Myofascial Release & Myofascial Release & Trigger Point TherapyTrigger Point Therapy
Modern Manual Therapy IModern Manual Therapy I
KNR 494KNR 494
FasciaFascia• 3D network of connective tissue from 3D network of connective tissue from
head to toehead to toe
• ContainsContains- Vascular structuresVascular structures- Adipose cellsAdipose cells- Sensory receptors Sensory receptors (Manheim, 2001)(Manheim, 2001)
• Myofascial tissue?Myofascial tissue?
Myofascial TissueMyofascial Tissue(Marieb, 2004)
Myofascial PainMyofascial Pain• Originates in both muscle & fasciaOriginates in both muscle & fascia
• SymptomsSymptoms- Deep, sharp, burning, dull, diffuse, Deep, sharp, burning, dull, diffuse,
heavy, squeezing heavy, squeezing
• Needs to be treated quicklyNeeds to be treated quickly- Why?Why?
What is Myofascial Release What is Myofascial Release (MFR)?(MFR)?
• Interactive stretching technique that Interactive stretching technique that uses manual pressure to facilitate uses manual pressure to facilitate maximum relaxation of tight or maximum relaxation of tight or restricted tissuesrestricted tissues- DirectionDirection- ForceForce- Duration Duration (Manheim, 2001; (Manheim, 2001; Ferguson & Ferguson &
Gerwin)Gerwin)
““Fixes/Anchors”Fixes/Anchors”• ForearmForearm• ElbowElbow• FistFist• Palm Palm • GripGrip• Reinforced thumbsReinforced thumbs• Finger(s)Finger(s)• Knuckle(s)Knuckle(s)• External devices External devices
(Manheim, 2001)
Direction of StretchDirection of Stretch
• Horizontal Horizontal • DiagonalDiagonal• Perpendicular Perpendicular • Vertical Vertical
Why not just use a gross Why not just use a gross stretch?stretch?
Benefits of MFR over GTBenefits of MFR over GT
• Less expensiveLess expensive• Patient easePatient ease• Less invasiveLess invasive• Self-treatSelf-treat• Tightness vs. restrictionsTightness vs. restrictions• Difficult to evaluate some areas with Difficult to evaluate some areas with
GTGT
General IndicationsGeneral IndicationsMyofascial restrictionsMyofascial restrictions• Pain has not been alleviated by other Pain has not been alleviated by other
treatmentstreatments• Pain is complex, global, or specific pain Pain is complex, global, or specific pain • Underlying chronic condition causing Underlying chronic condition causing
tightness and restrictionstightness and restrictions• Complex postural asymmetriesComplex postural asymmetries• Athlete needs stretching to increase Athlete needs stretching to increase
performance and prevent injury performance and prevent injury (Manheim, 2001)
Precautions/Precautions/ContraindicationsContraindications
Myofascial RestrictionsMyofascial Restrictions• Inflammation Inflammation • Patient uncomfortable with touchPatient uncomfortable with touch• DermatitisDermatitis• Contagious/infectious disease Contagious/infectious disease • Fractures/open woundsFractures/open wounds• Circulatory problemsCirculatory problems• Taking blood clotting medicine Taking blood clotting medicine • Osteoporosis Osteoporosis (Manheim,
2001)
MFR Treatment StepsMFR Treatment Steps
1.1. Gross stretch of entire body area Gross stretch of entire body area
2.2. Focused stretch of muscles in same Focused stretch of muscles in same body areabody area
3.3. Finish with gross stretch of entire Finish with gross stretch of entire musclemuscle
Focused StretchFocused Stretch• One hand, finger or body One hand, finger or body
weight acts as anchor weight acts as anchor • Use broad surface to apply Use broad surface to apply
stretch if possible for large stretch if possible for large musclesmuscles
• For smaller muscles – use For smaller muscles – use 1 or 2 fingers1 or 2 fingers
Focused StretchFocused Stretch• 1-2 fingers of each hand1-2 fingers of each hand• 1 or both hands may move1 or both hands may move• Distance between fingers may be Distance between fingers may be
several millimeters/inchesseveral millimeters/inches
Levels of MFRLevels of MFR
1.1. No stretch/pre-tension No stretch/pre-tension
2.2. Pre-tension (stripping)Pre-tension (stripping)
3.3. Moderate passive stretch Moderate passive stretch
4.4. Active MFRActive MFR(Leahy & Mock)(Leahy & Mock)
Common MistakesCommon Mistakes
• Too much pressureToo much pressure
• Too long of stretchToo long of stretch
• Too many applicationsToo many applications
Myofascial Trigger PointsMyofascial Trigger Points
Myofascial Trigger Points Myofascial Trigger Points (TP)(TP)
• A hyperirritable spot located within a A hyperirritable spot located within a taut band of skeletal muscle or its taut band of skeletal muscle or its fasciafascia- ActiveActive- Latent Latent
(Travell & Simons, (Travell & Simons, 1983)1983)
(Marieb, 2004)
Overloading Stretch/shorteni
ng Micro/macro
trauma
Destruction of sarcolema & SR
Release of Ca2+
Sustained muscle
contractionIschemia, hypoxia,
metabolic waste
Trigger point formation/activatio
n
Release of nociceptive substances
Local pain, muscle guarding & REFERRED PAIN
Loss of flexibility
(Kostopoulos & Rizopoulos, 2001)
How can TP therapy How can TP therapy alleviate this pathologic alleviate this pathologic cycle?cycle?
Considering FibromyalgiaConsidering Fibromyalgia
Trigger PointsTrigger Points• No gender biasNo gender bias
• Can be sudden & Can be sudden & related to specific related to specific movementsmovements
• Often have taut Often have taut bands and twitch bands and twitch responsesresponses
FibromyalgiaFibromyalgia
General IndicationsGeneral Indications
Myofascial Trigger PointsMyofascial Trigger Points• Frequently complaints of Frequently complaints of
referred painreferred pain• Autonomic & Autonomic &
proprioceptive proprioceptive disturbances disturbances
• Taut band Taut band • Tender and painful Tender and painful
nodules nodules • Local twitch responseLocal twitch response• Limited ROMLimited ROM• Muscle weaknessMuscle weakness
(Kostopoulos & Rizopoulos, 2001)
Precautions/Precautions/ContraindicationsContraindications
Trigger PointsTrigger Points• Inflammation Inflammation • Patient uncomfortable with touchPatient uncomfortable with touch• DermatitisDermatitis• Contagious/infectious disease Contagious/infectious disease • Fractures/open woundsFractures/open wounds• Circulatory problemsCirculatory problems• Taking blood clotting medicine Taking blood clotting medicine • Osteoporosis Osteoporosis (Manheim,
2001)
Trigger Point TherapyTrigger Point TherapyProgressive pressure Progressive pressure
technique/Ischemic Compressiontechnique/Ischemic Compression• Use pain as guideUse pain as guide
- Varying pressure (light Varying pressure (light pressure/stretching, heavy pressure)pressure/stretching, heavy pressure)
• 10 seconds to 2 minutes10 seconds to 2 minutes• Follow with myofascial stretching Follow with myofascial stretching • Positive stretch signPositive stretch sign
(Kostopoulos & Rizopoulos, 2001)
Trigger Point Therapy: Self Trigger Point Therapy: Self TreatmentTreatment
Trigger Point TherapyTrigger Point Therapy
Positional Release Therapy/Strain-Positional Release Therapy/Strain-CounterstrainCounterstrain
• Trigger points are addressed while Trigger points are addressed while body is a position of comfortbody is a position of comfort
(D’Ambrogio & Roth, 1997)(D’Ambrogio & Roth, 1997)
Physiologic basis?Physiologic basis?Reduce muscle spindle Reduce muscle spindle inputinput
Trigger Point TherapyTrigger Point TherapyIce-and-stretchIce-and-stretch• Apply ice in sweeping motion Apply ice in sweeping motion • Slow continual passive stretch is applied at same Slow continual passive stretch is applied at same
time as ice applicationtime as ice application• Can also add contraction of antagonistCan also add contraction of antagonist• Can repeat for several cyclesCan repeat for several cycles
Trigger Point TherapyTrigger Point Therapy
Stripping MassageStripping Massage• Deep-stroking massage applied with Deep-stroking massage applied with
minimal lubrication on the fingertipsminimal lubrication on the fingertips• Increase pressure with each successive Increase pressure with each successive
pass along musclepass along muscle
Both stripping and ischemic compression Both stripping and ischemic compression are believed to cause a reflexive hyperemia are believed to cause a reflexive hyperemia that returns the site to a normal conditionthat returns the site to a normal condition
Myofascial & Trigger Myofascial & Trigger Point Treatments:Point Treatments:Upper ExtremitiesUpper Extremities
Gross Stretch of Upper Gross Stretch of Upper QuarterQuarter
Arm PullArm Pull• Supine Supine • Stretch parallel to floorStretch parallel to floor• Hold for release and repeatHold for release and repeat
CautionCaution• ATC must be relaxedATC must be relaxed• Elbow flex contracture Elbow flex contracture • Hypermobile elbow Hypermobile elbow
Gross Stretch of Upper Gross Stretch of Upper QuarterQuarter
Bilateral Arm PullBilateral Arm Pull• Supine/proneSupine/prone• Stretch parallel to Stretch parallel to
floorfloor• Hold for release and Hold for release and
repeatrepeat
Posterior Cervical: TPPosterior Cervical: TP
SuboccipitalsSuboccipitals
Splenius capitusSplenius capitus
Posterior CervicalPosterior Cervical
Make sure you know pathologies associated with muscles
Posterior CervicalPosterior Cervical
Posterior CervicalPosterior Cervical
Scalenes: TPScalenes: TP
PathologyCombine with joint mobilizationIntercostals
Upper Trapezius: TPUpper Trapezius: TP
Upper TrapeziusUpper Trapezius
Upper Trapezius (Active Upper Trapezius (Active MFR)MFR)
(Johnson, 2009)
Sternocleidomastoid: TPSternocleidomastoid: TP
Subacromial Impingement: Subacromial Impingement: Forward HeadForward Head
• Causes:Causes:- Stretch of levator scapulaeStretch of levator scapulae
• Decreases scapular:Decreases scapular:- Posterior tiltPosterior tilt- Upward rotation Upward rotation
(Ludewig et al, 1996)(Ludewig et al, 1996)
Levator Scapulae: TPLevator Scapulae: TP
X
Levator Scapulae (Active Levator Scapulae (Active MFR)MFR)
(Johnson, 2009)
Acromioclavicular Ligament: Acromioclavicular Ligament: ReleaseRelease
Subacromial Impingement: Subacromial Impingement: Rounded ShouldersRounded Shoulders
• Causes:Causes:- Tight serratus anterior & Tight serratus anterior &
pectoralis minor & majorpectoralis minor & major
(Kendall, 2005)(Kendall, 2005)
• Increases scapular:Increases scapular:- ProtractionProtraction
Pectoralis Major: TPPectoralis Major: TP
Pectoralis MajorPectoralis Major
Pectoralis Major: ReleasePectoralis Major: Release
Pectoralis Major: Traction Pectoralis Major: Traction ReleaseRelease
Scapular Release:Scapular Release:ProtractionProtraction
Scapular Release:Scapular Release:ProtractionProtraction
Scapular ReleaseScapular Release
• Translate scapula toward spineTranslate scapula toward spine- SuperiorlySuperiorly- InferiorlyInferiorly
Scapular Release with Pectoral Scapular Release with Pectoral StretchStretch
Scapular ReleaseScapular Release
• Side lyingSide lying• Push scapula superiorlyPush scapula superiorly• Pull humerus inferiorlyPull humerus inferiorly
Pathology?Pathology?
Anterior Capsule ReleaseAnterior Capsule Release
Effective for adhesive capsulitisEffective for adhesive capsulitis
Pectoralis Minor: TPPectoralis Minor: TP
Pectoralis MinorPectoralis Minor
Perctoralis MinorPerctoralis Minor
SupineSupine
Pectoralis MinorPectoralis Minor
Deltoids: TPDeltoids: TP
DeltoidsDeltoids
Latissimus Dorsi: TPLatissimus Dorsi: TP
Latissimus DorsiLatissimus Dorsi
Latissimus DorsiLatissimus Dorsi
Prayer position
Middle/Lower Trapezius: TPMiddle/Lower Trapezius: TP
Lower/Middle TrapeziusLower/Middle Trapezius
Middle TrapeziusMiddle Trapezius
Lower TrapeziusLower Trapezius
Rhomboids: TPRhomboids: TP
RhomboidsRhomboids
Teres Major: TPTeres Major: TP
Teres MajorTeres Major
Serratus Anterior: TPSerratus Anterior: TP
Serratus AnteriorSerratus Anterior
Side lying with arm behind back
Subscapularis: TPSubscapularis: TP
Focused Stretch: Focused Stretch: SubscapularisSubscapularis
Subscapularis ReleaseSubscapularis Release
Subscapularis ReleaseSubscapularis Release
Supraspinatus: TPSupraspinatus: TP
SupraspinatusSupraspinatus
GIRDGIRD
Infraspinatus: TPInfraspinatus: TP
X
InfraspinatusInfraspinatus
Infraspinatus (Passive MFR)Infraspinatus (Passive MFR)
Teres Minor: TPTeres Minor: TP
Teres MinorTeres Minor
• Additional stretchAdditional stretch- Place patient’s arm in internal rotationPlace patient’s arm in internal rotation
Teres Minor (Passive MFR)Teres Minor (Passive MFR)
Posterior Capsule (Passive Posterior Capsule (Passive MFR)MFR)
Biceps Brachii: TPBiceps Brachii: TP
Biceps BrachiiBiceps Brachii
Triceps: TPTriceps: TP
Supinator: TPSupinator: TP
Supinator: TPSupinator: TP
Extensor Carpi RadialisExtensor Carpi Radialis(Longus & Brevis): TP(Longus & Brevis): TP
Pronator Teres: TPPronator Teres: TP
Carpal Tunnel SyndromeCarpal Tunnel Syndrome
Flexor Carpi Ulnaris: TPFlexor Carpi Ulnaris: TP
Flexor MassFlexor Mass