterior;palpatesuperiorlyfromthemidlinetopalpateslipsofserratusanterior lyingonribs1 through5.Triggerpointsaremostcommonlyfoundatthemidaxillary line at the level of ribs 5 and 6. However, trigger points candevelopinanyoftheslips(digitations)ofserratusanterior.Painpattern:Painintheanterolateralaspectofthechestaswellasthemedialtotheinferiorangleofthescapula.Painmayradiatedowntheulnarsurfaceofthe homolateral arm and may extend as far as the palm and the ring finger.Symptomsincludepainthatispersistent, intense,andunaffectedbymovementor position; shortness of breath or the inability to take a deep breath withoutpain;inabilitytoexpandthelowerchestduringinspiration;breastornipplepain.Causative or perpetuating factors: Fast or prolonged running, push-ups,overheadlifting,chin-ups,severecoughing.

Serratusanteriorpainpattern

Satellite trigger points: Latissimus dorsi, scalenes, and sternocleidomastoid(theaccessorymusclesofbreathing).Affectedorgansystems:Respiratoryanddigestivesystems.Associated zones, meridians, and points: Lateral zone; Hand Tai Yin Lungmeridian,FootTaiYinSpleenmeridian,FootShaoYangGallBladdermeridian;SP21,GB22and23.Stretchexercises:

1.Sittingonachair,placethearmoftheaffectedsideoverthebackofthechairandholdtheseatofthechairbehindyou.Usingthatarmtofixyourshoulder blade, slowly turn your thorax in the opposite direction—forexample,ifthepainfulsideisyourleftside,holdthebackofthechairwithyourleftarmandturnyourtorsotowardtheright.2.Lowerandmiddlepositionsofthedoorwaystretch—seepage81:Withthe forearms placed firmly on each side of a doorway, stretch the body

through the outstretched arms, opening the chest and anterior shoulderregion.Position1:place thepalmsapproximatelyatear level.Position2:placetheelbowslevelwiththeshoulders.

Strengtheningexercise:Nostrengtheningexerciseisneededduetothenatureofthismuscle.

Stretchexercise:Serratusanterior

Pectoralisminorandtriggerpoints

PECTORALISMINOR

Proximalattachment:Coracoidprocessofthescapula.Distalattachment:Anteriorchestwall,ontheuppersurfacesofribs3,4,and5.Action: Pulls the scapula and shoulder down and forward; assists in forcedinspiration.Palpation:Pectoralisminorliesdeeptopectoralismajorandmaybedifficulttopalpate.During palpation the two pectoralismusclesmay be differentiated bythedirectionoftheirfibers.Tolocatepectoralisminor,identifythefollowingstructures:

Coracoid process of the scapula—Projecting anteriorly from the superiorborder of the head of the scapula. Find the most concave aspect of thelateral clavicle; move your palpating hand distally approximately 1 inchinto the deltopectoral triangle. Pressing posterolaterally, youwill feel thecoracoidprocessasabonyprominence.Thisareacanbequitesensitive.Ribs 2 through 5—Locate the sternal articulations of ribs 2 through 5.Follow the course of each rib and rib space from the sternum toward theshoulder, noting the upward contours of the ribs as you palpate laterally.Notethatrib1liesundertheclavicleandsocannotbeeasilydistinguishedthrough palpation. Rib 2 is the first distinctly palpable rib distal to theclavicle.

Askthepatienttoliesupinewithhisforearmrestingcomfortablyonhisbodyat the level of hiswaist. Ask him to bring his shoulder forward (anterior) byliftinghisscapulaoff the tableandthento takeadeepbreath.Palpationat thearea of pectoralis minor will note the then-activated muscle. Palpate throughpectoralismajortodetectconstrictedfibersofpectoralisminor.

Pectoralisminorpainpattern

Pain pattern: Pain is referred to the front of the shoulder (anterior deltoidregion)andpossiblythefrontofthechest;somepainmaybereferreddowntheulnar aspect of the arm to the fourth and fifth digits. Symptomsmay includelimitation in reachingforwardandupor in reachingbackwardwith thearmattheleveloftheshoulder.Causative or perpetuating factors: Stooped, forward-leaning posture;compression,asthatwhichmightoccurfromthepressureofabackpackstraponthearea.Satellite trigger points: Pectoralis major, anterior deltoid, scalenes,sternocleidomastoid.Affectedorgansystem:Respiratorysystem.Associated zones, meridians, and points: Ventral zone; Hand Tai Yin Lungmeridian;SP19and20.

Stretchexercise:With the forearmsplaced firmlyon each sideof a doorway,thepalmsapproximatelyatear level, stretch thebody through theoutstretchedarms, opening the chest and anterior shoulder region. It is essential that thestretchissufficienttoretractthescapulae.Strengthening exercise: Because the pectoralis minor is a postural muscle,strengtheningexercisesaregenerallynotnecessary.

Stretchexercise:Pectoralisminor

Pectoralismajorandtriggerpoints

PECTORALISMAJOR

Proximal attachment: Medial two-thirds of the clavicle; sternum; costalcartilagesofribs2–7;superficialaponeurosesoftheexternalobliqueandrectusabdominis.Distalattachment:Laterallipofthebicipitalgrooveofthehumerus.Action:Adductionandmedialrotationofthearm.Clavicularfibers:flexionofthearm,asintouchingthelobeoftheoppositeear.Palpation:Pectoralismajorformstheanteriorwalloftheaxilla.Asasuperficialmuscleofthechestwall,pectoralismajorisclearlyobservablewhenthepatientpressesmediallyagainsthisiliaccrest.Tolocatepectoralismajor,identifythefollowingstructures:

Clavicle—Follow the curved course of the clavicle, from its articulationwith the sternum to its articulation with the acromion. Medially thecontoursoftheclavicleareconvex;laterallyitscontoursareconcave.Sternum—The breastbone: a long, flat bone that forms the center of theanteriorthorax.Bicipital groove of the humerus (intertubercular groove)—Identify thegreaterandlessertuberositiesofthehumerus,justdistaltothelateralaspectoftheacromion.(Thesearebestpalpatedwiththearmexternallyrotated.)Thebicipitalgrooveliesmedial tothegreatertuberosityandlateral tothelessertuberosity.Notethatthetendonofthelongheadofthebicepsbrachiirunsthroughthebicipitalgroove.

Locate pectoralismajorwith the patient lying supine, his arm resting at hisside. Palpate pectoralis major throughout its course, beginning at its medialattachmentat thesternumand themedial two-thirdsof thedistalaspectof theclavicle. Move laterally across the chest wall to its lateral attachment at thebicipital groove. The lateral aspect of themuscle, its free edge,may be lifted

slightlyoff the chestwall inorder todirectlypalpate the fibersusingapincergrasppalpationtechnique.Painpattern:Painintheanterioraspectoftheshoulder,attheanteriordeltoidregion; the pain pattern may include the anterior chest and breast. Pain mayextenddowntheulnaraspectofthearmtothefourthandfifthdigits.Painmaysometimesmimicanginapectoris.Causativeorperpetuatingfactors:Overloadstressesduetoheavyliftingwitharms in front of the body; immobilization of the arm in an adducted position;sustained round-shouldered position; sustained anxiety levels; referredphenomenaviaaviscerosomaticrouteassociatedwithcardiacinfarction.

Pectoralismajorpainpattern

Strengtheningexercise:Lieinthesupineposition,armsabductedto90degreesandpalmsfacingtheceiling.Horizontallyflexthearmsacrossthechest,keepingtheelbowsstraight.Slowlyreturnthearmstothestartingposition.Repeatfive

totentimes,flexingtoacountoftwoandreturningtothestartingpositiontoacountoffour.Satellite trigger points: Anterior deltoid, sternocleidomastoid, scalenes,trapezius,rhomboids.Affectedorgansystems:Respiratoryandcardiovascularsystems.Associated zones, meridians, and points: Ventral zone; Foot Yang MingStomachmeridian,HandTaiYinLungmeridian,FootTaiYinSpleenmeridian,FootShaoYinKidneymeridian;ST14,15,and16;ST18;LU1,2,and3;SP19and20;KI22–27.Stretchexercise:With the forearmsplaced firmlyon each sideof a doorway,stretch the body through the outstretched arms, opening the chest and anteriorshoulderregion.

1.Placethepalmsapproximatelyatearleveltostretchtheupperfibersofpectoralismajor.2.Placetheelbowslevelwiththeshoulderstostretchthemiddlefibersofpectoralismajor.3. Extend the arms fully, placing the handswell above the level of theheadtostretchthelowerfibersofpectoralismajor.

Stretchexercise1:Pectoralismajor

Stretchexercise2:Pectoralismajor

Stretchexercise3:Pectoralismajor

Deltoid(anterior)andtriggerpoints

Deltoid(posterior)andtriggerpoints

DELTOID

Proximalattachment:Anteriorfibers: lateralone-thirdof theclavicle.Medialfibers:acromion.Posteriorfibers:spineofthescapula.Distalattachment:Deltoidtuberosityofthehumerus.Action:Anterior fibers: flexion and internal rotation of the humerus.Medialfibers: abduction of the humerus. Posterior fibers: extension and externalrotationofthehumerus.Palpation:Tolocatethedeltoid,identifythefollowingstructures:

Clavicle—Follow the curved course of the clavicle, from its articulationwith the sternum to its articulation with the acromion. Medially thecontoursoftheclavicleareconvex;laterallyitscontoursareconcave.Theanterior deltoid attaches to the clavicle at its lateral concavity where thepectoralismajormuscleends.Acromion—Theflat,lateralaspectofthescapulaatthemostlateraltipoftheshouldergirdle.Abductingthehumerusasyoupalpatethelateraltipoftheshouldergirdle,youcanclearlydistinguishbetweentheacromionandtheheadofthehumerus.Spine of the scapula—Follow the course of the acromion posteriorly andmedially along the spine of the scapula to the root of the spine of thescapula,aflattened,triangularsurfaceat themedialborderofthescapula.TherootofthespineofthescapulaislocatedonahorizontallinewiththespinousprocessofT3.Deltoid tuberosity of the humerus—The bony prominence locatedapproximatelymidwaydownthelateralaspectofthehumerus.

Palpate the deltoid from its attachments on the shoulder girdle to itsattachmentonthehumerus.Palpateanteriorly,notingtheareawherethedeltoidlies adjacent to the pectoralis at the lateral concavity of the clavicle.Note the

deltopectoralgrooveformedbythejunctionofthedeltoidandpectoralismajormuscles.Palpatethemedialfibers,notingtheattachmentofthedeltoidmuscletothe acromion; palpate posteriorly, noting the attachment to the spine of thescapula.Note how the three aspects of themuscle converge to insert onto thedeltoidtuberosityofthehumerus.

Deltoidpainpattern

Pain pattern:Anterior fibers: Pain is experienced in the anterior andmedialdeltoid;thepatientmayexperienceweakenedabductionoftheexternallyrotatedarm.Posteriorfibers:Painisexperiencedintheposteriorandmedialdeltoid;thepatientmayexperienceweakenedabductionoftheinternallyrotatedarm.Causativeorperpetuatingfactors:Directtraumaduetoimpact,overexertion,orsuddenoverload.Satellite trigger points: Anterior fibers: pectoralis major, biceps brachii,posteriordeltoid.Posteriorfibers:longheadofthetriceps,latissimusdorsi,teres

major.Affectedorgan systems:Anterior fibers: respiratory system.Posterior fibers:digestivesystem.Associatedzones,meridians,andpoints:Anterior fibers:ventralzone;HandTaiYinLungmeridian;LU1,2,and3.Posteriorfibers:dorsalandlateralzones;HandYangMingColonmeridian,HandShaoYangTripleWarmermeridian;CO14and15,SI10;TW13and14.Stretchexercises:1. Anterior fibers: Place the palms firmly on each side of a doorway at

approximately ear level. Stretch the body through the outstretched arms,openingthechestandanteriorshoulderregion.

2. Posteriorfibers:Pulltheaffectedarmacrossthechest,usingtheotherarmplacedproximaltotheelbowtoguidetheaction.

Strengtheningexercises:Bothstrengtheningexercisesshouldbeperformedinastandingpositionwiththearmsatthesides.1. Flex the affected arms—keeping the elbows straight, bring the arm to

shoulderlevel.Performthisflexiontoacountoftwo;returntothestartingpositiontoacountoffour.Repeateighttotentimes,increasingthenumberofrepetitionsasstrengthallows.Handweightsmaybeusedtoincreasetheworkeffortofthemuscle.

2. Abduct the affected arm, keeping the elbows straight; bring the arm toshoulderlevel.Abducttoacountoftwo;returntothestartingpositiontoacount of four. Repeat eight to ten times, increasing the number ofrepetitions as strength allows.Handweightsmay be used to increase theworkeffortofthemuscle.

Stretchexercise1:Anteriordeltoid

Stretchexercise2:Posteriordeltoid

Latissimusdorsiandtriggerpoints

LATISSIMUSDORSI

Proximalattachment:Latissimusdorsi fuseswith teresmajor toattachat themedialedgeofthebicipitalgroove,ontheanterioraspectofthehumerus.Distalattachment:SpinousprocessesofT6–T12,L1–L5andthesacrum,iliaccrest via the thoracolumbar aponeurosis, lower 3–4 ribs, inferior angle of thescapula.Action:Extension,adduction,andinternalrotationofthearmattheshoulder.Palpation:Thelatissimusdorsiandtheteresmajortogetherformtheposteriorwall of the axilla. The tendon of the latissimus dorsi twists upon itself beforefusingwithteresmajorattheattachmentonthebicipitalgroove.Tolocatelatissimusdorsi,identifythefollowingstructures:

Spinous processes of T6 through T12 and L1 through L5—Note thedifference in the size and shape of the spinous processes of the thoracicvertebraeversusthelumbarvertebrae.Iliaccrests—LyingonahorizontallinewiththejunctionofL4–L5.Inferior angle of the scapula—The sharp, triangular, distal aspect of thescapula.InmostcasestheinferiorangleofthescapulaliesonahorizontallinewithT7.Bicipital groove of the humerus (intertubercular groove)—Identify thegreaterandlessertuberositiesofthehumerus,justdistaltothelateralaspectoftheacromion.(Thesearebestpalpatedwiththearmexternallyrotated.)Thebicipitalgrooveliesmedial tothegreatertuberosityandlateral tothelessertuberosity.Notethatthetendonofthelongheadofthebicepsbrachiirunsthroughthebicipitalgroove.

Palpatelatissimusdorsiwiththepatientintheproneposition,armsrestingathis sides, palms up. Use a pincer grasp at the posterior axillary fold, gentlylifting the muscle off the thoracic wall. Grasp the muscle along its lateral

placement, proximal to the inferior angle of the scapula, at approximately themidpointof the lateral edgeof the scapula; follow themuscle toward the iliaccrest,wherethemusclefibersbecomeincreasinglyindistinct.

Latissimusdorsipainpattern

Pain pattern: Pain is located at the inferior angle of the scapula and thesurroundingmidthoracicregion,possiblyextendingtothebackof theshoulderanddown themedial aspect of the arm, forearm, andhand, including the ringand little fingers. The nature of the pain is an ache that shows neitheraggravationnorreliefwithactivityorchangeofposition.Causativeorperpetuatingfactors:Depressormovements thatoverload,as inpullingsomethingdownfromaboveorholdingaheavy,bulkyobject.Satellite trigger points: Teres major, triceps brachii, rectus abdominis,iliocostalisthoracis,andiliocostalislumborum.Affectedorgansystem:Digestivesystem.

Associated zones,meridians, and points: Dorsal and lateral zones; Foot TaiYangBladdermeridian,HandTaiYangSmallIntestinemeridian;BL23,SI9.Stretchexercise:Reachbotharmsabovethehead.Graspthewristofthehandon theaffected sidewith theoppositehand.Pull thewrist andarm toward theunaffectedside,bendingthetorsotothatside.Holdthispositionforacountoftentofifteen.Strengtheningexercise:Standingwiththelegsshoulder-widthapart,bendfromthewaist so that the upper body is parallel to the floor.Reach the armof theaffected side toward the opposite foot. Bend the elbow to make a 90-degreeangleandretractthescapula,extendingtheupperarm,bringingittoapositionalongside the torso. The final position is one inwhich both the torso and theupperarmareparalleltothefloorwhiletheforearmisperpendiculartothefloor.Drawthearmtothesidetoacountoftwo.Reachfortheoppositefoottoacountoffour.Repeateighttotentimes,increasingrepetitionsasthestrengthofthemuscle

allows.Donotallowthetorsotomoveduringthecourseoftheexercise.

Stretchexercise:Latissimusdorsi

Teresmajorandtriggerpoints

TERESMAJOR

Proximalattachment:Teresmajor fuseswith latissimusdorsi toattachat themedialedgeofthebicipitalgroove,ontheanterioraspectofthehumerus.Distalattachment:Inferiorangleofthescapula.Action:Internalrotation,adduction,andextensionofthearm.Palpation:Teresmajorandlatissimusdorsiarefusedattheirinsertionintothebicipitalgroove.Thetendonoflatissimusdorsi twistsuponitselfbeforefusingwithteresmajorattheattachmentatthebicipitalgroove.Tolocateteresmajor,identifythefollowingstructures:

Inferior angle of the scapula—The sharp, triangular, distal aspect of thescapula.InmostcasestheinferiorangleofthescapulaliesonahorizontallinewithT7.Bicipital groove of the humerus (intertubercular groove)—Identify thegreaterandlessertuberositiesofthehumerus,justdistaltothelateralaspectoftheacromion.(Thesearebestpalpatedwiththearmexternallyrotated.)Thebicipitalgrooveliesmedial tothegreatertuberosityandlateral tothelessertuberosity.Notethatthetendonofthelongheadofthebicepsbrachiirunsthroughthebicipitalgroove.

Palpateteresmajorattheposterioraxillaryfold,deeperandmoremedialthanlatissimus dorsi. Taut bands or trigger pointswithin teresmajorwill be foundproximaltothemidpointofthelateraledgeofthescapula.

Teresmajorpainpattern

Painpattern:Painisreferredtotheposteriordeltoidregion.Painmayextendtotheextensorsurfaceoftheforearm.Patienthasdifficultyabductingthearmandplacing it against the homolateral ear. Pain is experienced when reachingforwardandup,andthereislittlerestrictionofmotion.Causativeorperpetuatingfactors:Depressormovements thatoverload,as inpullingsomethingdownfromaboveorholdingaheavy,bulkyobject.Satellite trigger points: Long head of the triceps brachii, latissimus dorsi,posteriordeltoid,teresminor,subscapularis.Affectedorgansystem:Digestivesystem.Associatedzones,meridians,andpoints:Dorsalzone;HandTaiYangSmallIntestinemeridian;SI9.Stretchexercises:1. Reachbotharmsabovethehead.Graspthewristofthehandontheaffected

sidewith theoppositehand.Pull thewristandarm toward theunaffectedside,bendingthetorsotothatside.Holdthispositionforacountoftentofifteen.

2. Stand, or lie supine,with the elbow of the affected side close to the ear,forearmbehindthehead.Pulltheelbowtowardtheoppositeside.

Strengtheningexercise:Standingwiththelegsshoulder-widthapart,bendfromthewaistsotheupperbodyisparalleltothefloor.Reachthearmoftheaffectedside toward theopposite foot.Bend the elbow tomake a90-degree angle andretractthescapula,extendingtheupperarm,bringingit toapositionalongsidethetorso.Thefinalpositionisoneinwhichboththetorsoandtheupperarmareparallel to the floor,while the forearm is perpendicular to the floor.Draw thearmtothesidetoacountoftwo.Reachfortheoppositefoottoacountoffour.Repeateighttotentimes,increasingrepetitionsasthestrengthofthemuscle

allows.Donotallowthetorsotomoveduringthecourseoftheexercise.

Stretchexercise1:Teresmajor

Stretchexercise2:Teresmajor

Supraspinatusandtriggerpoints

SUPRASPINATUS

Proximalattachment:Supraspinatusfossaofthescapula.Distalattachment:Upperpartofthegreatertubercleofthehumerus.Action:Assists thedeltoid inabductionof thehumerusbypulling theheadofthehumerusinwardtowardtheglenoidfossa.Aidsinstabilizingtheheadofthehumerusintheglenoidfossa.Palpation: Supraspinatus is one of the fourmuscles that comprise the rotatorcuff. The othermuscles of the rotator cuff are infraspinatus, teresminor, andsubscapularis.Supraspinatusliesdeeptothetrapezius.Tolocatesupraspinatus,identifythefollowingstructures:

Supraspinatusfossaofthescapula—Thedorsalaspectofthescapulalyingproximaltothespineofthescapula.Acromion—Theflat,lateralaspectofthescapulaatthemostlateraltipoftheshouldergirdle.Abductingthehumerusasyoupalpatethelateraltipofthe shoulder girdle, you can clearly distinguish between the rectangularacromionandtheheadofthehumerus.

To palpate supraspinatus, palpate deep to the trapezius in the supraspinatusfossa, moving laterally toward the acromion. Trigger points and areas ofconstrictionmostcommonlycanbepalpatedapproximately1inchlateraltothemedial(vertebral)borderofthescapulajustsuperiortothespineofthescapulaand just medial to the acromion, between the clavicle and the spine of thescapula. Deep palpation is required to feel through the trapezius muscle;however,careshouldbetakentoavoidforcingthroughconstrictedmuscleinanefforttoreachanunderlyingmuscle.

Supraspinatus(anterior)painpattern

Supraspinatus(posterior)painpattern

Painpattern:Painconcentratesinthemiddledeltoidregionandisexperiencedasadeepachewhenthearmisatrest.Theacheextendsdownwardoverthearmand forearm and sometimes focuses over the lateral epicondyle. Pain iscommonlyfeltduringabduction.Causative or perpetuating factors: Carrying heavy objects with the armhangingattheside.Satellite trigger points: Subscapularis, infraspinatus, middle trapezius, uppertrapezius,deltoid,latissimusdorsi.Affectedorgansystems:Respiratoryanddigestivesystems.Associatedzones,meridians,andpoints:Dorsalzone;HandYangMingColonmeridian, Hand Tai Yang Small Intestine meridian, Hand Shao Yang TripleWarmermeridian;CO16,SI12,TW14and15.Stretchexercises:

1. Usingtheunaffectedarm,pulltheaffectedarmacrossthebackatthelevelofthewaistandpullupslightly.Holdthispositionforacountoffifteentotwenty.

2. As flexibility increases, reach the fingers of the affected arm toward theinferiorangleoftheoppositeshoulder.Holdforacountoffifteentotwenty.

Strengtheningexercise:Abductthearms,keepingtheelbowsstraight.Abducttoacountoftwo;returntothestartingpositiontoacountoffour.Repeateightto ten times, increasing the number of repetitions as strength allows. Handweightsmay be used to increase thework effort of themuscle. Supraspinatuswill work in the first 15 to 20 degrees of abduction, before deltoid fullyactivates.

Stretchexercise1:Supraspinatus

Stretchexercise2:Supraspinatus

Infraspinatusandtriggerpoints

INFRASPINATUS

Proximalattachment:Medial two-thirdsof the infraspinatus fossa,which liesdistaltothespineofthescapula.Distal attachment: Posterior aspect of the greater tuberosity of the humerus,distaltotheattachmentofsupraspinatus.Action:Externalrotationofthearm;aidsinstabilizingtheheadofthehumerusin the glenoid fossa during upward movement of the arm, assisted by teresminor.Palpation: Infraspinatus is one of the four muscles that comprise the rotatorcuff. The othermuscles of the rotator cuff are supraspinatus, teresminor, andsubscapularis.Constrictionsandtriggerpointactivity in infraspinatus isoneofthemostcommoncausesofshoulderpain.Itisthirdonlytouppertrapeziusandlevatorscapulaeinfrequencyofinvolvementintriggerpointactivity.Tolocateinfraspinatus,identifythefollowingstructures:

Infraspinatusfossaofthescapula—Theaspectofthescapulathatliesdistaltothespineofthescapula.Greater tuberosity of the humerus—Distal to the lateral aspect of theacromion, easiest palpated when the arm is in external rotation.Differentiatethegreatertuberosityfromthelessertuberosity,andlocatethebicipitalgroove,whichliesbetweenthem.

To palpate infraspinatus use flat digital palpation within the infraspinatusfossa, beginning at the medial (vertebral) border of the scapula and movinglaterally toward the insertion at the greater tuberosity of the humerus.Constrictionsandtriggerpointsaremostcommonlyfoundapproximately½to1inchdistaltothespineofthescapula.

Infraspinatus(anterior)painpattern

Infraspinatus(posterior)painpattern

Pain pattern: Proximal trigger points refer pain deep in the anterior deltoidregionandtheshoulderjoint,extendingdownthefrontandlateralaspectsofthearmandpossiblytheforearmandtheradialhalfofthehand.Painmayextendtothe suboccipital region and posterior cervical areas. Distal trigger points referpain between the spine of the scapula and the vertebral border of the scapula.Painisexperiencedwhensleepingoneitherside.Thepatientmaybeunabletoreachbehindhisback.Causativeorperpetuatingfactors:Overloadstresseswhilereachingbackwardandupward.Satellite triggerpoints:Teresminor,anteriordeltoid,posteriordeltoid,bicepsbrachii,supraspinatus,teresmajor,latissimusdorsi.Affectedorgansystem:Digestivesystem.Associatedzones,meridians,andpoints:Dorsalzone;HandTaiYangSmall

Intestinemeridian;SI9,10,and11.Stretchexercises:1. Startingwith the affected arm at 90 degrees horizontal abduction, extend

the arm toward the back, internally rotating at the shoulder. At thelimitationofextension,bendtheelbowandtouchtheinferiorangleoftheoppositescapula.

2. Pulltheaffectedarmacrossthechest,usingtheotherarmplacedproximaltotheelbowtoguidetheaction.

Strengthening exercise: Lie supine with the arm close to the torso and theelbowflexedto90degrees.Withoutmovingtheelbowandarmawayfromthetorso,rotatetheforearmasiftoplacethebackofthehandonthefloor.Returntothestartingposition.Repeateighttotentimes.Handweightsmaybeusedasstrengthdevelops,to

increasetheworkeffortplacedonthemuscle.

Stretchexercise1:Infraspinatus

Stretchexercise2:Infraspinatus

Teresminorandtriggerpoint

TERESMINOR

Proximalattachment:Proximaltwo-thirdsofthelateralborderofthescapula,onthedorsalsurface.Distal attachment: Posterior aspect of the greater tuberosity of the humerus,distaltotheattachmentofinfraspinatus.Action:Externalrotationofthearmattheshoulder;actswiththeinfraspinatustostabilizetheheadofthehumerusduringmovementofthearm.Palpation:Teresminorisoneofthefourmusclesthatcomprisetherotatorcuff.The other muscles of the rotator cuff are supraspinatus, infraspinatus, andsubscapularis.Tolocateteresminor,identifythefollowingstructures:

Infraspinatusmuscle—Seemuscledescriptiononpage99.Teresmajormuscle—Seemuscledescriptiononpage91.Greater tuberosity of the humerus—Distal to the lateral aspect of theacromion, easiest palpated when the arm is in external rotation.Differentiatethegreatertuberosityfromthelessertuberosity,andlocatethebicipitalgroove,whichliesbetweenthem.

Topalpateconstrictionswithinteresminor,palpatenearthelateraledgeofthescapula between the infraspinatus, lying above teres minor, and teres major,lyingbelowteresminor.Notethatteresminorattachesontheposterioraspectofthehumeruswhileteresmajorattachesontheanterioraspectofthehumerus.

Teresminorpainpattern

Painpattern:Paininthedistalposteriordeltoid,possiblyintotheposterolateralupper arm. Painmay be sharply localized and deep in nature, and it becomesmoreapparentwhenpainandrestrictionsininfraspinatusarereduced.Thereisusuallylittlerestrictionofmovement.Causativeorperpetuatingfactors:Overloadstresseswhenreachingbackwardandupward.Satellitetriggerpoints:Infraspinatus.Affectedorgansystem:Digestivesystem.Associatedzones,meridians,andpoints:Dorsalzone;HandTaiYangSmallIntestinemeridian;SI9.Stretchexercises:1. Startingwith the arm at 90 degrees horizontal abduction, extend the arm

toward the back, internally rotating at the shoulder. At the limit of

extension, bend the elbow and touch the inferior angle of the oppositescapula.

2. Pulltheaffectedarmacrossthechest,usingtheotherarmplacedproximaltotheelbowtoguidetheaction.

Strengthening exercise: Lie supine with the arm close to the torso and theelbowflexedto90degrees.Withoutmovingtheelbowandarmawayfromthetorso,rotatetheforearmasiftoplacethebackofthehandonthefloor.Returntothestartingposition.Repeateighttotentimes.Handweightsmaybeusedasstrengthdevelopsto

increasetheworkeffortplacedonthemuscle.

Stretchexercise1:Teresminor

Stretchexercise2:Teresminor

Subscapularisandtriggerpoints

SUBSCAPULARIS

Proximalattachment:Thesubscapularfossaontheanterior(costal)surfaceofthescapula.Distalattachment:Lessertubercleofthehumerusontheanterioraspectofthehumerus.Action: Internal rotation and adduction of the arm at the shoulder. Aids instabilizingtheheadofthehumerusintheglenoidfossaduringmovementofthearm.Palpation: Subscapularis is one of the fourmuscles that comprise the rotatorcuff.Theothermusclesof therotatorcuffaresupraspinatus, infraspinatus,andteresminor.Thismusclemaybequitedifficult topalpategiven its locationontheanterioraspectofthescapula,adjacenttothethorax.Tolocatesubscapularis,identifythefollowingstructures:

LateralborderofthescapulaPosteriorwalloftheaxilla,formedbylatissimusdorsi

Palpationofsubscapulariscanbeaccomplishedwiththepatientineitherthesupine or prone position. To palpate subscapularis, abduct the arm.Using flatpalpation,reachunder(anteriorto)theposterioraxillaryfold,movingmedialtoboth latissimus dorsi and teres major. Feel for the hard lateral border of thescapula with the pads of the fingers. Continue to reach medially, palpatingsubscapularisagainst theanterioraspectof thescapulaalong its lateralborder.The extent towhich themuscle can be palpatedwill depend on the degree offlexibilityofthepatient’sscapulaonthethorax.Pain pattern: Pain concentrates in the posterior deltoid area andmay extendover the scapula and down the posterior aspect of the arm. It may skip theforearmtoreappearasabandaroundthewrist.Symptomsarepainfulrestrictionofabductionandexternalrotationofthearm.Triggerpointsmaycontributetoa

subluxationoftheheadofthehumerus.Causative or perpetuating factors: Repetitive exertion requiring internalrotation,asintheswimmer’scrawl;suddenshouldertrauma.Satellite trigger points: Pectoralis major, teres major, latissimus dorsi, longheadofthetricepsbrachii,anteriordeltoid,posteriordeltoid.Affectedorgansystem:Respiratorysystem.Associatedzones,meridians,andpoints:

Subscapularispainpattern

Dorsalzone;HandTaiYangSmallIntestinemeridian;SI9and10.Stretchexercises:1. Bend at thewaist and rest one armon a table, torsoparallel to the floor.

Allowtheaffectedarmtohangstraightdownwhileholdingaheavyweight.Movetheweightedarminsmallcircles.Thistechniqueisalsousedtoaid

inthereadjustmentoftheshoulderjoint.2. Withtheforearmsplacedfirmlyoneachsideofadoorway,stretchthebody

through the outstretched arms, opening the chest and anterior shoulderregion.Firstperformtheexercisewiththeelbowslevelwiththeshoulders.Thenextendthearmsfully,placingthehandswellabovethehead.

3. With the elbow bent to 90 degrees, abduct the affected arm, raising theelbowto theshoulder level.Draw the forearmbackbehind thehead.Thestretchcanbeincreasedbyapplyingaslightposteriorpressuretotheupperarm,justproximaltotheelbow.

Strengthening exercise: Lie supine with the arm close to the torso and theelbowflexedto90degrees.Withoutmovingtheelbowandarmawayfromthetorso,rotatetheforearmasiftoplacethebackofthehandonthefloor.Returntothestartingposition.Repeateighttotentimes.Handweightsmaybeusedasstrengthdevelopsto

increasetheworkeffortplacedonthemuscle.

Stretchexercise1:Subscapularis

Stretchexercise2:Subscapularis

Stretchexercise3:Subscapularis

Bicepsbrachiiandtriggerpoints

BICEPSBRACHII

Proximalattachment:Longhead: supraglenoid tubercleof thescapula.Shorthead:coracoidprocessofthescapula.Distalattachment:Tuberosityoftheradius.Action:Flexionoftheforearmattheelbow;assistsinflexionofthearmattheshoulder.Aidsinsupinationoftheforearmagainstresistancewhentheelbowisflexed.Palpation:Tolocatebicepsbrachii,identifythefollowingstructures:

Bicipital groove of the humerus (intertubercular groove)—Identify thegreaterandlessertuberositiesofthehumerus,justdistaltothelateralaspectoftheacromion.(Thesearebestpalpatedwiththearmexternallyrotated.)Thebicipitalgrooveliesmedial tothegreatertuberosityandlateral tothelessertuberosity.Notethatthetendonofthelongheadofthebicepsbrachiirunsthroughthebicipitalgroove.Coracoid process of the scapula—Projecting anteriorly from the superiorborder of the head of the scapula. Find the most concave aspect of thelateral clavicle; move your palpating hand distally approximately 1 inchinto the deltopectoral triangle. Pressing posterolaterally, youwill feel thebonyprominenceofthecoracoidprocess.Thisareacanbequitesensitive.

Thepowerful bicepsbrachii canbepalpated throughout its course.Flex thearm 15 to 45 degrees to locate the tendon of attachment on the (bicipital)tuberosity of the radius. Palpate biceps brachii, moving superiorly. The longheadcanbepalpatedbyfollowingitstendonofattachmentasitpassesthroughthebicipitalgroove.Externalrotationofthearmfacilitatestheabilitytopalpatethe tendon within its groove. The short head can be palpated as it movesmediallytowarditsattachmentatthecoracoidprocessofthescapula.

Bicepsbrachiipainpattern

Pain pattern: Superficial aching pain in the anterior shoulder and arm, withsomerestrictionofmotion.Causativeorperpetuatingfactors:Sustainedelbowflexion;chronicoracutestraincausedbysportsorheavylifting.Satellitetriggerpoints:Brachialis,supinator,tricepsbrachii.Affectedorgansystem:Respiratorysystem.Associated zones, meridians, and points: Ventral zone; Hand Tai Yin Lungmeridian,HandJueYinPericardiummeridian;LU3,4,and5;PC2and3.Stretchexercise:Holdontoadoorjambwiththeaffectedarm.Thehandshouldbeatshoulder levelwith theelbowstraightandthethumbpointingtowardthefloor.Turnthebodyawayfromthearmwithoutallowinganyjointtobend.Holdthispositionforacountoffifteentotwenty.Strengtheningexercise:Standwiththearmsatyoursides,palmsfacingtoward

thebody.Flextheforearmsand,keepingtheelbowsclosetothebody,drawthepalmstowardtheshoulder.Slowlyreturntothestartingposition.Flextoacountoftwo;releasetoacountoffour.Nowstandwiththearmsatyoursides,thistimewithpalmsfacingoutward.

Flex the forearms and, keeping the elbows close to the body, draw the palmstoward the shoulder. Slowly return to the starting position. Flex to a count oftwo;releasetoacountoffour.Repeat both exercises eight to ten times, increasing repetitions as strength

allows. Hand weights may be used to increase the work effort placed on themuscle.

Stretchexercise:Bicepsbrachii

Tricepsbrachiiandtriggerpoints

Tricepsbrachiipainpattern

TRICEPSBRACHII

Proximalattachment:Longhead:infraglenoidlipofthescapula.Lateralhead:posterior humerus, superior to the radial groove. Medial head: posteriorhumerus,inferiortotheradialgroove.Distalattachment:Viaacommontendontotheolecranonprocessoftheulna.Action:Extensionoftheforearmattheelbow.Longhead:aidsinextensionandadductionofthearmattheshoulder.Palpation:Tolocatetricepsbrachii,identifythefollowingstructures:

HeadofthehumerusOlecranon process of the ulna—Large process at the proximal end of theulna

Palpate the tricepsmuscle throughout itscourse,movingfromtheolecranonprocess proximally along the posterior humerus. Palpate the long head to itsattachmentonthescapula,thenreturntothebodyofthemusclewhereitformsacommonmuscularbellywiththelateralhead.Themedialheadliesdeeptothelong head, but it can be palpated at the distal aspect of the medial humerus.Palpateboththeposterolateralandtheposteromedialaspectsofthearmfortautbandsandareasofconstrictionwithinthebodyofthemuscle.Pain pattern: Pain throughout the posterior aspect of the arm, including thelateralepicondyle.Painmaybeexperiencedinthefourthandfifthdigitsand/orthesuprascapularregion.Ifconstrictionsortriggerpointsarelocatedinthelonghead, the patient may be unable to straighten his arm against his ear whileholdingthearmupabovehishead.Causativeorperpetuatingfactors:Overloadstressesassociatedwithpushingheavyobjectsorwithrapidextensionoftheforearm.Satellite trigger points: Latissimus dorsi, teresmajor, teresminor, anconeus,

supinator,brachioradialis,extensorcarpiradialis.Affectedorgansystem:Digestivesystem.Associatedzones,meridians,andpoints:Dorsalzone;HandShaoYangTripleWarmermeridian;TW10–13.Stretchexercise:Placethepalmofthehandoftheaffectedarmonthespineofthe homolateral scapula. Draw the elbow toward the ear and back behind thehead.Gentleposteriorpressuretotheregionproximaltotheelbowwillincreasethestretch.Holdthispositionforacountoftentofifteen.Strengtheningexercise:Standorsit inacomfortableposition.Place thehandnear the spine of the homolateral scapula, drawing the elbow toward the ear.Withoutmovingtheupperarm,extendtheelbow,straighteningthearm.Extendtoacountoftwo;returntothestartingpositiontoacountoffour.Repeat eight to ten times, increasing repetitions as strength of the muscle

allows.Handweightsmaybeusedtoincreasetheworkeffortofthemuscle.

Stretchexercise:Tricepsbrachii

Brachialisandtriggerpoints

Brachialispainpattern

BRACHIALIS

Proximalattachment:Distalone-halfoftheshaftoftheanteriorhumerus.Distalattachment:Coronoidprocessoftheulna.Action:Flexionoftheforearmattheelbow.Palpation:Becauseofitsplacementontheanterioraspectsofthehumerusandulna,thebrachialisistheprimaryflexoroftheforearm.Tolocatebrachialis,identifythefollowingstructure:

Bicepsbrachii—Seemuscledescriptiononpage111.

Topalpatebrachialis,supinatethepatient’sarm.Flexthearmapproximately30degreesandmovethebulkofbicepsbrachiimedially,usingthepadsofthefingers.Pressdeeptothedisplacedbicepstopalpatebrachialisonthedistalone-thirdofthehumerus.Painpattern:Painandtendernessatthebaseofthethumb.Causativeorperpetuatingfactors:Liftingheavyobjectswithabentelbow.Satellitetriggerpoints:Brachioradialis,bicepsbrachii.Affectedorgansystems:Respiratoryandcardiovascularsystems.Associated zones, meridians, and points: Ventral zone; Hand Tai Yin Lungmeridian,HandJueYinPericardiummeridian,HandShaoYinHeartmeridian;LU5,PC3,HE3.Stretchexercise:Hyperextendthesupinatedarm,fullyextendingthehandandfingerstoincreasethestretchoftheforearm.Placementofthehandbesidetheseated body, with the palm down and fingers pointing back, will markedlyincreasethestretch.Holdthispositionforacountoftentofifteen.Strengtheningexercise:Standwiththearmsatthesides,palmsfacingoutward.Flex the forearms and, keeping the elbows close to the body, draw the palms

toward the shoulder. Slowly return to the starting position. Flex to a count oftwo;releasetoacountoffour.Repeat eight to ten times, increasing repetitions as strength allows. Hand

weightsmaybeusedtoincreasetheworkeffortplacedonthemuscle.

Stretchexercise:Brachialis

Brachioradialisandtriggerpoint

Brachioradialis(anterior)painpattern

Brachioradialis(posterior)painpattern

BRACHIORADIALIS

Proximal attachment: Lateral supracondylar ridge of the humerus and thelateralintermuscularseptumatthelevelofthemid-arm.Distalattachment:Styloidprocessoftheradius.Action:Flexionof theforearmat theelbow,expeciallywhenthearmis intheneutralposition;assistsresistedpronationandsupinationoftheforearm.Palpation:Brachioradialisisthemostsuperficialmuscleofthelateralaspectoftheforearm.Itgivestheupperforearmitscharacteristicshape.Tolocatebrachioradialis,identifythefollowingstructures:

Lateral supracondylar ridge of the humerus—The vertical ridge on thelateralaspectofthehumerusstartingjustabovethelateralepicondyleStyloidprocessoftheradius—Thelateral,distalendoftheradius

Tolocatebrachioradialis,flextheelbowagainstresistancewiththeforearmintheneutral(midprone)position—holdalightfistandpressupagainstthebottomof a tabletopusing the index finger/thumbpart of the fist.Thebrachioradialisbecomes clearly prominent. With the forearm in the neutral position, palpatebrachioradialisfromitsattachmentonthehumerus,throughthemusclebelly,toitstendinousattachmentonthestyloidprocessoftheradius.Painpattern:Painexperiencedat the lateralepicondyle through the lengthofthemuscletothewebofthethumbonthedorsalaspectofthehand.Thepainisoftendescribedas“tenniselbow”and isaccompaniedbyaweakorunreliablegrip.Causativeorperpetuatingfactors:Forcefulorrepetitivegrippingofalargeorwideobject.Satellitetriggerpoints:Handextensors.Affectedorgansystem:Respiratorysystem.

Associated zones, meridians, and points: Ventral zone; Hand Tai Yin Lungmeridian;LU4,5,and6.Stretchexercise:Withtheelbowstraightandthearmsupinated,fullyextendthewristandplacethehandinulnardeviation.Strengthening exercise: Stand with the arms at your sides, palms facingoutward.Flextheforearmsand,keepingtheelbowsclosetothebody,drawthepalmstowardtheshoulder.Slowlyreturntothestartingposition.Flextoacountoftwo;releasetoacountoffour.Repeat eight to ten times, increasing repetitions as strength allows. Hand

weightsmaybeusedtoincreasetheworkeffortplacedonthemuscle.

Stretchexercise:Brachioradialis

Handandfingerextensorsandtriggerpoints

HANDANDFINGEREXTENSORSEXTENSORCARPIRADIALISLONGUS,EXTENSORCARPIRADIALISBREVIS,EXTENSOR

DIGITORUM,EXTENSORDIGITIMINIMI,EXTENSORCARPIULNARIS1

Proximalattachment:Extensorcarpiradialislongus:lateralepicondyleofthehumerus via the common extensor tendon and the lateral supracondylar ridge.Extensor carpi radialis brevis: lateral epicondyle of the humerus via thecommon extensor tendon. Extensor digitorum: lateral epicondyle of thehumerus,intermuscularseptum,andantebrachialfascia.Extensordigitiminimi:lateral epicondyle of the humerus via the common extensor tendon.Extensorcarpi ulnaris: lateral epicondyle of the humerus via the common extensortendon,andtheproximalulna.Distal attachment: Extensor carpi radialis longus: base of the secondmetacarpal. Extensor carpi radialis brevis: base of the third metacarpal.Extensor digitorum: middle and distal phalanges of each of the four fingers.Extensordigitiminimi:middleanddistalphalangesofthelittlefinger.Extensorcarpiulnaris:baseofthefifthmetacarpal.Action:Extensor carpi radialis longus: extension and radial deviation of thehand.Extensorcarpiradialisbrevis:extensionofthehand.Extensordigitorum:extensionofthefourfingers.Extensordigitiminimi:extensionandabductionofthe little finger. Extensor carpi ulnaris: extension and ulnar deviation of thehand.Palpation:Eachof these superficialmusclesof thedorsal forearmcanharborconstrictionsthatmaybethesourceofmyofascialpain.Itisrecommendedthatareas of constriction be located using digital palpation along the dorsal(posterior) forearm, following the course of eachmuscle as itmoves from itsproximal position at the lateral epicondyle to the wrist and hand. In order toidentifyeachmuscle,movethehandandfingersthroughtheactionsperformedbyeachindividualmuscleasyoupalpate.Painpattern: Pain over the lateral epicondyle and the dorsumof the forearmandhandandpossiblythroughoutthefingers.Painmaybedescribedas“tennis

elbow” and may be accompanied by a weak or unreliable grip. Weakness ispronouncedwhenthehandisinulnardeviation.Causative orperpetuating factors: Repetitive or forceful handgrip; “writer’scramp.”

Handandfingerextensorspainpattern

Satellitetriggerpoints:Brachioradialis.Affectedorgansystem:Digestivesystem.Associatedzones,meridians,andpoints:Dorsalzone;HandTaiYangSmallIntestinemeridian,HandYangMingColonmeridian,Hand ShaoYangTripleWarmermeridian;SI6,7,and8;CO5–11;SJ4–10.Stretch exercise: Flex the wrist with the elbow fully extended. Whilemaintaining the extended elbow, place the dorsum of the hand on a table toincreasethestretch,orstabilizetheflexedhandusingtheoppositehand.

Strengtheningexercise:Formalightfistwhilemaintaininganeutralorslightlyflexedwristposition.Keepingtheelbowfullyextended,extendthewrist.Returntoaneutralposition.Repeateighttotentimes.Lighthandweightsmaybeusedtoincreasetheworkeffortofthehandextensors.

Stretchexercise:Handextensors

Handandfingerflexorsandtriggerpoints

HANDANDFINGERFLEXORSFLEXORCARPIRADIALIS,PALMARISLONGUS,FLEXORDIGITORUMSUPERFICIALIS,

FLEXORCARPIULNARIS1

Proximalattachment:Flexorcarpiradialis:medialepicondyleofthehumerusvia the common flexor tendon. Palmaris longus: medial epicondyle of thehumerusvia thecommonflexor tendon.Flexordigitorumsuperficialis:medialepicondyleofthehumerusviathecommonflexortendon,medialaspectofthecoronoidprocessoftheulna,andproximalone-halfoftheradius.Flexorcarpiulnaris:medial epicondyle of the humerus via the common flexor tendon andproximaltwo-thirdsoftheposteriorulna.Distalattachment:Flexorcarpiradialis: baseof the secondandpossibly thethird metacarpal. Palmaris longus: palmar aponeurosis. Flexor digitorumsuperficialis:middlephalangeofeachofthefourfingers.Flexorcarpiulnaris:pisiformbone.Action:Flexorcarpiradialis:flexionandradialdeviationofthehand.Palmarislongus:flexionofthehand.Flexordigitorumsuperficialis:flexionofthemiddlephalange of each of the four fingers.Flexor carpi ulnaris: flexion and ulnardeviationofthehand.Palpation: Each of the superficial muscles of the ventral forearm can harborconstrictions thatmaybe the sourceofmyofascialpain.Palpate thesemuscleswiththeforearmfullysupinatedandthehandandfingersextended.Locateareasof constriction using digital palpation along the ventral (anterior) forearm,following thecourseofeachmuscleas itmovesfromitsproximalpositiononthe forearm to thewrist andhand. In order to identify eachmuscle,move thehand and fingers through the actions performed by each individualmuscle asyoupalpate.Whileflexorcarpiradialis,palmarislongus,andflexorcarpiulnarismaybepalpated throughout theircourse, flexordigitorumsuperficialismaybepalpated in the distal one-third of the forearm, in between the tendons ofbrachioradialis and flexor carpi radialis on the radial side and between thetendonsofpalmarislongusandflexorcarpiulnarisontheulnarside.

Handandfingerflexorspainpattern

Pain pattern: Finger pain; possibly a “trigger finger,” in which theinterphalangeal joint locks inflexion;painwithrepetitiveforcefulorextensiveflexionofthehandandfingers;Palmarislongus:painradiatingintothecenterofthepalmofthehand.Causativeorperpetuatingfactors:Repetitiveorprolongedgripping,twisting,orpullingmovementsofthehandandfingers.Satellite trigger points: Each of the hand and finger flexors may developsatellitetriggerpointsinresponsetothepresenceoftriggerpointsinanyothermuscleofthegroup.Affectedorgansystems:Respiratoryandcardiovascularsystems.Associated zones, meridians, and points: Ventral zone; Hand Tai Yin Lungmeridian,HandJueYinPericardiummeridian,HandShaoYinHeartmeridian;LU5–9,HE3–7,PC3–7.

Stretch exercise: Slowly press the fingers and wrist into extension using theoppositehandorbypressingthepalmandfingersdownontoaflatsurfacewhilekeepingtheelbowstraight.Holdforacountoffivetoten.Strengtheningexercise:Formalightfistwhilemaintaininganeutralorslightlyextendedwristposition.Withtheelbowfullyextended,flexthewrist.Returntoaneutralposition.Repeat eight to ten times. Light handweightsmay be used to increase the

workeffortofthehandflexors.

Stretchexercise:Handandfingerflexors

Erectorspinaeandtriggerpoints

ERECTORSPINAEILIOCOSTALISTHORACIS,ILIOCOSTALISLUMBORUM,LONGISSIMUSTHORACIS,

SPINALIS

Of the three muscles identified as part the erector spinae group (iliocostalis,longissimus,andspinalis), iliocostalisandlongissimusareconsideredtobethemost clinically significant in most cases. The spinalis is the most mediallyplaced muscle of the group. It is generally poorly developed and has littleclinicalsignificance;itisthereforenotincludedinourdiscussion.Proximal attachment: Iliocostalis thoracis: angles of the upper six ribs.Iliocostalis lumborum: angles of the lowest six ribs. Longissimus thoracis:transverseprocessesofallthoracicvertebraeandadjacentribs.Distalattachment:Iliocostalisthoracis:anglesofthelowestsixorsevenribs.Iliocostalis lumborum and longissimus thoracis: via the shared lumbocostalaponeurosis of the erector spinae, attaching to the transverse processes of thelumbarvertebrae(L1–L5)andtothesacrum,iliaccrest,andspinousprocessesofthelumbarvertebrae.Action:Acting bilaterally: extension of the trunk. Acting unilaterally: lateralbending to the same side. The erector spinaemuscles contract stronglywhilecoughingorstrainingtohaveabowelmovement.Palpation:Theerectorspinaearethesuperficiallayeroftheparaspinalmuscles.Theyare considered the“true”backmusclesdue to theirworkofmaintainingpostureandtheirdirectactiononmovementofthevertebralcolumn.For the purpose of palpation, iliocostalis and longissimus should be

considered as one group. To locate iliocostalis and longissimus, identify thefollowingstructures:

SpinousprocessesofT1–T12Spinous processes of L1–L5. Note the change in shape and size of thelumbarspinousprocessesascomparedtothethoracicspinousprocesses.

SacrumIliaccrest—LyingonahorizontallinewiththejunctionofL4–L5

Topalpate theerector spinae,placeyourhandsparallel to the spine, fingerstogether, hands flat and relaxed, with your index fingers adjacent to but nottouching the spinousprocesses.With firmbutgentlepressure,palpate throughthe overlying trapezius and latissimus dorsi.Your handmovement follows thevertical course of fiber direction. As you move throughout the course of themuscle you may note cord-or ropelike consistency within areas of themusculature.Thisisacommonlyfoundindicatorofmyofascialconstriction.You may begin at either end of the spine, but palpate bilaterally and

throughoutthecourseofthemusculaturetoassesstheconditionofthecompletemusclegroup.Differentiatebetweenthesuperficialmusculatureandthedeepererectorspinaebynotingthedirectionof themusclefibers.Notethat itmaybedifficulttodifferentiatebetweeniliocostalisandlongissimus.Focusonthepalpationofiliocostalisthoracisbyassessingtheconditionofthe

mostlaterallyplacedverticalbandsofmusclelyinglateraltoT1–T12.Focusonthe palpation of iliocostalis lumborum by assessing the condition of themostlaterallyplacedverticalbandsofmusclelyinglateraltoT7–T12andextendingdownwardoverthelumbarregiontothesacrumandiliaccrests.Topalpatelongissimusthoracis,beginclosetothetransverseprocessesofthe

thoracic vertebrae and the adjacent ribs. Follow fiber direction to the lumbarregionwherethelumbocostalaponeurosisattachestothesacrumandiliaccrests.Withfocusedpalpation,trytodifferentiatebetweenthelaterallyplacedslipsofiliocostalisandthemoremediallyplacedslipsoflongissimus.Itmaybedifficulttodifferentiatethetwogroups.

Painpattern:Iliocostalis thoracis:pain in the thoracic regionof thebackandsometimes the abdomen, with restriction of spinal motion. Iliocostalislumborum: pain is referred downward, low in the buttock and along the iliaccrest.Longissimus thoracis: pain is referred low in the buttock.When triggerpointsare locatedbilaterallyat the levelofL1, thepatientwillhavedifficultyrisingfromachairand/orclimbingstairs.Causativeorperpetuatingfactors:Suddenoverloadthroughimproperlifting;sustained overload resultant from postural stresses (hyperlordosis); immobilityforextendedperiodsoftime.Satellitetriggerpoints:Eachmuscleof theerectorspinaegroupmaydevelopsatellitetriggerpointsinresponsetothepresenceoftriggerpointsinanyother

muscle of the group. Additional trigger points might also be found in thelatissimusdorsiandquadratuslumborummuscles.Affected organ systems: Due to the placement of the shu (chronic disease)points along this region, constrictionof regionsof thismusclemay reflect thecondition of the following organs. Iliocostalis thoracis: lung, stomach,gallbladder,liver,andspleen.Iliocostalislumborum:stomach,gallbladder,liver,spleen, kidney, and colon. Longissimus thoracis: lung, stomach, gallbladder,liver, spleen, kidney, and colon.We have observed constriction in thismusclebetweenT6andT12inpatientssufferingwithdiabetes.

Erectorspinaepainpattern

Associatedzones,meridians,andpoints:Dorsalzone;FootTaiYangBladdermeridian;Iliocostalisthoracis:BL11–21,BL41–50;Iliocostalislumborum:BL16–26,BL45–52;Longissimusthoracis:BL11–25,BL41–52.Stretchexercises:

1. Seatedforwardstretch:Sitcomfortablyonachairwiththefeetplacedflaton the floor. Fold the torso toward the floor, reaching forward and downwiththearms.Allowyourheadandnecktohangloosely.Holdthispositionforacountoftwentytothirty.Returntotheseatedpositionslowly.

2. Pelvictilts:Liesupine.Bendtheknees,placingthesolesofthefeetonthefloor.Exhaleandslowlydropthelumbarcurveofthebacktowardthefloor.Holdforacountoffive,thenrelease.Repeatseveraltimes.Becertainthatthedropofthelumbararchoccursasaresultoftherelaxationofthebackmuscles, not from an anterior tilt of the lower pelvis brought on bycontractingtheglutealmuscles.

3. Cats:Positionthebodyonthehandsandknees.Archtheback,liftingboththeheadandthebuttockstowardtheceiling.Holdforacountoffive.Thenroundtheback,aimingboththeheadandthecoccyxforthefloor.Holdforacountoffive.Alternatethesetwopositionsthreetofourtimes.

Strengtheningexercise:Lieprone,withthehandsclaspedbehindthehead.Lifttheupperportionof thebodyfromthefloor,makingsure tokeepthebuttocksandlegsrelaxed.Holdforacountofonetothree.Repeat twoor three times, increasingfrequencyanddurationas thestrength

ofthebackincreases.

Stretchexercise1:Erectorspinae

Stretchexercise2:Erectorspinae

Stretchexercise3:Erectorspinae

Quadratuslumborumandtriggerpoints

QUADRATUSLUMBORUM

Proximal attachment: Medial one-half of the twelfth rib and the transverseprocessesofL1–L4.Distalattachment:Uppermostposterioraspectofthecrestoftheilium.Action:Actingunilaterally: stabilizes the lumbarspine in theuprightposition;laterallyflexesthelumbarspine;actsasahiphiker.Actingbilaterally:extendsthelumbarspine;actsinforcedexhalation,asmightoccurincoughing;fixesthetwelfthrib,facilitatingcontractionofthediaphragm.Palpation:Quadratuslumborumisoneofthemusclesmostcommonlyinvolvedinlowerbackpain,yetitiscommonlyoverlookedasasource.Tolocatequadratuslumborum,identifythefollowingstructures:

Rib12—Thebottommostor“floating”ribistheshortestofthetwelveribs.Locate its freeanteriorborderposterior to themidaxillary line, levelwiththevertebralbodyofL2.TransverseprocessesofL1–L5Iliaccrests—LyingonahorizontallinewiththejunctionofL4–L5

Palpatequadratuslumborumwiththepatientlyingprone.Gentlydepresstheareabetweentheiliaccrestandthetwelfthribthroughthesoftlateralaspectofthetorso,pressingmediallyandobliquelytowardthetransverseprocessesofthelumbarvertebrae (notsagitally into thebody). Image the locationofquadratuslumborum.Asyoudosoyourhandwillencounterthelateralbandsofquadratuslumborum.Pain pattern: Superficial trigger points refer pain to the lateral border of theiliaccrestandoverthegreatertrochanter.Deeptriggerpointsreferpainovertheregion of the sacroiliac joint and deep within the center of the buttock. Thepatientmaybeunable tobearstandinguprightorwalkingdue todeep,achinglow back pain. Inability to turn over in bedwithout pain. Trigger pointsmay

produceanapparentleg-lengthdiscrepancy.Causative or perpetuating factors: Overload stress of simultaneous bendingand lifting; awkward lifting of heavy objects; sustained and repetitive strain;suddenleg-lengthdiscrepancyasmightoccurwiththeuseofananklecast.

Quadratuslumborumpainpattern

Satellite trigger points: Gluteus minimus, gluteus medius, thoracolumbarparaspinals,piriformis.Affectedorgansystem:Kidney/genitourinarysystem.Associatedzones,meridians,andpoints:Dorsalzone;FootTaiYangBladdermeridian,BL21–24,BL51and52.Stretchexercises:1. Lyingsupinewiththefeetonthefloorandthekneesbent,crossthelegon

theunaffectedsideover the legon theaffectedside.Use theupper leg to

gently pull the lower leg toward the floor.Hold for a count of fifteen totwenty.

2. Standwiththebackapproximately12inchesawayfromawall.Twist theupperbodytoplacebothpalmsonthewall.Holdforacountoffifteentotwenty.

3. Cross the affected leg behind the unaffected leg, shifting your weighttowardtheaffectedhip.Reachbotharmsabovethehead,graspingthewristof the homolateral arm with the opposite hand. Laterally bend the torsotowardtheunaffectedside.Holdthispositionforacountoftentofifteen.

Strengthening exercise: Because quadratus lumborum is a postural muscle,strengtheningexercisesaregenerallynotnecessary.

Stretchexercise1:Quadratuslumborum

Stretchexercise2:Quadratuslumborum

Stretchexercise3:Quadratuslumborum

Iliopsoasandtriggerpoints

ILIOPSOAS

Proximal attachment: Anterior bodies and intervertebral discs of T12–L5;uppertwo-thirdsoftheiliacfossa.Distalattachment:Lessertrochanterofthefemur.Action:Flexionofthethighatthehipwhenthetorsoisfixed;flexionofthehipon the thighwhen the thigh is fixed; assists in extension of the lumbar spine(increasinglordosis)inthestandingposition.Palpation: Iliopsoas is comprised of three muscles: iliacus, psoas major, andpsoasminor.Thesearemusclesof theposteriorabdominalwall.Together theyactas thestrongest flexorof the thighat thehip.Thedepthatwhich iliopsoasliesmakesitextremelydifficulttopalpatethesemusclesthroughouttheircourse,however a small portion of the attachment onto the lesser trochanter may bepalpable.Tolocateiliopsoas,identifythefollowingstructures:

Anterior superior iliac spine (ASIS)—Anterior bony projection lyingsomewhat below the iliac crest, readily palpable.TheASIS serves as theproximalattachmentoftheinguinalligament.Rectusabdominis—Seemuscledescriptiononpage143.Femoral triangle—Bounded superiorly by the inguinal ligament,mediallybyadductor longus(seemuscledescriptiononpage181),andlaterallybysartorius (seemuscle description on page 191). The floor of the femoraltriangle is formedmediallybypectiniusand laterallyby iliopsoas.Withinthis triangle the femoral pulse can be palpated 2 to 3 centimeters(approximately1 inch) inferior to the inguinal ligament,at themidlineofthebaseof the triangle that it forms.Both the femoralarteryandfemorallymphglandsliesuperficialtoiliopsoasandpectinius,whichthemselvesliesuperficial to the hip joint. The femoral artery lies just superficial to theheadofthefemur.Thepulsepointofthefemoralarterycanbepalpatedjust

superficialtotheheadofthefemur,inferiortothemidpointoftheinguinalligament.

Imagetheplacementofiliopsoasdeepwithintheabdomen,lyingjust lateraltothevertebralbodiesofT12–L5,passingtotheinneraspectsoftheilium,andattachingtothelessertrochanterofthefemur.Topalpatethemostdistalfibersofiliopsoas, abduct the thigh, flexing the lower leg. Locate the femoral triangle.Palpate iliopsoas at the lateral aspect of the floor of the triangle, medial tosartoriusandslightlydistaltotheinguinalligament.Due to the sagittal depth of thismuscle, success in palpating and treating a

constrictediliopsoasissomewhatelusive.However,wehavefoundthatmarkedchangesoftheiliopsoascanbeobtainedbyaffectingtheiliopsoasfasciaatthelateralone-halfoftheinguinalligament.Byusingacupunctureneedlingordirectdigitalpressureclosetothedistalportionoftheattachmentsofthesemusclesatthe ASIS and the lateral aspect of the inguinal ligament, the homolateraliliopsoascanbesignificantlyreleased.Releases of constriction in the upper fibers of iliopsoas can be obtained

throughtheapplicationofpressureorneedlingtechniquesthroughtheabdomen,at the level of the navel, lateral to the border of rectus abdominis. Pressureshouldbeappliedmediallyandobliquelytowardthemidline.

Iliopsoas(anterior)painpattern

Iliopsoas(posterior)painpattern

Pain pattern: Vertical pain that is worsened byweight-bearing activities andrelieved by rest; relief is greatest when the hip is flexed. Upper trigger pointrefersunilaterallyonthesideofthetriggerpointwithpain,extendingfromT12to the iliumandupperbuttock; lower triggerpointsreferpain to thegroinandthe anterior aspect of the upper thigh. Symptomsmay include the inability tostandupright.Causativeorperpetuating factors: Sitting for extended periods of timewiththehipsacutelyflexed.Satellite triggerpoints:Quadratus lumborum, rectus abdominis, tensor fascialatae, gluteus maximus, gluteus medius, gluteus minimus, thoracolumbarparaspinals,piriformis.Affectedorgansystems:Genitourinaryanddigestivesystems.Associated zones, meridians, and points: Ventral zone; Foot Yang Ming

Stomachmeridian,FootShaoYangGallBladdermeridian;ST25,GB27and28.Stretchexercises:1. Lyingona tableorbed,abduct the thighand legof theaffectedsideand

allowthelimbtohangoffthesideofthetableorbed.Flexthethighandlegoftheunaffectedsidetofixthepelvis,keepingthelumbarspineflatonthetableorbed.Allowgravitytostretchtheuppergroinarea.Holdforacountoftwentytothirty.

2. Cobra:Lyingprone,placethehandspalmsdownat thelevelof thechest.Raisetheupperbody,supportingitwiththeweightonthearms.Archtheheadandnecktowardtheceiling,keepingthehips,legs,andfeetrelaxedonthefloor.Holdforacountoftwentytothirty.Releasethestretchbyrelaxingthearms,bendingtheelbowstosupportthe upper bodyweight, and slowly bringing the body down to the proneposition.

Strengtheningexercise:Leglifts:Lieonthefloorinthesupineposition.Placethe hands, palms down, under the buttocks, reducing the lumbar arch andbringing it into contactwith the floor. (It is essential tomake certain that thelumbar region remains in contactwith the floor in order to reduce the risk ofinjury to the back in this exercise.) From this position, raise the legs, kneesslightly bent, approximately 12 inches and then return them to the startingposition.Repeateighttotentimes.

Stretchexercise1:Iliopsoas

Stretchexercise2:Iliopsoas

Rectusabdominisandtriggerpoints

RECTUSABDOMINIS

Proximalattachment:Cartilagesofribs5,6,and7;xiphoidprocess.Distalattachment:Crestofthepubicbone.Action:Flexionofthetrunk;upwardrotationofthepelvis.Palpation:The abdominalmuscles forma continuous sheathwithinwhich liethe abdominal viscera. This sheath is bounded superiorly by the diaphragm;posteriorlybythepsoas;posterolaterallybyquadratuslumborum;anterolaterallybytransversusabdominis,internaloblique,andexternaloblique(movingdeeptosuperficial);andanteriorlybyrectusabdominis.Themusclesofthepelvicfloorformtheinferiorboundaryofthissheath.By and large, rectus abdominis and the other abdominalmuscles—external

oblique,internaloblique,andtransversusabdominis—aredifficulttodistinguishfromoneanotherunlessoneisinastateofcontractionorharborstautbands.Forthepurposesofthetreatmentofmyofascialconstrictionswithinthisgroupit isrecommendedthat thepatient’sexperienceofpainbetheguidethatdirectsthepractitioner’shandstotheareasthatmayharborconstrictions.Thatis,palpationshouldbeginwherethepatientdescribeshispainordiscomforttobe.Palpationshouldbegentleenoughtoexaminetheabdominalmusculaturewithoutforcingthroughittotheunderlyingviscera.Tolocaterectusabdominis,identifythefollowingstructures:

XiphoidprocessCartilagesofribs5,6,and7CrestofthepubicboneLinea alba (white line)—Tendinous union of the bilateral aponeuroses oftheexternaloblique, internaloblique, and transversusabdominismuscles,lyingdeeptotheskininthemidlineofthetorso

Palpaterectusabdominisfromtheproximalattachmentatthecostalcartilages

to thedistal attachment at thepubicbone, following thevertical courseof themusclefibers.Placethehands,flatandrelaxed,ontheabdomen,withthefingerslying parallel to the direction of rectus abdominis; note the linea alba in themidline. The lateral boundary of the rectus abdominis is readily palpable inmuscularly developed people. Note the segments into which the rectusabdominis is divided. Palpate rectus abdominis throughout its course for tautbands.

Rectusabdominis(anterior)painpattern

Rectusabdominis(posterior)painpattern

Pain pattern: Trigger points within the proximal aspect of the muscle mayproduce bilateral midback pain; trigger points within the distal aspect mayproduce horizontal low back pain as well as unilateral pain in the lowerabdomen. Symptoms include heartburn, the sensation of abdominal fullness,indigestion, vomiting, and nausea; periumbilical involvement producesabdominal cramping. Lower trigger point involvement may result indysmenorrhea.Causativeorperpetuatingfactors:Acuteorchronicoverloadstrain;muscularoveruse;visceraldisease;abdominalsurgicalscars;paradoxicalbreathing;poorposture.Satellite trigger points: External oblique, internal oblique, transversusabdominis, iliocostalis thoracis, iliocostalis lumborum, longissimus thoracis,iliopsoas.Affectedorgansystems:Digestiveandgenitourinarysystems.

Associated zones, meridians, and points: Ventral zone; Foot Yang MingStomachmeridian,FootShaoYinKidneymeridian;ST19–30,KI11–21.Stretchexercise:Cobra:Lyingprone,placethehandspalmsdownatthelevelof the chest.Raise theupper body, supporting itwith theweight on the arms.Arch the head and neck toward the ceiling, keeping the hips, legs, and feetrelaxedonthefloor.Holdforacountoffifteentotwenty.Releasethestretchbyrelaxing the arms, bending the elbows to support the upper body weight andslowlybringingthebodydowntotheproneposition.Strengtheningexercises:1. Rolldowns:Beginintheseatedpositionwiththelegsextendedinfrontof

you. Bend the knees, placing the soles of the feet on the floor. Inhale.Exhale, dropping the chin to the chest, rounding the lumbar spine, andslowlyrollingbackwardtowardthefloor.Firstthelumbarspinetouchesthefloor,thenthethoracicspine,thentheupperback,thenthehead.Ifneedbeyoucancontrol thebackwardmovementofyourweightbyholdingon toyourlegsasyourollback.Greaterstresswillbeplacedontheabdominalmusclesthemoreslowlyyourolldown.Reversetheexercisetorollup.

2. Abdominalcrunches:Lyinginthesupinepositionbendtheknees,placingthesolesofthefeetonthefloor.Claspthehandsbehindtheheadorcrossthearmsonthechest.Inhaledeeply.Exhale,focusingontouchingthenavelto the spine, and roll up by bringing the chin to chest, raising the upperbody,andliftingthescapulaeoffthefloor.Slowlyrolldowntothestartingposition. Repeat three to five times, increasing repetitions as strengthallows.

Stretchexercise:Rectusabdominis

Abdominals(externaloblique)andtriggerpoints

Abdominals(internaloblique)andtriggerpoints

ABDOMINALSEXTERNALOBLIQUE,INTERNALOBLIQUE,TRANSVERSUSABDOMINIS

Proximal attachment: External oblique: six lower ribs. Internal oblique:iliopsoasfasciaadjacenttothelateralone-halfoftheinguinalligament,anterioriliaccrest,spinousandtransverseprocessesofthefivelumbarvertebraeviathethoracolumbar fascia, cartilages of ribs 9–12. Transversus abdominis: lumbarvertebrae via the thoracolumbar aponeurosis, the lower six ribs, anterior iliaccrest,iliopsoasfasciaadjacenttothelateralaspectoftheinguinalligament.Distalattachment:Externaloblique: lineaalbavia anabdominal aponeurosisforming the anterior rectus sheath (passing superficial to rectus abdominis),anterior iliac crest, pubis. Internal oblique: linea alba via the abdominalaponeurosis forming the anterior rectus sheath (passing superficial to rectusabdominis).Transversus abdominis: linea alba via the abdominal aponeurosisformingtheposteriorrectussheath(passingdeeptorectusabdominis),pubis.Action:Compressionoftheabdomen.Externaloblique:rotationofthetrunktotheoppositeside.Lateralflexionofthetrunktothesamesidewhenactingwiththehomolateralinternaloblique.Internaloblique:lateralflexionandrotationofthetrunktothesamesidewhenactingwiththecontralateralexternaloblique.Palpation:Forgeneralinstructiononpalpatingtheabdominalmuscles,seepage143.To locate external oblique, internal oblique, and transversus abdominis,

identifythefollowingstructures:Ribs7–12AnterioraspectoftheiliaccrestPubicboneLinea alba (white line)—Tendinous union of the bilateral aponeuroses ofthe external oblique, internal oblique, and transversus abdominis, lyingdeeptotheskininthemidlineofthetorso

Palpateexternalobliqueonthelateralaspectofthetorso.Notethatitsfibersrun obliquely down andmedially.Begin palpation on the lateral aspect of the

lowerribcage,placingyourhandsalongthefiberdirectionofthemuscle.Handmovement will move downward andmedial to the iliac crest and toward thepubic bone. Palpation must be gentle enough to examine the musculaturewithoutforcingthroughittotheunderlyingviscera.Itmaybedifficulttodistinguishexternalobliquefromtheunderlyinginternal

oblique and transversus abdominis; however, the right external oblique can bepalpatedwhenrotation to the left is resistedandviceversa.Ask thepatient torotatehis right shoulder towardhis left hip.Resist thismotionat the shoulderwhileplacingthepalpatinghandproximaltotheiliaccrest.Externalobliquecanbepalpatedasitcontractstoperformthismovement.Palpateinternalobliquethroughtheoverlyingexternalobliqueonthelateral

aspectofthetorso.Notethatitsfibersrunobliquelyupwardandlateral.Beginpalpationon the lateralaspectof the lower ribcage,palpating toward the iliaccrestandtheinguinalligament.Itmaybedifficulttodistinguishinternalobliquefrom the overlying external oblique; however, the left internal oblique can bepalpatedwhenrotation to the left is resistedandviceversa.Ask thepatient torotatehis right shoulder towardhis left hip.Resist thismotionat the shoulderwhileplacingthepalpatinghandproximaltotheiliaccrest.Internalobliquecanbepalpatedasitcontractstoperformthismovement.Transversusabdominis isobscured topalpationdue to itsplacementdeep to

externalobliqueandinternaloblique.Painpattern:Externaloblique:Heartburn,epigastricpain,flankpain,groinandtesticularpainwhentriggerpointsarepresentinbothtransversusabdominisandinternal oblique. Visceral dysfunction represents considerable symptomologyassociatedwithtriggerpointsintheinternalobliqueandtransversusabdominis,making pictorial representation of pain patterns unnecessary. Internal oblique:Symptomsareirritabilityandspasmoftheurinarysphincter,leadingtourinaryfrequency,retentionofurine,andgroinpain.Transversusabdominis:Symptomsaregroinandtesticularpainwhentriggerpointsarepresentinexternalobliqueandinternaloblique.Causativeorperpetuatingfactors:Acuteorchronicoverloadstrain;muscularoveruse;abdominalsurgicalscars;visceraldisease;paradoxicalbreathing;poorposture;sustainedorvigoroustwistingofthetorso.Satellite triggerpoints: Each abdominalmusclemay develop satellite triggerpointsinresponsetothepresenceoftriggerpointsinothermusclesofthegroup.Additional trigger points might also be found in the iliopsoas, iliocostalisthoracis,andlongissimusthoracis.

Affectedorgansystems:Digestive,genitourinary,andreproductivesystems.Associatedzones,meridians,andpoints:Ventralandlateralzones;FootYangMingStomachmeridian,FootShaoYangGallBladdermeridian,FootJueYinLivermeridian,FootTaiYinSpleenmeridian;SP14,15,and16;LIV13;GB25–28.

Abdominalspainpattern

Stretchexercises:1. Cobra:Lyingprone,placethehandspalmsdownat thelevelof thechest.

Raisetheupperbody,supportingitwiththeweightonthearms.Archtheheadandnecktowardtheceiling,keepingthehips,legs,andfeetrelaxedonthe floor.Release the stretchby relaxing thearms,bending theelbows tosupport theupperbodyweight,andslowlybringingthebodydowntotheproneposition.

2. Standwiththebackapproximately12inchesawayfromawall.Twist the

upperbodyandplacebothpalmsonthewall.Holdforacountoffifteentotwenty. Note: To stretch the right external oblique the patient must turntowardtheright;tostretchtherightinternaloblique,thepatientmustturntowardtheleft.

Strengtheningexercises:Transversecrunches:Lyinginthesupineposition,bendthekneesandplacethesolesofthefeetonthefloor.Claspthehandsbehindtheheadorcrossthearmsonthechest.Inhaledeeply.Exhale,focusingontouchingthenaveltothespine,androllupbybringingthechintochest,raisingtheupperbody,andliftingthescapulaeoffthefloor.Twistthebody,aimingtherightshoulderforthelefthip.Slowlyrolldowntothestartingposition.Repeattheexercise, thistimeaimingtheleftshoulderfortherighthip.Repeattheset(left/right)threetofivetimes,increasingrepetitionsasstrength

allows.For strengthening theabdominalsasagroup,youcanalsodo the following

twoexercises.1. Rolldowns:Beginintheseatedpositionwiththelegsextendedinfrontof

you. Bend the knees, placing the soles of the feet on the floor. Inhale.Exhale, dropping the chin to the chest, rounding the lumbar spine, andslowlyrollingbackwardtowardthefloor.Firstthelumbarspinetouchesthefloor,thenthethoracicspine,thentheupperback,thenthehead.Ifneedbeyoucancontrol thebackwardmovementofyourweightbyholdingon toyourlegsasyourollback.Greaterstresswillbeplacedontheabdominalmusclesthemoreslowlyyourolldown.Reversetheexercisetorollup.

2. Abdominalcrunches:Lyinginthesupinepositionbendtheknees,placingthesolesofthefeetonthefloor.Claspthehandsbehindtheheadorcrossthearmsonthechest.Inhaledeeply.Exhale,focusingontouchingthenavelto the spine, and roll up by bringing the chin to chest, raising the upperbody,andliftingthescapulaeoffthefloor.Slowlyrolldowntothestartingposition. Repeat three to five times, increasing repetitions as strengthallows.

Stretchexercise1:Abdominals

Stretchexercise2:Abdominals

Gluteusmaximusandtriggerpoints

GLUTEUSMAXIMUS

Proximalattachment:Posterioriliaccrest,lateralsacrum,andcoccyx.Distalattachment:Iliotibialbandofthefasciaelataeandtheglutealtuberosityofthefemur.Action: Powerful extension of the thigh at the hip during strenuous activitiessuchas running, jumping, stair climbing, and in rising froma seatedposition;helps maintain an erect posture; assists in lateral rotation of the hip. Upperfibers:abductionofthethigh.Lowerfibers:adductionofthethigh.Palpation:Tolocategluteusmaximus,identifythefollowingstructures:

Posterior superior iliac spine (PSIS)—Bonyprominence lyingdeep to thecharacteristic dimples above the buttocks. The PSIS lie horizontal to thesecondsacralsegment.Eachisapproximately2centimeters( )belowthesuperiorborderofthesacrum.Iliaccrest—LyingonahorizontallinewiththejunctionofL4–L5.SacrumCoccyxGreater trochanter—Bony prominence on the lateral aspect of the femur,approximately one hand-length below the iliac crest. From the anteriorplanethegreatertrochanterlieshorizontalwiththepubiccrest.Ischial tuberosity—Easily palpable when seated, this bony prominencecarriesmostoftheweightofthetorsointheseatedposition.Itislocatedatthecenterofthebuttock,approximatelylevelwiththeglutealfold.

To locate gluteus maximus, approximate its borders as follows: image itssuperiorborderbyvisualizingalinedrawnfromthePSIStoslightlyabovethegreatertrochanter;imageitsinferiorborderbyvisualizingalinedrawnfromthecoccyxtotheischialtuberosity.Topalpategluteusmaximus,followthedirectionofmuscle fibersobliquelyand laterally,moving from the lateralmarginof the

sacrumtothegreatertrochanter.

Gluteusmaximuspainpattern

Painpattern:Medial triggerpoints, locatedadjacent to thesacrum, referpainbeside the gluteal cleft, including the sacroiliac joint. Distal trigger points,locatedabovetheischialtuberosity,referpainthroughoutthebuttock,includingtenderness deep within the buttock. Symptoms include local pain fromprolongedsittingand increasedpainwhenwalkinguphill ina forward-leaningposition.Causativeorperpetuatingfactors:Stressoverloador impact from traumaorfall;prolongedwalkinginaforward-leaningposition;injection.Satellite trigger points: Posterior gluteus medius, posterior gluteus minimus,hamstrings,iliopsoas,rectusfemoris.Affectedorgansystem:Eliminationaspectofthedigestivesystem;colon.

Associated zones,meridians, and points: Dorsal and lateral zones; Foot TaiYangBladdermeridian,FootShaoYangGallBladdermeridian;BL26–30,35and36,53and54,GB30.Stretchexercise:Lyingsupine,drawthekneetowardthehomolateralshoulder,grasping the posterior thigh; pull the thigh and leg toward the shoulder,stretchingthegluteusmaximus.Holdforacountoftentofifteen.Release.Thendraw theknee toward theopposite shoulder.Hold for a countof ten to fifteenandrelease.Strengtheningexercise:Posteriorpulseswithabentknee:Flex the legof theaffected side.Contract thegluteusmaximus to extend the thigh.Repeat ten totwelvetimes.Patientpositioningwilldetermine thedegreeofstressplacedon themuscle.

PhaseI(patientintheweakestcondition):Instructthepatienttodothisexerciseinthestandingposition,supportinghisbalancebyholdingontoawallorchair.PhaseII:Patientcanbepositionedside-lying,workingtheglutealmuscleoftheupper leg.PhaseIII:Patientcanbepositionedonhishandsandknees.Pulseswillbeworkingagainstgravityandwillrequirethemostforce.

Stretchexercise:Gluteusmaximus(kneetohomolateralshoulder)

Stretchexercise:Gluteusmaximus(kneetooppositeshoulder)

Gluteusmediusandtriggerpoints

GLUTEUSMEDIUS

Proximalattachment:Anteriorthree-quartersoftheiliaccrest.Distalattachment:Greatertrochanterofthefemur.Action:Abductionofthethigh;assistsinmedialrotationofthethigh.Anteriorfibersflexandinternallyrotatethethigh;posteriorfibersextendandexternallyrotatethethigh.Stabilizesthepelvisduringambulation.Palpation:Theposteriorportionof thismuscle liesdeep togluteusmaximus;theanteriorportionliesanteriortogluteusmaximusandissuperficial.Portionsofthismuscleliebothanteriorandposteriortothehipjoint.Gluteusmediusisafrequentlyoverlookedsourceofbackpain.Tolocategluteusmedius,identifythefollowingstructures:

Iliaccrest—LyingonahorizontallinewiththejunctionofL4–L5.Greater trochanter—Bony prominence on the lateral aspect of the femur,approximately one hand-length below the iliac crest. From the anteriorplanethegreatertrochanterlieshorizontalwiththepubiccrest.Anterior superior iliac spine (ASIS)—Anterior bony projection lyingsomewhat below the iliac crest, readily palpable.TheASIS serves as theproximalattachmentfortheinguinalligament.Piriformisline—Animaginarylinedrawnfromthesecondsacralsegment(justmedialtotheposteriorsuperioriliacspine[PSIS])totheupperborderof the greater trochanter. This line represents the superior border of thepiriformismuscleandtheposteriorborderofthegluteusmediusmuscle.

Palpategluteusmediuswiththepatientpositionedeitherproneorside-lying.Palpatewithflatdigitalpressurejustdistaltotheiliaccrest,followingitscourseon either side of the hip joint.Areas of constriction of gluteusmedius can bepalpatedthroughoutthecourseoftheexternalilium.

Gluteusmediuspainpattern

Pain pattern: Medial trigger points refer pain to the crest of the ilium, thesacroiliac joint,and thesacrum.Lateral triggerpoints referpain to thebuttockandpossiblytheupper lateralposterior thigh.Anterior triggerpointsmayreferbilaterallyoverthesacrumandthelowerlumbarregion.Symptomsincludepainwhenwalking,whenlyingonthebackorontheaffectedside,andwhensittingslouchedinachair.Causativeorperpetuatingfactors:Overuseinjuries;suddenoverload;chronicoverloadduetoprolongedflexionofthehip;leg-lengthdiscrepancies;sacroiliacjointdysfunction.Satellite trigger points: Quadratus lumborum, gluteus minimus, piriformis,tensorfasciaelatae.Affectedorgansystem:Genitourinarysystem.Associatedzones,meridians,andpoints:Lateral zone;FootShaoYangGall

Bladdermeridian;GB29and30.Stretchexercises:1. Cross the affected leg behind the unaffected leg, shifting your weight

towardtheaffectedhip.Reachbotharmsabovethehead,graspingthewristof the homolateral arm with the opposite hand. Laterally bend the torsotowardtheunaffectedside.Holdthispositionforacountoftentofifteen.

2. Supportyourbalancebyholdingontoawallortable.Crosstheaffectedlegbehindtheunaffectedleg.Bendthekneeoftheunaffectedlegasyouslidetheaffectedlegawayfromthetorso, towardtheoppositeside,aimingthehipforthefloor.Holdthispositionforacountoftentofifteen.

Strengtheningexercise:Positionedon thehandsandknees, shiftyourweightonto one knee, allowing freedom of motion of the working thigh and leg.Keepingthekneeoftheworkinglegbent,abductthelegtobringtheinnerthighparallelwiththefloor.Returnthelegtothestartingposition.Repeatfivetotentimes.Walkingisoneofthebestexercisesforthismuscle.

Stretchexercise1:Gluteusmedius

Stretchexercise2:Gluteusmedius

Gluteusminimusandtriggerpoints

GLUTEUSMINIMUS

Proximalattachment:On the ilium, between the anterior and inferior gluteallines,deeptogluteusmedius.Distalattachment:Upperaspectofthegreatertrochanterofthefemur.Action: Abduction of the thigh; internal rotation of the thigh. Stabilizes thepelvisduringambulation.Palpation:Gluteusminimus,thesmallestofthethreeglutealmuscles,liesdeepto gluteus medius and tensor fasciae latae. The fiber arrangements of gluteusmedius and gluteus minimus are quite similar; consequently, their actions,stretches,andstrengtheningexercisesareverymuchthesame.Tolocategluteusmiminus,identifythefollowingstructures:

Iliaccrest—LyingonahorizontallinewiththejunctionofL4–L5.Anterior superior iliac spine (ASIS)—Anterior bony projection lyingsomewhat below the iliac crest, readily palpable.TheASIS serves as theproximalattachmentoftheinguinalligament.Gluteusmedius—Seemuscledescriptiononpage157.Tensorfasciaelatae—Seemuscledescriptiononpage165.Piriformisline—Animaginarylinedrawnfromthesecondsacralsegment(justmedialtotheposteriorsuperioriliacspine[PSIS])totheupperborderof the greater trochanter. This line represents the superior border of thepiriformis muscle and the lower posterior border of the gluteus mediusmuscle.

Tolocatetheanteriorfibersofgluteusminimus,beginwiththepatientlyingin the supine position. Palpate just distal and lateral to the ASIS, palpatingdeeplyboth anterior to andposterior to the tensor fasciae latae.Taut bandsofconstrictedmusclelyingdeeptothesuperficialmusculaturemaybeencounteredwithdeeppalpation.

Tolocatetheposteriorfibersofgluteusminimus,beginwiththepatientlyingprone. Taut bands of constrictedmuscle may be palpated deep to the gluteusmediusjustsuperiorandlateraltothemidpointofthepiriformisline.Althoughpalpatingdeeply,itisessentialtousecautiontoavoidcausingunduepaintothepatientorinjurytothesuperficialmusculature.

Gluteusminimus(lateral)painpattern

Gluteusminimus(posterior)painpattern

Painpattern:Anterior triggerpoints referpain to the lower lateralpartof thebuttock,thelateralaspectofthethighandknee,andthelateralaspectofthelegas far as the ankle; posterior trigger points refer to the buttock, the posteriorthigh and calf, and sometimes to the back of the knee. Symptoms include hippainthatmaycausealimpduringwalking;painwhilelyingonthesameside;painuponrisingfromachair;painwhilestandingstraightorstandingstill.Thepain pattern displayed by this muscle when it harbors trigger points closelyresembleswhatiscommonlyreferredtoassciatica.Causative or perpetuating factors: Sudden, acute, or chronic repetitiveoverload;sacroiliacjointdysfunction;gaitdistortion;leg-lengthdiscrepancies.Satellite triggerpoints: Piriformis, gluteusmedius, vastus lateralis, quadratuslumborum,gluteusmaximus.Affectedorgansystem:Genitourinarysystem.

Associatedzones,meridians,andpoints:Lateral zone;FootShaoYangGallBladdermeridian;GB29and30.Stretchexercises:1. Cross the affected leg behind the unaffected leg, shifting your weight

towardtheaffectedhip.Reachbotharmsabovethehead,graspingthewristof the homolateral arm with the opposite hand. Laterally bend the torsotowardtheunaffectedside.Holdthispositionforacountoftentofifteen.

2. Supportyourbalancebyholdingontoawallortable.Crosstheaffectedlegbehindtheunaffectedleg.Bendthekneeoftheunaffectedlegasyouslidetheaffectedlegawayfromthetorso, towardtheoppositeside,aimingthehipforthefloor.Holdthispositionforacountoftentofifteen.

Strengtheningexercise:Positionedon thehandsandknees, shiftyourweightonto one knee, allowing freedom of motion of the working thigh and leg.Keepingthekneeoftheworkinglegbent,abductthelegtobringtheinnerthighparallelwiththefloor.Returnthelegtothestartingposition.Repeatfivetotentimes.Walkingisoneofthebestexercisesforthismuscle.

Stretchexercise1:Gluteusminimus

Stretchexercise2:Gluteusminimus

Tensorfasciaelataeandtriggerpoint

TENSORFASCIAELATAE

Proximalattachment:Anterioriliaccrest,justposteriortotheanteriorsuperioriliacspine(ASIS).Distalattachment:Throughtheiliotibialbandtothelateralcondyleofthetibia.Action: Assists flexion, abduction, and internal rotation of the thigh; helpsstabilize the knee.Aids gluteusmedius andgluteusminimus in stabilizing thepelvisduringwalking.Palpation:Tolocatetensorfasciaelatae,identifythefollowingstructures:

Anterior superior iliac spine (ASIS)—Anterior bony projection lyingsomewhat below the iliac crest, readily palpable.TheASIS serves as theproximalattachmentoftheinguinalligament.Greater trochanter—Bony prominence on the lateral aspect of the femur,approximately one hand-length below the iliac crest. From the anteriorplanethegreatertrochanterlieshorizontalwiththepubiccrest.Iliotibialband—Along,thin,flatbandoffascialyingontheoutersurfaceof the thigh. The iliotibial band is a thickening of the normal fascia thatsurrounds the thigh; its distal end inserts onto the lateral condyle of thetibia.Theinsertionontothelateralcondylecanbepalpatedanteriortotheinsertionofthebicepsfemoristendon(seemuscledescriptiononpage173).Theiliotibialbandcanbepalpatedintheseatedpositionbyraisingtheheelofyourfootoffthefloorwhilekeepingyourkneeflexed.

To locate tensor fasciae latae place the patient in the supine position.Havehiminternallyrotatethethighagainstmildresistance;tensorfasciaelataeshouldbecome readily palpable.Using flat digital palpation, follow the attachment attheASIS to theconnectionwith the iliotibialbandon the lateral aspectof thethigh,wherethefibersbecometendinous.Tensorfasciaelataeliesanteriortothegreatertrochanterofthefemur.

Tensorfasciaelataepainpattern

Pain pattern: Pain deep in the hip and down the lateral aspect of the thightoward theknee.Painmayfeel like thesensationsassociatedwith trochantericbursitis.Painpreventswalkingrapidlyorlyingcomfortablyontheaffectedside,andmayinterferewiththeabilitytositwiththehipfullyflexed.Causativeorperpetuatingfactors:Walkingorrunningonanunevensurface;immobilizationofthelimbforextendedperiodsoftime;suddenoverload.Satellitetriggerpoints:Anteriorfibersofthegluteusminimus,rectusfemoris,iliopsoas,sartorius.Affectedorgansystem:Genitourinarysystem.Associatedzones,meridians,andpoints:Lateral zone;FootShaoYangGallBladdermeridian;GB29,GB31.Stretchexercises:1. Standorsitontheedgeofachair.Flexthelowerleg,externallyrotatingthe

thigh,andgrasptheanklewiththehomolateralhand.Drawtheheeltowardthebuttock,extendingthethighandhipasfaraspossible.Holdforacountoftentofifteen.

2. Supportyourbalancebyholdingontoawallortable.Crosstheaffectedlegbehindtheunaffectedleg.Bendthekneeoftheunaffectedlegasyouslidetheaffectedlegawayfromthetorso, towardtheoppositeside,aimingthelateralhipforthefloor.Holdthispositionforacountoftentofifteen.

Strengtheningexercise:Positionedon thehandsandknees, shiftyourweightonto one knee, allowing freedom of motion of the working thigh and leg.Keepingthekneeoftheworkinglegbent,abductthelegtobringtheinnerthighparallelwiththefloor.Returnthelegtothestartingposition.Repeatfivetotentimes.

Stretchexercise1:Tensorfasciaelatae

Stretchexercise2:Tensorfasciaelatae

Piriformisandtriggerpoints

PIRIFORMIS

Proximalattachment:Anteriorsurfaceofthesacrum.Distal attachment: Through the sciatic foramen, attaching to the greatertrochanterofthefemur.Action:Externalrotationofthethigh;actsinabductionwhenthethighisflexedto90degrees.Palpation:Tolocatepiriformis,identifythefollowingstructures:

Greater trochanter—Bony prominence on the lateral aspect of the femur,approximately one hand-length below the iliac crest. From the anteriorplanethegreatertrochanterlieshorizontalwiththepubiccrest.Piriformisline—Animaginarylinedrawnfromthesecondsacralsegment(justmedialtotheposteriorsuperioriliacspine[PSIS])totheupperborderof the greater trochanter. This line represents the superior border of thepiriformismuscleandtheposteriorborderofthegluteusmediusmuscle.

Palpate piriformiswith thepatient side-lyingor prone. Image thepiriformisline;palpateslightlydistaltothatline,sinceitmarksthesuperiorborderofthepiriformismuscle.Palpatethemusclethroughoutitscourse,fromtheborderofthe sacrum to the greater trochanter. Taut bands of a constricted piriformismusclecanbepalpatedthroughgluteusmaximus.Areasofconstrictionaremostlikely todevelop in themedial aspectof the lateral one-thirdof thepiriformislineandthelateralaspectofthemedialone-thirdofthatline.

Piriformispainpattern

Painpattern:Painin thesacroiliacregion, thebuttock, theposterioraspectofthehipjoint,andpossiblytheproximaltwo-thirdsoftheposteriorthigh.Painisincreasedbysitting,standing,andwalking.Causativeorperpetuatingfactors:Acuteoverload;sustainedoverloadduetoimmobilizationintheexternallyrotatedposition;arthritisofthehipjoint;pelvicinflammatorydisease.Satellitetriggerpoints:Gluteusmedius,gluteusminimus.Affected organ systems: Genitourinary system; elimination aspect of thedigestivesystem.Associated zones,meridians, and points: Dorsal and lateral zones; Foot TaiYangBladdermeridian,FootShaoYangGallBladdermeridian;GB30.Stretchexercise: Lying supinewith the feet on the floor and the knees bent,cross the legon the unaffected side over the legon the affected side.Use the

upper leg to gently pull the lower leg toward the floor.To ensure that the hipdoes not rise off the floor or table, the patient may gently apply downwardpressuretotheanteriorsuperioriliacspine(ASIS)ontheaffectedsidewithhishand.Holdforacountoffifteentotwenty.Strengtheningexercise:Positionedon thehandsandknees, shiftyourweightonto one knee, allowing freedom of motion of the working thigh and leg.Keepingthekneeoftheworkinglegbent,abductthelegtobringtheinnerthighparallelwiththefloor.Returnthelegtothestartingposition.Repeatfivetotentimes.

Stretchexercise:Piriformis

Bicepsfemoris

Semitendinosus

Semimembranosus

Hamstringsandtriggerpoints

HAMSTRINGSBICEPSFEMORIS,SEMITENDINOSUS,SEMIMEMBRANOSUS

Proximal attachment: Biceps femoris, long head: ischial tuberosity, by acommontendonwithsemitendinosus.Bicepsfemoris,shorthead:lineaasperaofthe femur, along the same portion to which the adductor magnus attaches.Semitendinosus: on the ischial tuberosity, by a common tendonwith the longheadofbicepsfemoris.Semimembranosus:ontheischialtuberosity,lateralanddeeptothecommontendonofbicepsfemorisandsemitendinosus.Distal attachment: Biceps femoris: both long and short heads attach by acommon tendon to the posterior and lateral aspects of the head of the fibula.Semitendinosus: medial side of the superior part of the tibia, medial andsuperficial to semimembranosus, forming the pes anserinuswith sartorius andgracilis.Semimembranosus:posterioraspectof themedialcondyleof the tibia,deeptosemitendinosus.Action:Bicepsfemoris,longhead:extensionofthethigh.Bicepsfemoris,bothheads:flexionoftheleg,externalrotationoftheflexedleg.Semitendinosusandsemimembranosus: extension of the thigh and flexion of the leg; assists ininternalrotationofthelegattheknee.Palpation:Tolocatethehamstrings,identifythefollowingstructures:

Ischial tuberosity—Easily palpable when seated, this bony prominencecarriesmostoftheweightofthetorsointheseatedposition.Itislocatedatthecenterofthebuttock,approximatelylevelwiththeglutealfold.Popliteal fossa—Posterior aspect of the knee joint, which appears as ahollowwhen the knee is flexed. It is bordered laterally by the tendon ofbiceps femoris and medially by the tendon of semitendinosus. As youslowlyextend the legyoucanpalpate thefleshysemimembranosus, lyingdeeptosemitendinosus,asitbulgesposteriorlyandlaterally.

Palpate thehamstringgroupwith thepatient lyingprone.Byflexing the leg

against resistance the tendons of distal attachment of both the biceps femoris,lyinglaterally,andthesemitendinosus,lyingmedially,arereadilyobserved.Palpate biceps femoris through its course, from attachment at the ischial

tuberosity toattachmenton theheadof the fibula.Thebulkofsemitendinosusfiberslieontheproximalone-halfofthemedialaspectofthefemur,wheretheycanbepalpatedalongtheircourse.Palpatesemitendinosusfromitsattachmentatthe ischial tuberosity to its attachment on the proximal tibia. The bulk ofsemimembranosus fibers lie on the distal one-half of themedial aspect of thefemur. Semimembranosus fibers can be palpated here, lying deep tosemitendinosus, which is less prominent at this portion of the thigh.Semimembranosus remains muscular through to its attachment deep tosemitendinosus;itstendonofinsertionisnotreadilypalpable.

Bicepsfemoris

SemitendinosusandSemimembranosus

Hamstringspainpattern

Painpattern:Biceps femoris: deep aching pain at the posterior and/or lateralknee, possibly extendingup the posterior lateral thigh toward the gluteal fold.Semitendinosus and semimembranosus: pain in the lower buttock and upperthigh. Painmay extend to the posteriormedial thigh and knee, aswell as theproximalone-halfofthemedialcalf.Causativeorperpetuatingfactors:Compressionoftheposteriorthigh,whichmayoccurwhilesittingforextendedperiodsoftimeorinapoorlysizedchair.Satellite trigger points: Each muscle of the hamstring group may developsatellitetriggerpointsinresponsetothepresenceoftriggerpointsinanyothermuscle of the group. Additional satellite trigger points could also appear inadductormagnus, iliopsoas, quadriceps, quadratus lumborum, paraspinals, andrectusabdominis.

Affectedorgansystem:Genitourinarysystem.Associatedzones,meridians,andpoints:Dorsalzone;FootTaiYangBladdermeridian;BL36–40.Semitendinosusandsemimembranosus:alsoFootShaoYinKidneymeridian;KI10.Stretch exercises: The short head of the biceps femoris forms a functionalhamstringwithadductormagnus.Therapeuticstretchingofthehamstringgroupmust therefore coincide with therapeutic stretching of the adductor group inorderforeachmusclegrouptoobtainfullbenefit.(Seepage183.)1. Place the heel of the leg to be stretched on a step, ledge, or chair. Lean

forward slowly, keeping the thigh and hips square. The higher the step,ledge,orchairthegreaterthestretchonthismusclegroup.Holdforacountoftwentytothirty,thenrelease.

2. Instanding,crosstheankles;keepthekneesstraightandtheweightevenlydistributed.Bendforwardfromthehips,maintainingfullextensionthroughtheknees.Holdforacountoftwentytothirty,thenrelease.

Strengtheningexercise:Lyingprone, flex theworking leg to a count of two;extend it to return to the prone position to a count of four. The pelvis mustremainflatonthefloorthroughoutthisexercise.Repeateighttotentimes.Ankleweightsmaybeusedtoincreasethedemandplacedonthehamstrings

duringthisexercise.Theamountofweightusedmustbegaugedinaccordancewiththeneedsandcapabilitiesofthepatient.

Stretchexercise1:Hamstrings

Stretchexercise2:Hamstrings

Rectusfemoris

Vastuslateralis

Vastusmedialis

Vastusintermedius

Quadricepsandtriggerpoints

QUADRICEPSRECTUSFEMORIS,VASTUSLATERALIS,VASTUSMEDIALIS,VASTUSINTERMEDIUS

Proximal attachment: Rectus femoris: via two tendons, one at the anteriorsuperioriliacspine(ASIS)andtheotherattheilium,superiortotheacetabulum.Vastus lateralis: lateral side of the upper three-quarters of the posterior femurand the lineaasperaon theposterior femur.Vastusmedialis: full lengthof theposteromedialaspectoftheshaftofthefemur.Vastusintermedius:anteriorandlateralsurfacesoftheuppertwo-thirdsoftheshaftofthefemur.Distalattachment:Allquadricepsattachtothepatellabymeansofacommontendonviathepatellarligamenttothetibialtuberosity.Action:Rectusfemoris:extensionof the leg;flexionof the thighon thepelviswhen the pelvis is fixed; flexion of the pelvis on the thighwhen the thigh isfixed.Vastuslateralis,vastusmedialis,andvastusintermedius:extensionoftheleg at the knee. Vastus lateralis and vastusmedialis working together help tomaintainnormalpositionandtrackingofthepatella.Palpation:Thequadricepsgroup,the“greatextensor,”istheheaviestmuscleinthebody,weighingapproximately50percentmorethanthenextlargestmuscle,the gluteusmaximus.Rectus femoris, vastus lateralis, and vastusmedialis arereadily palpable.Vastus intermedius lies deep to rectus femoris and cannot bedirectlypalpated.Of thefourmuscles thatcomprise thequadricepsgroup,onlyrectusfemoris

crosses two joints (the knee and the hip). Therefore, in addition to being anextensoroftheleg,rectusfemorisisaflexorofthethighandpelvis.Tolocatethequadriceps,identifythefollowingstructures:

Anterior superior iliac spine (ASIS)—Anterior bony projection lyingsomewhat below the iliac crest, readily palpable.TheASIS serves as theproximalattachmentoftheinguinalligament.Greater trochanter—Bony prominence of the lateral aspect of the femur,approximately one hand-length below the iliac crest. From the anterior

planethegreatertrochanterlieshorizontalwiththepubiccrest.Iliotibialband—Along,thin,flatbandoffascialyingontheoutersurfaceof the thigh. The iliotibial band is a thickening of the normal fascia thatsurrounds the thigh; its distal end inserts onto the lateral condyle of thetibia.Theinsertionontothelateralcondylecanbepalpatedanteriortotheinsertionofthebicepsfemoristendon(seemuscledescriptiononpage173).Theiliotibialbandcanbepalpatedintheseatedpositionbyraisingtheheelofyourfootoffthefloorwhilekeepingyourkneeflexed.Patella—AsesamoidboneinthecommontendonofthequadricepsgroupTibialtuberosity

Locate rectus femoris, vastus lateralis, and vastusmedialis when the leg isextended against resistance. Palpate rectus femoris from its attachment on theanteriorsuperioriliacspine(ASIS)toitsattachmentviathecommontendontothetibialtuberosity.The bulk of vastus lateralis lies proximal to the bulk of vastus medialis.

Palpatethefleshyportionsofvastuslateralisalongtheanterolateralaspectofthethigh, anterior to the iliotibial band, from the greater trochanter through itsattachment via the common tendon. Palpate the fleshy portions of vastusmedialis along the anteromedial aspect of the thigh through its attachment viathecommontendon.

Rectusfemoris

Vastuslateralis

Vastusmedialis

Vastusintermedius

Quadricepspainpattern

Constrictionsinrectusfemorismustbereducedbeforeanattemptismadetoidentify and reduce constrictions invastus intermedius.Once rectus femoris isfreeofconstriction,tautbandsmaybelocatedinvastusintermediusbylocatingtheproximallateralborderofrectusfemoris.Followthisborderdistallyuntilthefingers can palpate vastus intermedius, deep to rectus femoris, close to thefemur.

Painpattern:Painfromactivetriggerpointsisexperiencedatvariouslocationsrelativetothemusclemostinvolved.Rectusfemoris:Painisexperiencedintheanterior knee, sometimes deep in the joint. Painmay be experienced at night;walking down stairs may be difficult.Vastus lateralis: Pain is referred to theposterolateral aspect of theknee; it can refer throughout the full courseof thelateralthightothekneeandashighasthecrestoftheilium.Distaltriggerpointsmayimmobilizethepatella,causingpainwhilewalking.Symptomsmayinclude

difficulty lyingon the same side at night.Vastusmedialis: Anteromedial kneepain;pain extends through thedistal one-half of themedial thigh;bucklingoftheknee.Vastusintermedius:Painisreferredovertheanteriorthigh,extendinganterolaterallyovertheupperthigh.Painmaybemostintenseatmidthighlevel.Walkingupstairsmaybedifficult,asisstraighteningthelegaftersitting.Causative orperpetuating factors: Sudden overload throughmisstep or fall;sustainedoverloadduetoexcessivelytightenedhamstringmuscles.Satellite trigger points: Each muscle of the quadriceps group may developsatellitetriggerpointsinresponsetothepresenceoftriggerpointsinanyothermuscle of the group. Additional satellite trigger points could also appear insemimembranosus, semitendinosus, biceps femoris, tensor fasciae latae, andiliopsoas.Affected organ systems: Rectus femoris, vastus lateralis, and vastusintermedius: digestive system.Vastusmedialis: genitourinary and reproductivesystems.Associated zones,meridians, andpoints:Rectus femoris: ventral zone; FootYangMingStomachmeridian;ST31–34,SP10and11.Vastuslateralis:ventraland lateral zones; Foot Yang Ming Stomach meridian, Foot Shao Yang GallBladdermeridian;ST31–34,GB31.Vastusmedialis:ventralzone;FootTaiYinSpleen meridian; SP 10 and 11.Vastus intermedius: ventral zone; Foot YangMingStomachmeridian;ST31–34,SP10and11.Stretchexercise: Stand, or sit on the edge of a chair. Flex the lower leg andgrasptheanklewiththehomolateralhand.Lifttheheeltowardthebuttockandextend the thigh and hip as far backward as possible. Tilt the pelvis to avoidexcessivearchingof the lumbar spine.Hold thisposition for a countof ten tofifteen.Strengtheningexercise:Sitonachairwith thefeeton thefloor.Fullyextendtheworking leg to a count of two.Return the leg to the starting position to acountoffour.Repeatthisexercisetentotwelvetimes,workingonelegatatime.Ankleweightsmaybeusedtoincreasethedemandplacedonthequadriceps

duringthisexercise.Theamountofweightusedmustbegaugedaccordingtotheneedsandcapabilitiesofthepatient.

Stretchexercise:Quadriceps

Adductormagnus

AdductorlongusandAdductorbrevis

Adductorsandtriggerpoints

ADDUCTORSADDUCTORMAGNUS,ADDUCTORLONGUS,ADDUCTORBREVIS

Proximal attachment: Adductor magnus: inferior pubic ramus, ramus ofischium, ischial tuberosity.Adductor longus: pubic tubercle. Adductor brevis:inferiorramusofthepubis.Distal attachment: Adductor magnus: linea aspera of the posterior femur,adductor tubercle of the medial femur. Adductor longus: linea aspera on themiddle one-third of the femur. Adductor brevis: proximal aspect of the lineaasperaofthefemur,lateralanddeeptoadductorlongus.Action:Adductormagnus:anteriorfibersadductandinternallyrotatethethigh;posterior fibers extend the thigh. Adductor longus and adductor brevis:adductionofthethighatthehip.Palpation:Of themuscles in the adductorgroup, adductor longus is themostprominentandmostreadilyaccessibletopalpation.Tolocatetheadductors,identifythefollowingstructures:

Femoral triangle—Bounded superiorly by the inguinal ligament,mediallyby adductor longus, and laterally by sartorius. The floor of the femoraltriangle is formedmediallybypectiniusand laterallyby iliopsoas.Withinthis triangle the femoral pulse can be palpated 2 to 3 centimeters(approximately1 inch) inferior to the inguinal ligament,at themidlineofthebaseofthetrianglewhichitforms.Boththefemoralarteryandfemorallymphglandsliesuperficialtoiliopsoasandpectinius,whichthemselvesliesuperficial to the hip joint. The femoral artery lies just superficial to theheadofthefemur.Thepulsepointofthefemoralarterycanbepalpatedjustsuperficialtotheheadofthefemur,inferiortothemidpointoftheinguinalligament.Ischial tuberosity—Easily palpable when seated, this bony prominencecarriesmostoftheweightofthetorsointheseatedposition.Itislocatedatthecenterofthebuttock,approximatelylevelwiththeglutealfold.

Palpate adductormagnus andadductor longuswith thepatient lying supine.To palpate adductor magnus, flex the leg of the thigh to be palpated, thenexternallyrotateandabductthethighinordertopositionthesoleofthefootofthat legapproximately8 to10 inches lateral to the inner thighof theextendedleg. If necessary, a pillow may be placed beneath the bent knee for patientcomfort. Palpate adductor magnus posterior to adductor longus and adductorbrevis,fromtheischialtuberositytothemedialaspectofthefemur.Topalpateadductorlongus,placethesoleofthefootagainsttheinnerthighof

the extended leg. In this position adductor longus becomes clearly visible andpalpable.Palpateadductorlongusanteriortoadductormagnus,fromitsproximalaspectnearthepubistoitsdistalaspectatthemiddleone-thirdofthefemur.Adductor longus and pectineus lie superficial to adductor brevis. Therefore

adductorbreviscannotbedirectlypalpated.

Adductormagnus

AdductorlongusandAdductorbrevis

Adductorspainpattern

Painpattern:Adductormagnus: Trigger points in the proximal aspect of themuscle, near the ischial tuberosity, refer severe, deep pelvic pain that mayincludepainatthepubicbone,vagina,rectum,andpossiblythebladder.Triggerpoints in themiddleportionofadductormagnusreferpainto theanteromedialaspectofthethigh,fromthegrointojustabovetheknee.Adductorlongusandadductorbrevis: Pain in the groin that is experienced during activity; reducedabductionandexternalrotationofthethigh.Paindeepinthegroinandpossiblytheanteromedialaspectoftheupperthigh;painabovethemedialaspectofthekneeandpossiblyovertheshin.Triggerpointsneartheproximalattachmentofadductorlongusmaycausekneepainandstiffness.Causativeorperpetuatingfactors:Suddenoverloaddue toamisstepor fall;arthritisof thehip joint;sustainedoverloaddue toactivitiessuchashorsebackriding or sitting with the legs crossed for lengthy periods of time; emotional

stresses.Satellite trigger points: Each muscle of the adductor group may developsatellitetriggerpointsinresponsetothepresenceoftriggerpointsinanyothermuscle of the group. Additional satellite trigger points could also appear invastusmedialisandgracilis.Affectedorgansystem:Reproductivesystem.Associated zones, meridians, and points: Adductor magnus: Ventral zone;FootJueYinLivermeridian,FootShaoYinKidneymeridian;LIV10and11,BL36and37.Adductorlongusandadductorbrevis:ventralzone,FootJueYinLivermeridian;LIV9,10,and11.Stretchexercises:Adductormagnusformsafunctionalhamstringwiththeshortheadof the biceps femoris.Therapeutic stretchingof the adductor groupmustthereforecoincidewiththerapeuticstretchingofthehamstringgroupinordertoobtainthefullbenefitforeachmusclegroup.1. Lyingwiththebuttocksagainstawallandthelegsextendedupwardonthe

wall,slowlyseparatethelegstostretchtheinnerthighs.Holdthispositionfor30to60seconds,allowinggravitytoactontheabductedlegs.

2. Positionedsupine,withthethighandlegoftheaffectedsideoffthesideofanexaminingtableorbed,flexthethighandlegoftheunaffectedsidetofixthepelvis,keepingthelumbarspineflatonthetable.Abductthethighand leg, allowing it tohangoff the sideof the tableorbed.The forceofgravitywillstretchtheuppergroinregion.Holdthispositionforacountof20to30.

Strengtheningexercise:Sittingon theedgeofachair,placea large, softballbetween the thighs.Adduct the thighs, squeezing theball.Hold for a countoffivetoeightandrelease.Repeattentotwelvetimes.

Stretchexercise1:Adductors

Stretchexercise2:Adductors

Pectineusandtriggerpoint

PECTINEUS

Proximalattachment:Crestofthesuperiorramusofthepubis.Distalattachment:Onthefemur,justdistaltothelessertrochanter.Action:Flexion,adduction,andinternalrotationofthethighatthehip.Palpation:Tolocatepectineus,identifythefollowingstructures:

Femoral triangle—Bounded superiorly by the inguinal ligament,mediallybyadductor longus (seemuscledescriptiononpage181)and laterallybysartorius (seemuscle description on page 191). The floor of the femoraltriangleisformedmediallybypectineusandlaterallybyiliopsoas.Withinthis triangle the femoral pulse can be palpated 2 to 3 centimeters(approximately1 inch) inferior to the inguinal ligament,at themidlineofthebaseof the triangle that it forms.Both the femoralarteryandfemorallymphglandsliesuperficialtoiliopsoasandpectinius,whichthemselvesliesuperficial to the hip joint. The femoral artery lies just superficial to theheadofthefemur.Thepulsepointofthefemoralarterycanbepalpatatedjust superficial to the head of the femur, inferior to the midpoint of theinguinalligament.Pubic tubercle—The bony prominence at the lateral aspect of the pubiccrest. The pubic tubercle serves as the distal attachment for the inguinalligament.

Palpatepectineuswith thepatient lyingsupine.Abductandexternallyrotatethethightobepalpated,thenflexthelegtobringthesoleofthefootadjacenttotheopposite inner thigh. Ifnecessaryapillowmaybeplacedbeneath thebentknee for patient comfort. Locate the femoral triangle and pubic tubercle.Pectineus occupies the medial aspect of the floor of the femoral triangle. Tolocatepectineuspalpatewithinthefemoraltriangle,approximately1inchlateraland1inchdistaltothepubictubercle.

Pectineuspainpattern

Painpattern:Deep,localgroinpain,justdistaltotheinguinalligament.Causativeorperpetuatingfactors:Suddenoverloadfromanunexpectedfall;chronic overload in adduction and flexion, such as sitting cross-legged for anextendedperiodoftime;diseasesorsurgeriesaffectingthehipjoint.Satellite trigger points: Adductor longus, adductor brevis, adductor magnus,iliopsoas.Affectedorgansystem:Reproductivesystem.Associated zones, meridians, and points: Ventral zone; Foot Jue Yin Livermeridian;LIV9,10,and11.Stretchexercise:Lyingonatableorbed,abducttheaffectedthighandlegandallowthelimbtohangoffthesideofthetableorbed.Flextheunaffectedthighandlegtofixthepelvis,keepingthelumbarspineflatonthetableorbed.Letgravitystretchtheuppergroinregion.Holdforacountoftwentytothirty.

Strengtheningexercise:Sittingon theedgeofachair,placea large, softballbetween the thighs.Adduct the thighs, squeezing theball.Hold for a countoffivetoeight,andrelease.Repeattentotwelvetimes.

Stretchexercise:Pectineus

Gracilisandtriggerpoints

Gracilispainpattern

GRACILIS

Proximalattachment:Inferiorpubicramus.Distal attachment:Medial side of the superior part of the tibia, distal to thetibialcondyle,formingthepesanserinuswithsartoriusandsemitendinosus.Action:Adductionofthethighat thehip;flexionoftheleg;assistsininternalrotationofthethighandflexedleg.Palpation:Tolocategracilis,identifythefollowingstructures:

MedialsurfaceofthetibialcondyleDistal attachment of semitendinosus—Identify the popliteal fossa, theposterioraspectofthekneejointthatappearsasahollowwhenthekneeisflexed.Thedistalattachmentofsemitendinosusformsthemedialborderofthe popliteal fossa; the lateral border is formed by the tendon of bicepsfemoris.

Palpate the knee of the flexed leg at the popliteal region and identify theprominenttendonofsemitendinosusformingthemedialborderofthepoplitealfossa.Moveslightlymediallytolocatethetendonofgracilis,whichliesanteriorand medial to the tendon of semitendinosus. Offering resistance to internalrotationofthethighallowsgracilistobecomemoreprominent.Palpatethisthin,bandlikemusclealongitscourseonthemedialaspectofthethigh.Painpattern:Hot,stinging,superficialpainalongthemedialthigh.Causativeorperpetuatingfactors:Suddenoverloaddue toamisstepor fall;arthritisof thehip joint;sustainedoverloaddue toactivitiessuchashorsebackriding or sitting with the legs crossed for lengthy periods of time; emotionalstresses.Satellitetriggerpoints:Sartorius.Affectedorgansystems:Reproductiveandgenitourinarysystems.

Associated zones, meridians, and points: Ventral zone; Foot Jue Yin Livermeridian;SP9,LIV8–11.Stretchexercise:Lyingwith thebuttocksagainstawallandthe legsextendedupwardonthewall,slowlyseparatethelegstostretchtheinnerthighs.Holdthispositionfor30to60seconds,allowinggravitytoactontheabductedlegs.Strengtheningexercise:Sittingon theedgeofachair,placea large, softballbetween the thighs.Adduct the thighs, squeezing theball.Hold for a countoffivetoeight,andrelease.Repeattentotwelvetimes.

Stretchexercise:Gracilis

Sartoriusandtriggerpoints

Sartoriuspainpattern

SARTORIUS

Proximalattachment:Anteriorsuperioriliacspine(ASIS).Distal attachment:Medial side of the superior part of the tibia, distal to thetibialcondyle,formingthepesanserinuswithsemitendinosusandgracilis.Action:Assistsinflexion,abduction,andexternalrotationofthethigh;assistsinhipflexionandkneeflexionduringwalking.Palpation:Tolocatesartorius,identifythefollowingstructures:

Anterior superior iliac spine (ASIS)—Anterior bony projection lyingsomewhat below the iliac crest, readily palpable.TheASIS serves as theproximalattachmentoftheinguinalligament.MedialsurfaceofthetibialcondyleDistal attachment of semitendinosus—Identify the popliteal fossa, theposterioraspectofthekneejointthatappearsasahollowwhenthekneeisflexed.Thedistalattachmentofsemitendinosusformsthemedialborderofthe popliteal fossa; the lateral border is formed by the tendon of bicepsfemoris.

Locate sartorius with the patient seated and the leg flexed to 90 degrees.Offering resistance to external rotation of the thigh, sartorius will becomeprominent from its attachment at the ASIS. Palpate sartorius from the ASISthroughoutitscoursetoitsdistalattachment,distaltothemedialsurfaceofthetibialcondyle.Thetendonofinsertionofsartoriusliesanteriortothetendonsofinsertionofgracilisandsemitendinosusandformstheflattestandmostanteriortendonofthepesanserinus.Painpattern:Superficialtinglingpainalongthecourseofthemuscle.Causative or perpetuating factors: Trigger points occur in this muscle as aresultofitsplacementwithinthepainreferralzoneofanassociatedmuscle.

Satellitetriggerpoints:Rectusfemoris,vastuslateralis,vastusmedialis,vastusintermedius.Affectedorgansystem:Genitourinarysystem.Associated zones, meridians, and points: Ventral zone; Foot Yang MingStomachmeridian;ST31,LIV8.Stretch exercise: Digital compressions directly along the muscle produce aneffectivelocalstretch.Strengthening exercise: Strengthening exercises specific to this muscle aregenerallynotindicated.

Popliteusandtriggerpoint

Popliteuspainpattern

POPLITEUS

Proximalattachment:Lateralaspectofthelateralcondyleofthefemur.Distalattachment:Proximalone-thirdoftheposterioraspectofthetibia.Action: Internally rotates the legon thefemurwhen the thigh is fixedand thelegisfreeandexternallyrotatesthefemurontheleginweightbearingwhentheleg is fixed; unlocks the knee joint to facilitate bending of the knee; preventsforwarddisplacementofthefemuronthetibiawhencrouching.Palpation:Popliteusformspartofthedistalaspectofthefloorofthepoplitealfossa.Palpatepopliteuswith thepatientside-lyingon theaffectedside, the legslightlyflexed.Thedistal,medialattachmentofthemuscleliesontheposterioraspectofthetibiaandcanbepalpatedbetweenthetendonofsemitendinosusandthemedial head of gastrocnemius. To palpate taut bandswithin this aspect ofpopliteus, laterally displace the overlying gastrocnemius and soleus. Theproximal,lateralendofpopliteusliesinthepoplitealspacejustabovetheheadof the fibula, between the tendon of biceps femoris and the lateral head ofgastrocnemiusandplantaris.Palpatethroughtheoverlyingmusculature.Painpattern:Pain in thebackof theknee,oftenwhencrouching, running,orwalking downhill or going down stairs; inability to straighten the knee fullywithout pain. Pain from trigger points in thismuscle is rarely experienced inisolation;painismostoftenexperiencedincombinationwithgastrocnemiusandbicepsfemoris,whichareusually identifiedas thesourceof theposteriorkneepain. Once the gastrocnemius and biceps femoris trigger points are reduced,popliteuscanbemorereadilyidentifiedasthesourceofposteriorkneepain.Causativeorperpetuatingfactors:Muscleoverloadwhilebrakingtheforwardmotionofthefemurduringatwistingturn,withthebodyweightontheslightlybentkneeofthesidetowhichthebodyisturning.Thisisespeciallycommoninsoccer or football or when running or skiing downhill. Trigger points inpopliteus may develop secondary to a tear of the plantaris muscle and mayremainlongaftertheplantaristearishealed.

Satellitetriggerpoints:Gastrocnemius.Affectedorgansystems:Genitourinarysystem.Associatedzones,meridians,andpoints:Dorsalzone;FootTaiYangBladdermeridian;BL39and40.Stretchexercises:Flextheleg15to20degrees;withthethighfixed, laterallyrotate the leg.Makesure that the leg(not the thigh) isbeingrotated.Hold thepositionforacountoffifteentotwenty.Repeattwotothreetimes.Strengthening exercise: Due to the nature of this muscle, strengtheningexercisesarenotnecessary.

Stretchexercise:Popliteus

Gastrocnemiusandtriggerpoints

GASTROCNEMIUS

Proximalattachment:By twoheads, themedialheadattaching to themedialepicondyleofthefemur,thelateralheadattachingtothelateralepicondyleofthefemur.Distal attachment: Via the tendocalcaneus (Achilles tendon) to the posteriorsurfaceofthecalcaneus,withsoleus.Action:Plantarflexion;aidsinflexionofthekneewhenthelegisnotbearingweight.Palpation:Tolocategastrocnemius,identifythefollowingstructures:

MedialepicondyleofthefemurLateralepicondyleofthefemurTendocalcaneus (Achilles tendon)—The thickest and strongest tendon inthe body, the tendocalcaneus is the common tendon of insertion for thegastrocnemiusandsoleusmuscles.Thistendonispalpablefromthelowerone-thirdofthecalftothecalcaneus.

Due to its superficial position on the posterior calf, gastrocnemius is easilypalpable.Palpateboth themedial and lateral heads throughout their course, totheirattachment to the tendocalcaneus.Note that themedialhead is somewhatlongerthanthelateralhead.

Gastrocnemiuspainpattern

Pain pattern: Local calf pain without reduced range ofmotion or weakness;paininthebackoftheknee;possiblypainintheinstep;nocturnalcalfcramps.Causativeorperpetuatingfactors:Chronicoverloadduetoexcessiveplantarflexion;immobilityofthelegs;reducedcirculationintothelegs.Satellitetriggerpoints:Soleus,hamstrings.Affectedorgansystem:Genitourinarysystem.Associatedzones,meridians,andpoints:Dorsalzone;FootTaiYangBladdermeridian;BL56,57,and58,GB36.Stretchexercises:1. Placetheballofthefootonasteporcurbandallowtheheelofthefootto

dropbelowthelevelofthestep.Keepthekneestraightasyoustretchthecalf.Holdthispositionforacountoftwenty-fivetothirty.

2. Standapproximately12inchesfromawall,thehandsplacedonthewallat

thechestlevel.Placethelegtobestretchedapproximately18inchesbehindthe other, keeping the toes of both feet facing thewall and the feet hip-width apart. Bend the front knee, keeping the rear leg straight.Hold thispositionforacountoftwenty-fivetothirty.

Strengtheningexercise:Standingandholdingontoawallorchairforbalance,raiseupontotheballofthefoot,bringingtheheelwelloffthefloor.Holdthisposition for a count of five. Slowly return the heel to the floor.Repeat ten totwelvetimes.

Stretchexercise1:Gastrocnemius

Stretchexercise2:Gastrocnemius

Soleusandtriggerpoints

SOLEUS

Proximal attachment: Posterior aspect of the head of the fibula and theproximalone-thirdoftheposteriorfibulaandmiddleone-thirdofthetibia.Distal attachment: Via the tendocalcaneus (Achilles tendon) to the posteriorsurfaceofthecalcaneus,withgastrocnemius.Action: Plantar flexion of the foot; assists inversion; contributes to kneestability;providesanklestability.Palpation:Toidentifysoleus,locatethefollowingstructures:

Tendocalcaneus (Achilles tendon)—The thickest and strongest tendon inthe body, the tendocalcaneus is the common tendon of insertion for thegastrocnemiusandsoleusmuscles.Thistendonispalpablefromthelowerone-thirdofthecalftothecalcaneus.

Soleusliesdeeptogastrocnemius.Palpatesoleusonthedistalone-halfofthelowerleg,lateralanddistaltothelateralheadofgastrocnemiusandmedialanddistaltothemedialheadofgastrocnemius.

Soleuspainpattern

Painpattern:Heelpain,tenderness,restricteddorsiflexion;walkinguphillorupstairs may be difficult. Trigger points in the proximal aspect of the muscleradiatetotheposteriorcalf;distaltriggerpointsradiatetotheposterioraspectofthe heel, possibly including its plantar surface and the distal aspect of theAchilles tendon; pain may be experienced at the sacroiliac joint on the sameside.Causativeorperpetuatingfactors:Chronicoverloadduetoexcessiveplantarflexion;suddenoverloadduetomisstep;poorcirculationinthelegs.Satellitetriggerpoints:Gastrocnemius,homolateralquadriceps.Affectedorgansystem:Cardiovascularsystem.Associatedzones,meridians,andpoints:Dorsalzone;FootTaiYangBladdermeridian,FootShaoYinKidneymeridian;BL59,KI7,KI9.Stretchexercises:

1. Placetheballofthefootonasteporcurbandallowtheheelofthefoottodropbelowthelevelofthestep.Keepthekneebentasyoustretchthecalf.Holdthispositionforacountoftwenty-fivetothirty.

2. Standapproximately12inchesawayfromawall, thehandsplacedonthewall at chest level. Place the leg to be stretched approximately 18 inchesbehindtheother,keepingthetoesofbothfeetfacingthewallandthefeethip-widthapart.Bendbothkneestostretchsoleus.Holdthispositionforacountoftwenty-fivetothirty.

Strengtheningexercise:Standingandholdingontoawallorchairforbalance,raiseupontotheballofthefoot,bringingtheheelwelloffthefloor.Holdthisposition for a count of five. Slowly return the heel to the floor.Repeat ten totwelvetimes.

Stretchexercise1:Soleus

Stretchexercise2:Soleus

Tibialisposteriorandtriggerpoint

Tibialisposteriorpainpattern

TIBIALISPOSTERIOR

Proximalattachment:Proximaltwo-thirdsoftheposteriorsurfacesofthetibiaandthefibulaandtheinterosseusmembrane.Distalattachment:Passingbehindthemedialmalleolustoattachtomostofthebones that form the arch of the foot: the navicular, each cuneiform, and thecuboid;thecalcaneus;andmetatarsals2,3,and4.Action: Invertsandadducts(supinates) thefreefoot;assists inplantarflexion.Prevents excessive pronation of the foot during walking; prevents excessiveweightbearingonthemedialfoot;distributesweightevenlyalongtheheadsofthemetatarsals,helpingtoshifttheweightlaterally.Palpation:Tibialisposterioristhedeepestmuscleofthecalf,lyingbetweentheinterosseus membrane anteriorally and the soleus posteriorally. Along withflexor digitorum longus and flexor hallucis longus it comprises the deepposteriorcompartmentof the leg.Due to thedepthof itsplacementon the legthis muscle cannot be palpated directly; however, tenderness can be elicitedthrough deep palpation. Identify the posterior border of the tibia on theposteromedial surface of the leg. Palpate the proximal half of the lower leg,partiallydisplacingthesoleusposteriorly,toidentifytheposteriorsurfaceofthetibiathroughtheoverlyingsoleus.Painpattern: Tibialis posterior is rarely involved in isolation from other calfmuscles.Painradiatesover theAchilles tendonabovetheheel;additionalpainmaycoverthemidcalf,theheel,andtheplantarsurfaceofthefootandtoes.Painisexperienced in thesoleof thefootwhenwalkingorrunning,particularlyonunevensurfaces.Causative or perpetuating factors: Jogging on uneven surfaces such ascrownedroads;hypermobilityofthemidfoot;badlywornfootwearthatdoesnotprotectagainsteversionandrockingofthefoot.Satellitetriggerpoints:Flexordigitorumlongus,flexorhallucislongus,andtheperonealmuscles.

Affectedorgansystems:Genitourinarysystem.Associatedzones,meridians,andpoints:Dorsalzone;FootTaiYangBladdermeridian;BL55,56,and57.Stretch exercise: Stretch this muscle by dorsiflexing and everting the foot.Sittingwith the legsextended infrontofyou,placeabeltor towelaroundthemidfoot of the leg to be stretched. Pull the band toward you, stretching theposteriorcalf.Pullwithslightlygreaterforceon theoutsideof thefoot,whichwillallowthelateralsideofthefoottobeeverted.Holdthispositionforacountoffifteentotwenty.Repeatthreetofivetimes.Strengthening exercise: Due to the nature of this muscle, strengtheningexercisesaregenerallynotnecessary.

Stretchexercise:Tibialisposterior

Tibialisanteriorandtriggerpoint

TIBIALISANTERIOR

Proximal attachment: Lateral condyle of the tibia and the upper one-half totwo-thirdsofthelateralsurfaceofthebodyofthetibia,interosseusmembrane,andsurroundingfascia.Distalattachment:Medial andplantar surfacesof themedial cuneiformboneandthebaseofthefirstmetatarsal.Action:Dorsiflexion and supination (inversion) of the foot.Helps tomaintainstandingbalance,prevents footslapatheelstrike,andhelps footclear flooratswingphase.Vigorouslyactiveduringmostsportsactivities,includingjogging,running,sprinting,andtwo-leggedjumps.Helpsmaintainstandingbalance.Palpation: Tibialis anterior, peroneus tertius, extensor digitorum longus, andextensor hallucis longus comprise the anterior compartment of the leg. Thissuperficialcalfmusclecanbepalpatedattheproximalone-halftotwo-thirdsofthe lateral calf. Palpate themusclemass lateral to the sharp edge of the shin,fromthelateralcondyleofthetibiadistallytowardtheankle.Continuepalpatingthemuscleasitcrossestheanklemediallyandattachesatthemedialarch.Themusclecanbevisually identifiedat the levelof theankle jointbydorsiflexingandinvertingthefoot.Triggerpointsarecommonlylocatedatthejunctionoftheproximal and middle thirds of the tibia; however, they can develop in themidbellyofthemuscleatanylevel.Painpattern:Painattheanteromedialankleandthegreattoe.Somepainmaybeexperiencedalongthecourseof theshin to theankle.Symptomsassociatedwith trigger points may include ankle weakness, tripping or falling whenwalkingbecauseofweakdorsiflexion,andfootdrop.Causativeorperpetuatingfactors:Muscleoverloadthatmayoccursecondaryto ankle sprain or fracture; walking on rough ground or slanted surfaces;excessivetightnessinthetricepssurae.

Tibialisanteriorpainpattern

Satellite trigger points: Peroneus longus, extensor hallucis longus, possiblyextensordigitorumlongus.Affectedorgansystems:Digestivesystem.Associated zones, meridians, and points: Lateral zone; Foot Yang MingStomachmeridian;ST36–40;LIV4.Stretchexercise:Stretchthetibialisanteriorbycrossingastronglypointedfootover the ankle of the standing leg.Bend the knee of the standing leg into thebackofthekneeofthebentleg.Careshouldbetakentoensurethattheheelisraisedandthattheankleisneithersupinatednorpronated.Strengthening exercise: Stretch a dynaband or other elastic exercise bandbetweenthelegsofachairortable3to4inchesfromthefloor.Sitonthefloorwiththelegsextendedandpositionthefootsothebandliesacrossthedorsumofthe foot (not across the toes). Flex and supinate (invert) the foot against the

resistanceprovidedbytheband.Holdforacountofthreetofive.Repeatfivetotentimes.

Stretchexercise:Tibialisanterior

Peroneuslongus

Peroneusbrevis

Peroneustertius

Peronealsandtriggerpoints

PERONEALMUSCLESPERONEUSLONGUSPERONEUSBREVIS,PERONEUSTERTIUS

Proximalattachment:Peroneuslongus:headofthefibulaanduppertwo-thirdsofthelateralsurfaceofthefibulaandtheadjacentintermuscularsepta.Peroneusbrevis:lyingdeeptolongus,distaltwo-thirdsofthelateralsurfaceofthefibulaand the adjacent intermuscular septa. Peroneus tertius: distal one-half of theanteriormarginofthefibulaandtheadjacentintermuscularseptum,incommonwiththelowerfibersofextensordigitorumlongus.Distal attachment: Peroneus longus: passing behind the lateral malleolus,runningobliquelyacrossthesoleofthefootfromlateraltomedial,andendingon the base of the firstmetatarsal and themedial cuneiform bones.Peroneusbrevis:passingbehindthelateralmalleolus,endingat thedorsalsurfaceof thebase of the fifth metatarsal. Peroneus tertius: passing in front of the lateralmalleolus,endingonthedorsalsurfaceofthebaseofthefifthmetatarsal.Action:Peroneuslongusandperoneusbrevis:eversionandweakplantarflexionof the foot; controls excessive inversion andmediolateral balance inwalking.Peroneustertius:dorsiflexionandeversionofthefoot.Asagrouptheperonealsare prime movers in the eversion of the free foot, working with extensordigitorumlongus.Palpation: Peroneus longus and peroneus brevis comprise the lateralcompartment of the leg. Peroneus tertius, alongwith tibialis anterior, extensordigitorum longus, and extensor hallucis longus, comprise the anteriorcompartmentoftheleg.Topalpatetheperoneals,firstidentifytheheadandshaftof the fibula and the extensor digitorum longus, which lies just anterior toperoneuslongus.Peroneuslongustautbandscanbeeasilyidentifiedagainsttheshaftofthefibula.Triggerpointsinperoneuslongusaremostcommonlyfoundapproximately1inchdistaltotheheadofthefibula.For peroneus brevis, palpate along the shaft of the fibula on either side of

longus,nearthejunctionofthemiddleandlowerthirdsoftheleg.Unlikelongusandbrevis, peroneus tertius liesproximal andanterior to the lateralmalleolus.

Palpate fibers of peroneus tertius distal and anterior to brevis. The tendon ofperoneustertiusisreadilypalpableandobservableintheanterolateralaspectofthefoot,lateraltotheextensordigitorumlongustendon,whenthepatientevertsthefoot.

Painpattern:Forperoneuslongusandbrevis,thepainpatternisoverthelateralmalleolus:above,behind,andbelowitandpossiblyalong the lateralaspectofthefoot.Forperoneustertius,thepainpatternisovertheanterolateralaspectoftheankle,anterior to the lateralmalleolus,withsomepainontheoutersideofthe heel. Symptoms include weak or unstable ankles; there are complaints ofpainandtendernessintheankleoverthelateralmalleolus,particularlyafteraninversion sprain.Tenderness due to trigger points canbe differentiated fromalateralligamentinjurybytheabsenceofswellingintheimmediateareaandthepresenceofpaininalarger,morediffusearea.

PeroneuslongusandPeroneusbrevis

Peroneustertius

Peronealspainpattern

Causative or perpetuating factors: Ankle inversion or twisting; prolongedimmobilization of the leg and foot by a cast; chronic tightness of the tibialisanteriorortibialisposterior;crossinglegswhenseated,wearinghighheels;tightelasticaroundtheleg;flatfeet;sleepingwiththefeetstronglyplantarflexed;assatellite trigger points from trigger points existing in anterior fibers of gluteusminimus.Satellite trigger points: Peroneus longus, peroneus brevis, peroneus tertius,extensor digitorum longus, tibialis anterior, tibialis posterior, extensor hallucislongus,flexorhallucislongus.Affectedorgansystems:Gastrointestinalsystem.Associatedzones,meridians,andpoints:Lateral zone;FootShaoYangGallBladdermeridian;GB37–40.

Stretchexercise:Sitwiththelegtobestretchedextendedinfrontofyou.Placeastraportowelaroundthefoot.Holdingthetowel,pullthefootgently,allowingit tomove into dorsiflexion, inversion, and adduction.Hold the position for acountoffifteentotwenty.Repeatthreetofivetimes.Strengthening exercise: Due to the nature of this muscle, strengtheningexercisesaregenerallynotnecessary.

Stretchexercise:Peroneals

Extensordigitorumlongus

Extensorhallucislongus

Longextensorsofthetoesandtriggerpoints

LONGEXTENSORSOFTHETOESEXTENSORDIGITORUMLONGUSANDEXTENSORHALLUCISLONGUS

Proximalattachment:Extensordigitorumlongus: lateralcondyleof the tibia,proximal three-quarters of the fibula, interosseusmembrane.Extensor hallucislongus: middle one-third of the anterior surface of the fibula, interosseusmembrane.Distalattachment:Extensordigitorumlongus:middleanddistalphalangesofthefourlateraltoes.Extensorhallucislongus:distalphalangeofthegreattoe.Action:Extensordigitorumlongus:extensionofthefourlateraltoes;assistsindorsiflexion and eversion of the foot; works very strongly in a vertical jumpfromastandingposition.Extensordigitorumlongus:extensionofthegreattoe;assistsindorsiflexionandinversionofthefoot.Palpation:Extensordigitorumlongusandextensorhallucislongus,alongwithtibialisanteriorandperoneus tertius,comprise theanteriorcompartmentof theleg.Topalpateextensordigitorumlongus, identifytibialisanterioranteriorlyand

peroneus longus posteriorly to locate extensor digitorum longus. Palpate tautbandsapproximately3inchesdistaltotheheadofthefibula.Extensorhallucislongusliesbetweenanddeeptotibialisanteriorandextensordigitorumlongusthroughout the upper two-thirds of the lower leg. It can be palpated where itbecomes superficial just distal to the level of the lower one-third of the leg,anteriortothefibula.

Painpattern:Extensordigitorum longus: Painon thedorsumof the foot andthecentralthreedigits.Sometimespaincanbeexperiencedattheankle;thepainmay move upward as far as the lower one-half of the lower leg. Extensorhallucislongus:Painatthefirstmetatarsalandthegreattoe.Itmayalsoextendtowardtheankle,followingthecourseofthemuscle.Symptomsincludepainonthedorsumofthefoot,“footslap”duringwalking,andnightcrampsalongthecourseof themuscle.Presenceof tautbandsand triggerpointsover timemayleadtothedevelopmentofhammertoesorclawtoes.

Causativeorperpetuatingfactors:L4-L5radiculopathy;acutestressoverloadcaused by walking in soft sand; walking or jogging on uneven ground orcrowned roads; tripping or falling; using the lengthened muscle in continualplantar flexion position (such as wearing high-heeled shoes or driving with asteepacceleratorpedal);prolongedplantarflexion;prolongedimmobilizationasaresultofwearingacast;verytightgastrocnemiusandsoleusmuscles.

Extensordigitorumlongus

Extensorhallucislongus

Longextensorsofthetoespainpattern

Satellite trigger points: Peroneus longus, peroneus brevis, peroneus tertius,tibialisanterior.Affectedorgansystems:Digestivesystem.Associated zones, meridians, and points: Lateral zone; Foot Yang MingStomachmeridian;ST40and41.Stretchexercise:Positionastronglypointedfootovertheankleofthestandingleg,placingthetoesofthelegtobestretchedbesidetheheelofthestandingleg.Bend thekneeof the standing leg into thebackof thekneeof thebent leg tostretchthedorsumofthefoot.Strengtheningexercise:Work theextensorsbyalternatingplantar flexionanddorsiflexionofthefootandtoes.Beginwithyourlegsextendedinfrontofyouandyour footandankle inaneutral, relaxedposition.Plantarflex the footand

toesstrongly.Holdforacountofthreetofive.Beginningwiththetoes,slowlyextendthetoesanddorsiflexthefoot.Holdforacountofthreetofive.Repeatthesetwoactionsfivetoseventimes,movingthrougheachpositionslowlyandwithoutallowingthefoottoevertorinvert.

Stretchexercise:Longextensorsofthetoes

Flexordigitorumlongus

Flexorhallucislongus

Longflexorsofthetoesandtriggerpoints

LONGFLEXORSOFTHETOESFLEXORDIGITORUMLONGUSANDFLEXORHALLUCISLONGUS

Proximal attachment: Flexor digitorum longus: middle one-third of theposterior surface of the tibia. Flexor hallucis longus: lateral aspect of theposteriorsurfaceofthefibula.Distal attachment: Flexor digitorum longus: passing behind the medialmalleolustoattachtothedistalphalangesofthefourlateraltoes.Flexorhallucislongus:passingbehindthemedialmalleolus,deeptoflexordigitorumlongus,toattachtothedistalphalanxofthegreattoe.Action:Flexordigitorumlongus:flexionofthefourlateraltoes;actsweaklyinplantar flexion;assists inversionandsupination(adduction)of thefoot.Flexorhallucislongus:flexionofthegreattoe.Bothmusclesservetomaintainbalancewhen the body weight is on the forefoot and help stabilize the ankle duringwalking.Botharevigorouslyactiveduringthetake-offandlandinginaverticaltwo-leggedjump.Palpation:Thesemuscles lie deep togastrocnemius and soleus andmedial totibialisposterior.Alongwithtibialisposterior,theycomprisethedeepposteriorcompartment of the leg. Flexor digitorum longus may be palpated with thepatientlyingontheinvolvedsidewiththekneeflexedto90degreesandthefootrelaxed. Pressure is applied to the posterior aspect of the shaft of the tibia,approximately 3 inches below the joint line. The gastrocnemius is movedlaterallytoidentifytheposteriortibia.Pressureisdirectedlaterallytopalpatetheflexordigitorumlongus.Flexorhallucislonguscanonlybepalpatedthroughtheoverlyingaponeurosis

of thegastrocnemiusandsoleusmuscles.Thepatient lies in thepronepositionwith his foot off the table. Pressure is applied to the posterior fibula at thejunctionofthemiddleandlowerthirdsofthecalf,justlateraltoitsmidline.

Painpattern:Flexordigitorumlongus:Painradiatestothemiddleofthesoleofthe foot and possibly over the plantar surface of the four lateral toes.Occassionally pain may be experienced at the medial ankle and calf. Flexor

hallucislongus:Painradiatestotheplantarsurfaceofthegreattoeandtheheadof the firstmetatarsal. Symptoms include pain in the sole of the foot and theplantarsurfaceofthetoes,particularlywhenweightbearing.Hammertoesand/orclawtoesmaydevelopasaresultofthepresenceoftautbandsinthesemuscles.

Flexordigitorumlongus

Flexorhallucislongus

Longflexorsofthetoespainpattern

Causativeorperpetuatingfactors:Runningonunevenground,particularlyinfootwearthatdoesnotprovideadequatesupportinthesoleortheheel;walkingor running on soft sand or on crowned surfaces; wearing shoes that areinsufficientlyflexible.Satellite triggerpoints:Tibialisposterior,extensordigitorumlongus,extensordigitorumbrevis.Affectedorgansystem:Genitourinarysystem.Associatedzones,meridians,andpoints:Dorsalzone;FootTaiYangBladdermeridian;BL56–59.Stretchexercise:Sittingwiththelegsextendedinfrontofyou,reachforward,placingthepalmsofthehandsontheplantarsurfaceofthetoes.Slowlypullthetoesandfeetintodorsiflexion.Holdthispositionforacountoffifteentotwenty.

Strengtheningexercise:1. Usingonlythetoes,graspasmallobjectsuchasamarbleorpencil.2. Placeatowelonthefloorand,usingonlythetoes,trytograspthetowel.

Repeatseveraltimes.

Stretchexercise:Longflexorsofthetoes

APPENDIX1

MERIDIANPATHWAYS

According to the Oriental conception, the body is imbued with an intricate,weblikesystemofpathwaysthatconnectupperandloweraspectsofthebodyaswell as connecting superficial regions with internal organ systems. Thesepathways, ormeridians, are connected to one another aswell as to a specificorganorsystem.Theoftenfar-reachingeffectsofacupunctureoracupressureareattributedtotheinterconnectednessofthissystemofpathways.The following basic information on meridian pathways and pairings is

included for thosewhoareunfamiliarwith rudimentaryOrientalanatomy.Theinterestedreadercanrefertothefollowingtextstobroadenhisknowledgeinthisarea:

The Foundations of Chinese Medicine by Giovanni Maciocia (London:ChurchillLivingstone,1989)ChineseAcupunctureandMoxibustioneditedbyChengXinnong(Beijing:ForeignLanguagePress,1987)TheManualofAcupuncturebyPeterDeadmanandMaxinAl-KhafajiwithKevin Baker (East Sussex, England: Journal of Chinese MedicinePublications,1998)

Meridianname:HandTaiYinLungHand/footpairing:FootTaiYinSpleenYin/Yangpairing:HandYangMingColonOrgans throughwhich themeridianpasses in its internal pathway:Lung,colonMusclestraversedbythemeridian:Pectoralismajor,pectoralisminor,anteriordeltoid,bicepsbrachii,brachialis,brachioradialis,pronatorteres,musclesofthethenareminence

Meridianname:HandYangMingColonHand/footpairing:FootYangMingStomachYin/Yangpairing:HandTaiYinLungOrgans throughwhichthemeridianpasses in its internalpathway:Colon,lungMusclestraversedbythemeridian:Extensorpollicislongus,extensorpollicisbrevis, extensor carpi radialis longus, extensor digitorum, supinator longus,brachioradialis, triceps brachii, deltoid, supraspinatus, trapezius,sternocleidomastoid,scalenes,orbicularisoris

Meridianname:FootYangMingStomachHand/Footpairing:HandYangMingColonYin/Yangpairing:FootTaiYinSpleenOrgansthroughwhichthemeridianpassesinitsinternalpathway:Stomach,spleen,largeintestineMuscles traversed by the meridian: Orbicularis oculi, zygomaticus major,orbicularis oris, masseter, temporalis, sternocleidomastoid, pectoralis major,rectus abdominis, external oblique, internal oblique, transversus abdominis,rectusfemoris,vastuslateralis,tibialisanterior,extensordigitorumlongus

Meridianname:FootTaiYinSpleenHand/footpairing:HandTaiYinLungYin/Yangpairing:FootYangMingStomachOrgansthroughwhichthemeridianpassesinitsinternalpathway:Spleen,stomach,heartMuscles traversedby themeridian:Extensorhallucis, flexorhallucisbrevis,adductor hallucis, tibialis anterior, soleus, gastrocnemius, rectus femoris,sartorius,vastusmedialis,adductorlongus,adductorbrevis,pectineus,iliopsoas,external oblique, internal oblique, transversus abdominis, pectoralis major,pectoralisminor,serratusanterior

Meridianname:HandShaoYinHeart

Hand/footpairing:FootShaoYinKidneyYin/Yangpairing:HandTaiYangSmallIntestineOrgans throughwhich themeridianpasses in its internalpathway:Heart,smallintestine,lungMuscles traversedby themeridian: Biceps brachii, triceps brachii, pronatorteres,palmarislongus,forearmflexors,flexorcarpiulnaris

Meridianname:HandTaiYangSmallIntestineHand/footpairing:FootTaiYangBladderYin/Yangpairing:HandShaoYinHeartOrgans throughwhich themeridianpasses in its internal pathway: Smallintestine,stomach,heartMuscles traversed by the meridian: Extensor digiti minimi, extensordigitorum, triceps brachii, latissimus dorsi, teres major, infraspinatus, teresminor, posterior deltoid, trapezius, supraspinatus, levator scapulae, scalenes,sternocleidomastoid,masseter,zygomaticusmajor,temporalis

Meridianname:FootTaiYangBladderHand/footpairing:HandTaiYangSmallIntestineYin/Yangpairing:FootShaoYinKidneyOrgansthroughwhichthemeridianpassesinitsinternalpathway:Bladder,kidneyMuscles traversed by the meridian: Orbicularis oculi, frontalis, occipitalis,splenius capitis, splenius cervicis, semispinalis capitis, semispinalis cervicis,trapezius, levator scapulae, rhomboids, latissimus dorsi, quadratus lumborum,erector spinae group, gluteus maximus, gluteus medius, gluteus minimus,piriformis, semimembranosus, semitendinosus, biceps femoris, soleus,gastrocnemius,tibialisposterior,peroneusbrevis,peroneuslongus

Meridianname:FootShaoYinKidneyHand/footpairing:HandShaoYinHeartYin/Yangpairing:FootTaiYangBladder

Organsthroughwhichthemeridianpassesinitsinternalpathway:Bladder,kidney,liver,lung,heartMuscles traversed by the meridian: Adductor hallucis, flexor digitorumbrevis,flexordigitorumlongus,tibialisposterior,soleus,gastrocnemius,gracilis,semitendinosus, semimembranosus, sartorius, adductor magnus, iliopsoas,quadratuslumborum,lowerabdominals,rectusabdominis,pectoralismajor

Meridianname:HandJueYinPericardium(HeartConstrictor)Hand/footpairing:FootJueYinLiverYin/Yangpairing:HandShaoYangTripleWarmerOrgansthroughwhichthemeridianpasses in its internalpathway:Upper,middle,andlowerburnersMuscles traversed by the meridian: Pectoralis major, brachialis, bicepsbrachii,flexorcarpiradialis,palmarislongus

Meridianname:HandShaoYangTripleWarmerHand/footpairing:FootShaoYangGallBladderYin/Yangpairing:HandJueYinPericardium(HeartConstrictor)Organsthroughwhichthemeridianpasses in its internalpathway:Upper,middle,andlowerwarmers;bladderMuscles traversed by the meridian: Extensor digitorum, triceps brachii,deltoid, infraspinatus,supraspinatus, trapezius,sternocleidomastoid, temporalis,orbicularisoculi

Meridianname:FootShaoYangGallBladderHand/footpairing:HandShaoYangTripleWarmerYin/Yangpairing:FootJueYinLiverOrgans through which the meridian passes in its internal pathway:Gallbladder,liverMuscles traversedbythemeridian:Orbicularisoculi, temporalis,epicranius,occipitalis, sternocleidomastoid, levator scapulae, trapezius, deltoid, pectoralismajor, serratus anterior, external oblique, internal oblique, transversus

abdominis, quadratus lumborum, iliopsoas, gluteus minimis, gluteus medius,gluteus maximus, tensor fasciae latae, iliotibial band, vastus lateralis, tibialisanterior, soleus, peroneus brevis, peroneus longus, tibialis posterior, extensordigitorum

Meridianname:FootJueYinLiverHand/footpairing:HandJueYinPericardiumYin/Yangpairing:FootShaoYangGallBladderOrgans through which the meridian passes in its internal pathway:Gallbladder,liver,lungsMusclestraversedbythemeridian:Extensorhallucislongus,extensorhallucisbrevis, tibialis anterior, soleus, gastrocnemius, sartorius, gracilis, vastusmedialis, adductor magnus, adductor longus, adductor brevis, pectineus,iliopsoas,externaloblique,internaloblique,transversusabdominis

Dorsalzone

Lateralzone

Ventralzone

APPENDIX2

ONCUTANEOUSZONES

TheconceptofzonesasdevelopedbyMarkSeem,Ph.D.,isanintelligentviewof themeridian system useful in the treatment ofmyofascial pain syndromes.TheconceptofcutaneouszonesispartofDr.Seem’streatmentprotocol,whichisfullydescribedinhisbookANewAmericanAcupuncture(BluePoppyPress,1993).Zones as defined by Dr. Seem are composite representations of associated

meridian pathways; a given zone is comprised of the regular meridians,divergentluo,tendinomuscularmeridians,andanyextraordinaryvesselspassingthrough the region. Using the framework of the cutaneous zones one cantherefore treat, directly or indirectly, the complexmeridian systems containedwithinagivenregion.Dr.Seemhasdefinedthreezonesthroughwhichhetreats.Thecombinedhand

and foot aspects of Tai Yang (that is, Small Intestine and Bladder meridians,respectively) is named thedorsalzone due to their posterior placement in thebody.ThecombinedhandandfootaspectsofYangMing(ColonandStomachmeridians, respectively) is named the ventral zone due to their frontalpositioning in the body. The combined hand and foot aspects of Shao Yang,Triple Warmer, and Gall Bladder, respectively, is named the lateral zone inaccordancewiththeirpositioninginthebody.Sinceconstrictionsbothwithinthemusculatureandalongmeridianpathways

bothreflectandaffectmovementwithinthegivenregion—bothonagrosslevel,as in theabilityof themyofascia toproducecomplete,pain-freemovement,aswell as on the level of movement of blood and lymphatic fluid, nervousinnervation,andsoforth—itisessentialtoreleaseconstrictionsoneveryleveltoensurehealingonalllevels.Cutaneouszones,asdescribedbyDr.Seem,providea guide to the exploration and treatment of related areas as defined from theOrientalperspective.Itisalsointerestingtonotethatmusclesthatarepartofaparticularzoneoften

developsatellitetriggerpointsinresponsetothepresenceofactivetriggerpointsinothermuscles in that zone.Zonesalsomost commonlycontain the referred

painpatternforamusclelyingwithinagivenzone.

APPENDIX3

COMMONLYUSEDACUPOINTS

There are many useful texts delineating the use of acupuncture points (alsoknown asacupoints). The interested reader is encouraged to investigate thesepoints and study their applications. The following texts are recommended assourcesofacupointinformation:

The Foundations of Chinese Medicine by Giovanni Maciocia (London:ChurchillLivingstone,1989)ChineseAcupunctureandMoxibustioneditedbyChengXinnong(Beijing:ForeignLanguagePress,1987)TheManualofAcupuncturebyPeterDeadmanandMaxinAl-KhafajiwithKevin Baker (East Sussex, England: Journal of Chinese MedicinePublications,1998)

Thepointslistedherearethosewehavefoundtobeparticularlyeffectiveinthetreatmentofpatientsinwhommyofascialconstrictionisareflectionoforganor system dysfunction. Once a point is selected it should be treated throughneedlingordirectpressure,inconjunctionwiththetreatmentofthemyofascia.Additionally,thetreatmentoflocalpoints—acupuncturepointslocatedwithin

theaffectedregion—usedinconjunctionwithtriggerpointreleasemethodscanbe quite useful to the overall healing of a patient suffering with pain due tomyofascialdysfunction.

SOURCEPOINTS/ORGANPOINTSThe acupoints listed here directly treat the given organ. Sensitivity in thesepointsisoftenareflectionofdysfunctionwithintheorgan.

LU9forthelungsCO4forthecolon

ST42forthestomachSP3forthespleenHE7fortheheartSI4forthesmallintestineBL64forthebladderKI3forthekidneysPC7forcardiovascularfunctionTW4fordigestivefunctionGB40forthegallbladderLIV3fortheliver

HE/SEAPOINTSThese acupoints support the relationship between the given organ and thesuperficialmeridian.

LU5forthelungsCO11forthecolonST36forthestomachSP9forthespleenHE3fortheheartSI8forthesmallintestineBL40forthebladderKI10forthekidneysPC3forcardiovascularfunctionTW10fordigestivefunctionGB34forthegallbladderLIV8fortheliver

SUPPORTPOINTSWehavefoundthatcertainlocalpoints,oracupointslocatedwithintheregionofanorganorsystem,areusefultothehealingofthatorgan.

LU1and2supportrespirationST25supportstheabdomenandtreatsassociatedconditionssuchasthoserelatedtodigestionandeliminationKI16supportstheabdomen,kidneys,andpelvisandtreatsconditionsand

dysfunctionsassociatedwiththeseorgansandregionsKI21through27supportrespirationGB 26 and 27 support and open the pelvis and might be used to treatgynecologicalandeliminativedysfunctionsBL23supportsthelowerbackandkidneysandtreatsassociatedconditionsCV13and17supporttheupperwarmerCV12supportsthemiddlewarmerCV6and10supportthelowerwarmerCV3and4supportthelowerabdomen,includingurinaryfunction,andareusedtotreatgynecologicaldysfunction

Distalpoints,oracupointslocatedawayfromtheregionofanorganorsystem,arerelatedtothatregionthroughthemeridianandcanbeusefulinthetreatmentofthatorganorsystem.

LU7supportstheheadandneckCO4calmsandsupportsthesystemingeneralST36promotesgeneralhealthandisusedtotreatabdominalconstrictionsSP6supportstheabdomenandpelvisandtreatsconditionsassociatedwiththatregionSP10supportsgynecologicalfunctionSP21istheuniversalluo,orbalancingpoint,ofallmeridiansandisusedtosupportoverallhealthBL57supportsandtreatsthelowerbackandurinaryfunctionBL62supportscirculationthroughoutthebackGB 41 supports the pelvis and treats conditions associated withconstrictionswithinthepelvis

FOOTNOTES

Introduction:AGatheringofForces1. JanetTravell,M.D., andDavidSimons,M.D.,MyofascialPain andDysfunction: TheTriggerPointManual, 2 vols. (Baltimore:Williams andWilkins, 1982–92); Peter E.Baldry,AcupunctureTriggerPointsandMusculoskeletalPain(Edinburgh/London:ChurchillLivingstone,1989).

Chapter1:TheNatureofMusclesandTriggerPoints1.TravellandSimons,MyofascialPainandDysfunction,1:12.2.TravellandSimons,MyofascialPainandDysfunction,1:16.3.Ibid.

Chapter2:QI,Movement,andHealth1.TravellandSimons,MyofascialPainandDysfunction(2vols.).2. During theCulturalRevolution inChina, in themidtwentieth century, acupuncture and herbalmedicinewerestandardized,resultingintheschoolsofOrientalmedicineallgenerallyteachingthesamecurricula.Thatcurriculawasatthetimenamed“traditionalChinesemedicine.”Thefirstmajortranslated texts on Oriental medicine came from these Chinese programs; they served as thefoundation for the vastmajority of acupuncture curricula taught in theUnited States.Within thisperspectivetheactionsofacupuncturepointsandtheinfluencesofherbsuponthebodyaregenerallyviewedinthesameway:justascertainherbsareusedtoreduce“intestinalheat”oralleviate“spleendampness,”certainacupuncturepointsareneedled toassist inaccomplishing thesamepurpose. Inthisapproachtoacupuncture,needlingispracticedinordertosupporttheeffectsproducedbyherbs;theacupuncturepointsaregenerallylocatedbymeasurementorbylightsurfacepalpation.3. This relationship was supported by a study performed by A. J. R. Macdonald, in which hecorrelated the relationship between acupuncture pathways andpatterns of pain experiencedbyhispatients suffering with myofascial constrictions. See A. J. R. Macdonald in Peter E. Baldry,Acupuncture,44–45.4.LaoTsu,TaoteChing,trans.Gia-FuFengandJaneEnglish(NewYork:Vintage,1972),1.5.JohnMcMillanMennel,TheMusculoskeletalSystem:DifferentialDiagnosisfromSymptomsandPhysicalSigns(Gaithersburg,Md.:Aspen,1992),5.6.JwingMingYang,TaiChiTheoryandMartialPower(JamaicaPlain:YMAA,1987),27.

7. Giovanni Maciocia, The Foundations of Chinese Medicine (Edinburgh/London: ChurchillLivingstone,1989),36.8.EdwinA.Abbott,Flatland:ARomanceofManyDimensions(NewYork:HarperCollins,1983);ClaudeBradgon,APrimerofHigherSpace(London:Kessinger,1999).Originallypublished1939.9. David B. Jenkins, Hollinshead’s Functional Anatomy of the Limbs and Back, 6th ed.(Philadelphia:Saunders,1991),12.10.JohnUpledgerandJonVredevoogd,CraniosacralTherapy(Seattle:Eastland,1983),239.11.SeePaulaD.Scariati,“MyofascialReleaseConcepts,”inAnOsteopathicApproachtoDiagnosisand Treatment, eds. Eileen L. DiGiovanna, D.O., and Stanley Schiowitz, D.O. (Philadelphia:Lippincott,1991),365.

Chapter4:DiagnosisandTreatment1. TravellandSimonsidentifypotentialeffectsrelatedtosyndromesoftheabdominals,pectoralisminor,scalenes,serratusanteriorandposterior,andsternocleidomastoidmuscles.2.UpledgerandVredevoogd,CraniosacralTherapy,237–38.

Chapter5:HowtoUseThisManual1.FollowingintheworkofDr.JanetTravell,attachmentsofthemusculaturehavebeendescribedintermsofproximalattachmentanddistalattachmentratherthanoriginandinsertion.Wehaveoptedfor thisdescriptiondue to theeffectofmanymusclesonboth locationsofattachment,making thetermsoriginandinsertioninaccuratedescriptors.

HandandFingerExtensors1.Movinglateraltomedialonthedorsal(posterior)surfaceoftheforearm

HandandFingerFlexors1.Movinglateraltomedialonthedorsal(posterior)surfaceoftheforearm

BIBLIOGRAPHY

Abbott,EdwinA.Flatland,ARomanceofManyDimensions.NewYork:HarperandRow,1983.Baldry, P. E. Acupuncture, Trigger Points and Musculoskeletal Pain. Edinburgh/London: ChurchillLivingstone,1989.

Bragdon,Claude.APrimerofHigherSpace.London:Kessinger,1999.Originallypublished1939.Calais-Germaine,Blandine.AnatomyofMovement.Seattle:EastlandPress,1993.Chaitow,Leon.TheAcupunctureTreatmentofPain.NewYork:Thorsons,1983.Chaitow,Leon.PalpatoryLiteracy.London:Thorsons,1991.Denmei,Shudo.IntroductiontoMeridianTherapy.Seattle:EastlandPress,1990.DiGiovanna, Eileen and Schiowitz, Stanley, eds.AnOsteopathic Approach toDiagnosis and Treatment.Philadelphia:Lippincott,1991.

Dvorak,JiriandDvorak,Vaclav.ManualMedicine(2ndedition).Stuttgart:GeorgThiemeVerlag,1990.______.ManualMedicineChecklist,Stuttgart:GeorgThiemeVerlag,1990.Field,Derek.Anatomy,Palpation,andSurfaceMarkings.Oxford:Butterworth-Heinemann,1994.Goldfinger,Eliot.HumanAnatomyforArtists.NewYork:OxfordUniversityPress,1991.Gunn,C.Chan.TreatingMyofascialPain: Intramuscular Stimulation forMyofascialPain Syndromes ofNeuropathicOrigin. Seattle:MultidisciplinaryPainCenter,University ofWashingtonMedicalSchool,1989.

Hammer, Warren. Functional Soft Tissue Examination and Treatment by Manual Methods (TheExtremities).Gaithersburg,Md.:Aspen,1991.

Headley,B.J.,“EMGandMyofascialPain,”inClinicalManagement,vol.10,no.4.July-Aug.,1990.Hoppenfeld, Stanley. Physical Examination of the Spine and the Extremities, Norwalk, Ct.: Appleton-Century-Crofts,1976.

Jenkins,DavidB.Hollinshead’s Functional Anatomy of the Limbs andBack (6th edition). Philadelphia:Saunders,1991.

JwingMing,Dr.Yang.TaiChiTheoryandMartialPower.JamaicaPlain,Ma.:YMAAPublicationCenter,1987.

Kapit,Wynn,andLawrenceElson.TheAnatomyColoringBook.NewYork:HarperandRow,1977.Kendall,Florence,ElizabethMcCreary,andPatriciaProvance.Muscles:TestingandFunction.Baltimore:WilliamsandWilkins,1993.

LaoTsu.TaoteChing.TranslatedbyGia-FuFengandJaneEnglish.NewYork:Vintage,1972.Maciocia, Giovanni. The Foundations of Chinese Medicine. Edinburgh/London: Churchill Livingstone,1989.

Magee,DavidJ.OrthopedicPhysicalAssessment.Philadelphia:Saunders,1992.Mennell,JohnMcMillan.TheMusculoskeletalSystem.Gaithersburg,Md.:Aspen,1992.Moore,KeithL.ClinicallyOrientedAnatomy(2ndedition).Baltimore:WilliamsandWilkins,1985.Nielsen,Arya.GuaSha:ATraditionalTechniqueforModernPractice.NewYork:ChurchillLivingstone,1995.

Pirog,JohnE.ThePracticalApplicationofMeridianStyleAcupuncture.Berkeley:PacificView,1996.Platzer,Werner,M.D.ColorAtlas:TextbookofHumanAnatomy, vol I (LocomotorSystem) (4th edition).

NewYork:ThiemeMedical,1992.Richer,Paul.ArtisticAnatomy.NewYork:Watson-Guptil,1971.Schneider,Werner,HansSpring,andThomasTritschler.Mobility:TheoryandPractice.NewYork:ThiemeMedical,1992.

Seem,Mark.ANewAmericanAcupuncture.Boulder:BluePoppyPress,1993.Sieg, Kay, and Sandra Adams. Illustrated Essentials of Musculoskeletal Anatomy. Gainsville, Fl.:Megabooks,1985.

Tortora,Gerard,andNicholasAnagnostakos.PrinciplesofAnatomyandPhysiology.NewYork:HarperandRow,1981.

Travell, Janet, and David Simons.Myofascial Pain and Dysfunction:The Trigger Point Manual, vol I.Baltimore:WilliamsandWilkins,1983.

______.Myofascial Pain and Dysfunction:The Trigger Point Manual, vol II. Baltimore: Williams andWilkins,1992.

Upledger,John,andJonVredevoogd.CraniosacralTherapy.Seattle:EastlandPress,1983.Wadsworth, Carolyn T. Manual Examination and Treatment of the Spine and Extremities. Baltimore:WilliamsandWilkins,1988.

Essentials of Chinese Acupuncture. Compiled by Beijing College of Traditional Chinese Medicine,ShanghaiCollege ofTraditionalChineseMedicine,NanjingCollege ofTraditionalChineseMedicine,andtheAcupunctureInstituteofTraditionalChineseMedicine.Beijing:ForeignLanguagesPress,1980.

Academy of Traditional Chinese Medicine. An Outline of Chinese Acupuncture. Beijing: ForeignLanguagesPress,1975.

ABOUTTHEAUTHORS

Donna Finando, L.Ac., L.M.T., is a practitioner of acupuncture and massage,specializing inmyofascialmeridian therapy andmyofascial release techniquesfor the treatment of chronic and acute pain and dysfunction. She studiedextensivelywithJanetTravell,M.D.,apioneerinthefieldofpainmanagement.She livesonLongIsland,NewYork,whereshehasbeen incontinualpracticesince1976.She iscoauthorofTriggerPointTherapy forMyofascialPainandtheauthorofTriggerPointSelf-CareManual andAcupoint andTriggerPointTherapyforBabiesandChildren.

StevenFinando, Ph.D., L.Ac., is currently on the advisory board for theNewYork Chiropractic College School of Acupuncture and OrientalMedicine. Hestudied extensively with Janet Travell, M.D., a pioneer in the field of painmanagement. Steven lives on Long Island, New York, where he has been incontinualpracticeforthepast29years.

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