To copy n paste into a word document press n hold control ... · Web viewIf you have the textbook, Myofascial Pain and Dysfunction the Trigger Point Manual by doctors Janet Travell

Beyond Trigger Points Seminar UPPER TORSO & SHOULDER UNIT MODULE 1

Welcome to Beyond Trigger Point Seminars Module 1 on the Upper Torso and Shoulder. This is Cathy Cohen. In this presentation you will be studying the muscles of the rotator cuff. Our five learning objectives for this module are one: improving your ability to identify which muscles are involved by just listening to your client’s story of injury. Next you will be able to recognize a number of pain patterns and dysfunctions associated with the shoulder. Hopefully, your level of confidence in identifying perpetuating factors will increase so you can design a home program for your client. Fourth, you will be able to answer this commonly asked question, “Why didn’t my shoulder heal on its own?” Finally, you will be studying the 11 documented trigger points associated with these four muscles. Starting tomorrow, you can begin locating these trigger points on your clients. For those of you registered for a workshop, the hands-on portion of this program will further enhance your palpation skills.

A little housekeeping first, have you printed out the study guide for this unit? Even writing with the palest ink will help you remember what you are hearing. The study guide is also loaded with pictures found in our textbook. If you have the textbook, Myofascial Pain and Dysfunction the Trigger Point Manual by doctors Janet Travell and David Simons, you might prefer having it or some other text on trigger points nearby. Also, if you haven’t already listened to the introductory online lecture, I encourage you to do that now. It can be found at www.askcathycohen.com.

So as review, a trigger point (TrP) is a hyperirritable spot within a taut band of skeletal muscle. The spot is painful on compression and gives rise to predictable referred pain, tenderness, motor dysfunction and autonomic phenomena. An active trigger point reproduces the client’s pain patterns; when compressed the client can tell if the referred pain pattern is familiar. A latent trigger point also produces a predictable referral pattern but only hurt if you’re pressing on it. So latent trigger points are producing increased tension levels in the muscle but not spontaneously referring pain. However, it may not take much injury or strain to turn a latent TrP into an active one.


When one or more trigger points are present a physician would diagnosis the condition as a myofascial pain syndrome (MPS). When I was in training, the origin of trigger points was unknown. Now, thanks primarily to histological and electromyographic studies, researchers have proven trigger points to be a neuromuscular disease entity.

My first position out of training was with a neurologist, Dr. Byrd. He was very excited when I first met him. He had stayed up all night long reading our textbook, Myofascial Pain and Dysfunction the Trigger Point Manual by doctors Janet Travell and David Simons. He said to me I just figured out a third of all of my chronic pain patients have myofascial pain syndromes due to trigger points. Then he said with a gloomier face, I don’t have the time to treat them. That’s why he hired me. As a massage therapist we have the time to care for our clients. We have the time to treat soft tissue. We have the time to identify perpetuating factors and thoroughly treat the pain and dysfunction associated with myofascial pain syndromes due to trigger points.

There are a number of ways you can begin identifying trigger points. One way is to memorize where the documented trigger points are so you can make educated guess as to where to find them. Two of the rotator cuff muscles’ trigger points are located at attachment sites. The other 9 are central trigger points. By definition, an attachment trigger point is found in the muscle fibers merging into tendons or periosteal insertions. By definition, a central trigger point is found in the belly of a muscle. If you mentally chop off the tendons and then guess where the middle portions of the muscle fibers are, you can make good educated guesses on the central TrP location. The rotator cuff muscles have long parallel fiber arrangements. I think you’ll find these trigger points easy to locate.

I’ve saved the most important method for identifying a trigger point till now because, as a massage therapist, you are already trained and practiced in palpating for taut bands. How many times have you used a cross-fiber or longitudinal stripping stroke and felt a cord like speed bump of bunched up muscle fibers? If you have, then you already know how to look for a trigger point. By intentionally palpating along the taut band, you may locate an eighth of an inch to quarter of an inch exquisitely tender spot. Starting tomorrow slowly and gently compress that spot and ask your client, “Do you feel

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sensation traveling elsewhere?” If you are able to reproduce their pain complaint, then you can assure your client you may be able to help them.

At the top of page 2 of your student study guide, you can now fill in the blanks for the five criteria used in identifying active or latent trigger points.

1. Palpable taut bands. The fill-in is palpable. When we’re trying to assess if the source of pain is from a trigger point, remember to first find the taut band. 2. Exquisite tenderness. Remember we said by definition a trigger point is tender when you press on it otherwise it's not a trigger point.3. Patient recognition of their pain complaint when pressure is applied over the trigger point. I know this is a somewhat subjective finding; your client needs to recognize and report the sensations they are having while you are applying pressure. If we don’t ask them to communicate with us, they might not tell. So we need to be talking with our client about their pressure tolerance, and referred sensations. 4. Restricted range of motion. We’ll review ROM in our workshop. You’ll become experts at different types of assessment tests for the shoulder. If you're not already doing ROM testing, I want to encourage you to do ROM testing before and after a treatment. What you can measure makes such a difference in how a client perceives the work you just performed on them. If you can show and document measurable results, then you will instill in your client’s mind trust in your work. Also being able to document ROM improvements is helpful for the referring physician or insurance company. 5. Finally a local, and the fill-in is, twitch response, an LTR. When you're dead on the trigger point, the muscle may twitch. Have you seen this? A reflexive contraction of the muscles fibers within the taut band produces the LTR. With deeper muscles this response isn’t as observable. Nor will your client necessarily feel it twitch. However with a superficial muscle like the infraspinatus, an LTR is noticeable and thus a useful criteria for identifying the location of the trigger point.

Before we begin identifying the 11 trigger points of the rotator cuff, we need to regress for a moment and consider the bones forming the joints of the shoulder. The fill-ins at the bottom of page 2 are: scapula, humerus, clavicle and manubrium. These bones form the four joints.


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The glenohumeral joint is the primary shoulder joint. Because the articulation between the head of the humerus and the glenoid cavity on the scapula form a fairly shallow ball and socket joint, the shoulder is extremely mobile but not as stabile as say the hip joint. The most common dislocations causing ligament strain and tears occur with anteromedial movement such as when swinging a child under your legs or doing a dip type of push-up with a non-fixed scapula. All four of the rotator cuff muscles stabilize the glenohumeral joint by pulling the humerus head into scapula socket.

Another joint is formed where the acromion of the scapula articulates with the clavicle creating the acromioclavicular joint. On the bottom of page 3 of the study guide, do you see the lateral spine of the scapula articulating with the clavicle bone? This joint is also a reduced ball and socket joint and allows for a smooth gliding movement.

The sternalclavicular joint is formed where the sternum joins the medial head of the clavicle as seen on the top picture. This saddle joint allows for secondary movement of the scapula.

One more joint useful to assess when identifying problems of the subscapularis in particular is referred to as a pseudo joint. It is the area between the scapula and the ribs. It’s not a true joint in the sense that two bones are articulating. However the scapula should be able to float and move on top of the ribs. Some scapulas lift and move with freedom while others don’t. We’ll come back to that during the portion on the subscapularis.

On page 4 of study guide, the action to remember for the infraspinatus is lateral rotation.

Do you have colored pens or pencils ready? On page 533 of our textbook, 2nd

edition Volume 1, you see the documented trigger point sites for the infraspinatus. If you’re participating in this program without the textbook, that’s ok, just look at page 5 of your study guide with the infraspinatus picture and its four documented trigger points. Using a colored pencil or pen, draw on the body scan on page 4 of the study guide where you think the trigger points are located. Again, I suggest drawing an “X” on the body scan picture on page 4 where you think the trigger points are located and then draw the pain patterns just as you see them on page 5. The solid colored area you are drawing to the


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front and side of the deltoid and a little down the front of the bicep area is the primary pain complaint area. The client will take their hand and cup their deltoid to show you where it hurts. Now draw the dotted area extending down the arm, into the hand and possibly up to the base of the skull. These patterns are called secondary or spillover patterns. These spillover patterns may or may not be present when you compress on any of the three trigger points you just drew. So if you were to begin memorizing the pain pattern for the infraspinatus, commit the solidly colored area to memory first. Now draw the fourth trigger point shown on picture B. Its primary pain complaint is along the medial shoulder blade.

To help clinicians remember the pain pattern of the infraspinatus, Dr Travell nicknamed this muscle Shoulder Joint Pain. There is room on page 5 for you to write Shoulder Joint Pain if you think that might help you remember a key characteristic of this muscle.

Let’s move on to answer the question at the bottom of page 4, how is the infraspinatus activated and perpetuated?

The client usually knows how they injured this muscle because the onset is quick. You could think of the infra as the shoulder whip lash muscle. It is commonly involved in car accidents. If the hand is on the dash board or steering wheel, the shoulder will whip forward and rebound back again. The infraspinatus could then develop a TrP.

A tennis serve is another activating or perpetuating factor. Reaching out and back like when a person is falling, can activate the infraspinatus.

A woman presented to my office. She had a TrP in her infraspinatus which reproduced her pain complaint when compressed. She told me on the first visit she had no idea how this happened. During the second visit, because I was curious, I questioned her again about onset. She then sheepishly admitted trying to back slap her troublesome child in the back seat. One of my classes now refers to this as the “slapping the kid in the back seat” muscle!

Let’s go to page 6 now and answer the question, what findings and tests confirm involvement of the infraspinatus?


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Do you see the picture of the Hand to Shoulder Blade test? That movement requires the shoulder to adduct and medially rotate. When you place your dominate hand behind your back, do your fingertips reach within an inch of the opposite shoulder blade’s spine? If you do the same with your non-dominate hand, do the fingertips touch the spine of the scapula? So assuming you have a normal arm length, you would test negative for infraspinatus involvement if the fingertips come close to the mark. Because the range of motion shown in the picture is significantly diminished, we say that is a positive finding for infraspinatus involvement. If a person tells you they are having a difficult time fastening their bra or tucking in their shirt-tail, then you have another clue for an infraspinatus problem. Again, infraspinatus causes restriction of medial, also called internal, rotation.

It’s fun doing the detective work! Another finding to query your client about is their sleep position. People tend to sleep on the pain free side with infra involvement. It hurts too much to lie on the painful shoulder if they are a side sleeper. It causes too much medial rotation. According to one study, this is the third most common muscle to have a latent trigger point; the upper trapezius is the most common. So now because you know where to find the trigger points, you may begin encountering that front of the shoulder pain with more frequency.

Because the referred pain of an infraspinatus TrP is felt deep into the anterior joint; your client will want to dig at it to describe where it hurts. Bicep Tendonitis is a common diagnosis given for what really might be a myofascial pain syndrome. That diagnosis, Bicep Tendonitis, is the last finding for you to jot down.

This brings us to corrective actions. The infraspinatus responds beautifully to moist heat and self applied pressure such as rolling on a tennis ball or using a backknobber. For other ideas on self massage tools you could sell or use in your practice, visit the resource tab of www.beyondtriggerpoints.com. We also need to teach anatomical sleep positions to our clients. Picture A at the bottom of page 6 shows how to place the shoulder in neutral by resting the arm on a pillow placed near the chest. Picture B shows how most side lying sleepers rest until you train them otherwise. Having the shoulder rolled forward at night might have been fine before they developed a problem however if they want to maintain the muscular relieve gained from your great therapy, it’s absolutely BEYOND TRIGGER POINTS SEMINARS WWW.BEYONDTRIGGERPOINTS.COM © 2009-20018 Cathy Cohen, LMT

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critical they correct faulty sleep positions. Teaching anatomical sleep positions might be the most important life long tool you give your client.

The other critical piece distinguishing you from an ordinary therapist is your ability to motivate and teach your client how to enhance your therapy with a home stretching program. You could give the Hand to Shoulder Blade position as one home stretch repeated three to five times through out the day. The resource tab of the website will have several suggestions and the workshop spends a great deal of time educating on corrective actions. For now, to make your notes complete, write down stretches.

Spending the extra time to educate your clients on self care will distinguish you from the crowd of other therapist doing relaxation work. What will also put you a head above the others is completing your education on the Travell and Simons’ methodology of treating myofascial pain through this program or through some other school of neuromuscular therapy and then sitting for the National Board Examination of Certified Myofascial Trigger Point Therapists. If you decide you enjoy the challenge of being a clinical detective and are suited for motivating your clients to take care of themselves, consider gearing your studies towards this exam. At www.beyondtriggerpoints.com click on the Courses tab at the top and then follow the accreditation tab on the right side of the page where you will find more information on the Board Exam and the National Association of Myofascial Trigger Point Therapists. You want to be listed on their website. The number of certified trigger point therapists is relatively small now, but based on the impressive traffic visiting the National site, the public is looking to find therapists specializing in this proven, evidenced based protocol of trigger point treatment. So you want to be listed on their therapist directory to increase your business. Again, check out the link on my website and find out more about the National Association and the Board Exam.

Now let’s move on to the teres minor beginning on page 7 of the study guide.

As you may remember, teres minor is the little brother to infra. It has the same action of lateral rotation just like the infraspinatus but with a different innervation. We can nickname the teres minor the Silver Dollar Pain. On page 8 of the study guide or page 565 in the book, you will see one documented BEYOND TRIGGER POINTS SEMINARS WWW.BEYONDTRIGGERPOINTS.COM © 2009-20018 Cathy Cohen, LMT

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trigger point. The pain pattern is a patch of pain to the back of the shoulder about the size of a coin with some possible spillover down the back of the arm but not to the elbow. Now that you’ve drawn that and committed it to memory, I can say to you- this is the least involved. It’s usually involved in conjunction with other shoulder muscles.

So if you know the infraspinatus is the primary muscle involved, then on the 2nd

or 3rd treatment make sure you clean up teres minor as well. It’s activated and perpetuated by acute overload stresses such as with the arm up and back.

I had a student who worked on a ranch in Florida. She had a teres minor trigger point issue because she lassoed cattle. Having an arm up and back as in whipping a rope around is an action that can strain both the infra and teres minor.

What findings, testing and corrective actions are similar to the infraspinatus? It’s the same restricted hand to shoulder blade test you learned for the infraspinatus. The correctives for the teres minor are the same as the infraspinatus as well. When you are palpating off the lateral border of the scapula, you’ll also be able to feel a distinctive taut band in the teres minor when it’s become involved.

Let’s go to the supraspinatus muscle now. I think the importance of this muscle is captured in its nickname, Major Actor. When someone has been given the diagnosis of a rotator cuff problem, the supraspinatus may be a prime suspect. Before we explore the validity of that statement consider this: the shoulder joint is so complex that’s it’s difficult for even a well trained doctor to diagnose a problematic shoulder.

In a study of 123 patients with painful shoulders who were first clinically examined, then anesthetized and then underwent arthroscopic surgery; 55% still had an unclear diagnosis of the problem. Keep in mind, trigger points were not considered in this study.

Do you see the supraspinatus pain pattern on page 10? There’s three documented trigger points. Go ahead and draw those now. The two more lateral points are difficult to reach because of the thickness of the overlying upper trapezius muscle. For a referred pain pattern to be elicited, deep pressure needs


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to be applied into the supraspinatus fossa. The tenderness over the most lateral attachment spot, shown on picture B, is likely caused from enthesopathy.

Enthesopathy occurs at the musculotendinous junctures where the tendons and ligaments attach into bones or joint capsules. You may have felt the fibrosis and calcification of these junctures on some clients. Recurring stress in the belly of the supraspinatus can provoke strain and subsequent formation of enthesitis at the attachment site. Therapist, it is much easier to treat the stress in the belly then to treat the symptom of that stress at the attachment sites. Regular massage and stretching is a good preventative measure!

All three spots share similar pain patterns described as an ache into the mid deltoid region extending half way down the arm. The pain from an infraspinatus trigger point is felt more deeply into the shoulder joint and is mistaken for arthritis. When a client presents to your office with supraspinatus referral they’ll show you where it hurts by wrapping their hand around the front and back of the deltoid area. The pain might also be concentrated in the lateral epicondyle of the elbow.

Let me ask you this. When a client presents with a painful shoulder what other diagnoses might they have been given? Some common diagnoses are: bursitis, frozen shoulder, tendonitis, C5-C6 radiculopathy and this is one of my favorites, rotator cuff. It’s the term used by the patient. You may be hanging on to your chair waiting for them to recall what the doctor said, but all you’ll get is rotator cuff. Possible what the doctor said is they have a rotator cuff tear.

That’s the diagnosis we’ll focus on now. A rotator cuff tear is most accurately diagnosed with an MRI or Ultrasound. So make sure you ask them if they had either of those tests. With the diagnosis of a rotator cuff tear, we can still safely treat our client but only using our non-stretching treatment techniques. We do not stretch a shoulder with a tear and your client won't let you stretch it because it’s too painful.

A shoulder needs time to heal from a tear. According to one study documented in our textbook, patients with a small tear of less than 1 cm showed continued improvement of the tear 18 months after onset without any surgical intervention. So without surgery tears can heal. Though there’s been no controlled studies I know of on the contribution of trigger points to rotator cuff


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tears, consider this. We know trigger points can significantly contribute to increased muscle tension leading to enthesopathy at muscular insertions. We know trigger points in the infraspinatus for example creates weakness in the shoulder and can inhibit the other rotator cuff muscles. When the balance is lost and the stronger muscles are compensating for the weaker ones; the smooth, aligned movement of the glenohumeral joint is disturbed.

A common symptom of a shoulder imbalance is a catching sensation. As you ask your client to elevate their arm, a particular degree of movement will cause this catch and pain. Often you will be able to relieve this by treating all the TrPs affecting the scapulohumeral muscle imbalance.

Because we want to be more careful with our folks who present with a rotator cuff tear, on page 11 of the study guide, we’ll answer the question, how would you test for a rotator cuff tear? The answer is pain during a small arc of abduction. When you ask your client to abduct their arm, through a particular small arc of movement, pain will cause them to likely yelp and bring it back to a neutral position. So pain occurring during a small arc of motion can be caused from a tear while a muscular imbalance will cause a catch which is relieved by moving around the stuck position.

Now let’s answer what findings and tests confirm involvement of supraspinatus? I list three.

1. Pain during rest or throughout movement. 2. Some clients will hear snapping & clicking sounds over the glenohumeral

joint. This suggests that tautness from the supraspinatus fibers is interfering with the normal glide of the humeral head in the glenoid fossa.

3. Difficulty elevating the arm- like when brushing their teeth or pulling a shirt over their head.

Two factors which activate and perpetuate the supraspinatus are:

1. Prolonged elevation or abduction of the arms. So welders, hairdressers, painters, bartenders or teachers who write on black boards.


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2. Carrying a heavy object such as a suitcase with the arm hanging down to the side. The supraspinatus responds to the weight in the hand by elevating the shoulders.

Keep in mind that the supraspinatus is rarely involved by itself and it’s usually associated with the infraspinatus and the upper traps.

The corrective actions for this muscle can be easy.

Avoid carrying heavy objects. Work with the arms down. Stretch the involved side by placing the arm behind the back as if you’re

tucking in a shirt tail and then pulling the forearm across and upward with the other arm.

Apply self trigger point compression using an S hook type backknobber.

Moving on now to page 12 of our study guide; the action of the subscapularis is medial rotation. As we said earlier, all the rotator cuff muscles stabilize the glenohumeral joint by keeping the head of the humerus in the glenoid fossa. To fully abduct or flex the arm, the humerus must and the fill-in is, laterally rotate. As we look at some of the ways you will determine subscapularis involvement, the significance of that statement will become evident.

But first on page 13 or page 598 of the book, take a look at the three documented TrPs of the subscapularis. Its nickname is Frozen Shoulder. This is the muscle I want you to think about when someone has that diagnosis. You can only reach the two laterally positioned TrPs along the lateral border of the ventral surface of the scapula by abducting the shoulder blade. So when the client is on their back and you’re sitting alongside them facing their head, you’ll need to pull the shoulder blade towards you to reach the lateral border of the subscapularis. The other more medially placed trigger point lays too medial for your finger to palpate.

Go ahead and draw the pain pattern. The primary complaint is to the back of the arm pit. There might also be a primary pain complaint across the dorsal side of their wrist. Your client might not think to tell you this unless you ask. Dr.


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Travell said to observe if they have taken their watch off. Even the light touch of any jewelry across the wrist can be uncomfortable.

This is a very interesting muscle to assess. I know I’m still learning. On page 14, some findings and tests you can rely on to confirm a moderately active subscapularis include two range of motion tests.

1. First, test shoulder abduction. Remember you wrote, to fully elevate the arm, both in abduction and flexion, the humerus has to laterally rotate. In other words, bringing the arm above shoulder height requires the humerus to laterally rotate in the glenohumeral joint. Trigger points in the subscapularis restrict lateral rotation. So if movement is limited to about 90 degrees or less, think subscapularis.

2. Next, if you are examining a shoulder with restricted abduction, determine if the scapula is moving freely. By placing your hand on the shoulder blade, you can determine if the scapula is moving during abduction of the arm. The subscapularis is involved by itself if the arm movement is restricted and the scapula moves freely. So again, along the pseudo joint between the shoulder blade and ribs, you will see or feel movement when the subscapularis is involved all by itself.

A visual confirmation for subscapularis is a medially rotated shoulder. On the table, one shoulder will be lifted off more than the other.

And finally, as is true for all the other rotator cuff muscles, if you can palpate a taut band, compress a hypersensitive spot within it and reproduce your client’s pain pattern, then bingo- you have a trigger point.

Activation and perpetuation of the subscapularis involve repetitive medial rotation. My niece is on a full collegiate swim scholarship at Penn State. She recently informed me how she had trained the team’s therapist to find her subscapularis. I thought that was rather brave of her considering how uncomfortable treating the subscapularis can be and how often she glared at me when my fingers were deep into her subscapularis. But she has her sight set on being an Olympian and appreciates the work. The repetitive motion of swimming particularly during the butterfly and free style stroke can put some serious tightness into the subscapularis. Baseball pitchers also develop subscapularis involvement.


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Other factors activating the subscapularis are trauma to the shoulder joint, prolonged immobilization as when someone has their arm in a sling for a broken arm.

When I worked with a group of neurologist on the Eastern Shore, Maryland, home of Perdue Chicken, a number of factor workers presented with the diagnosis of a frozen shoulder but who in fact had subscapularis trigger points. Their job was to pull dead chickens along a conveyor line while they pulled and plucked the carcass clean. All day long these workers would reach forward, pull the carcass along and pluck.

Piano players are also prone to subscapularis involvement. I’m sure each of you can think of some other job or recreational holding patterns which put the shoulders in a medially rotated position.

There are correctives to counteract the strain. I’ll mention three.

1. Good posture is number one. During the hands-on segment of this program, our structural goal is to take medial rotation out of the humerus. We aim to lift the chest and drop the shoulders down in the back.

2. A doorway stretch is an excellent way to elongate the subscapularis and can be found on the Resource tab of the website.

3. Finally correcting sleep positions as shown on the bottom of page 14 will also help.

That concludes the rotator cuff muscles. Stay in touch.


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Documents

To copy n paste into a word document press n hold control ... · Web viewIf you have the textbook, Myofascial Pain and Dysfunction the Trigger Point Manual by doctors Janet Travell