2. Lower Torso Pictorial index. The muscles that are likely to
refer pain to an illustrated region of the body are listed in the
Pain-and-Muscle Guide to the corresponding Part of the Manual. A
Guide is found at the beginning of each Part, which is marked by
red thumb tabs. Pain-and-Muscle Guide Chapter 3 Hip, Thigh, and
Knee Pain-and-Muscle Guide Chapter 11 BACK VIEW FRONT VIEW Leg,
Ankle, and Foot Pain-and-Muscle Guide Chapter 18
3. VOLUME 2 Myofascial Pain and Dysfunction The Trigger Point
Manual THE LOWER EXTREMITIES
4. This is the second of two volumes, and contains information
relating to the "lower half" of the body. Volume 1 deals with the
"upper half" of the body. The contents and indices for both volumes
are included in this book for the reader's convenience.
5. VOLUME 2 Myofascial Pain and Dysfunction The Trigger Point
Manual THE LOWER EXTREMITIES Illustrations by Barbara D. Cummings
JANET G. TRAVELL, M.D. Honorary Clinical Professor of Medicine The
George Washington University School of Medicine Washington, D.C.
DAVID G. SIMONS, M.D. Clincial Professor Department of Physical
Medicine and Rehabilitation University of California, Irvine
Irvine, California
6. Editor: John P. Butler Managing Editor: Linda Napora Copy
Editor: Shelley Potler Designer: JoAnne Janowiak Illustration
Planner: Wayne Hubbel Production Coordinator: Charles E. Zeller All
rights reserved. This book is protected by copyright. No part of
this book may be reproduced in any form or by any means, including
photocopying, or utilized by any information storage and retrieval
system without written permission from the copyright owner.
However, this book may be reproduced royalty free for United States
Governmental purposes. Accurate indications, adverse reactions, and
dosage schedules for drugs are provided in this book, but it is
possible that they may change. The reader is urged to review the
package information data of the manufacturers of the medications
mentioned. Made in the United States of America Library of Congress
Cataloging-in-Publication Data (Revised for volume 2) Travell,
Janet, 1901-1997 Myofascial pain and dysfunction. Includes
bibliographies and indexes. 1. MyalgiaHandbooks, manuals, etc. 2.
MusclesDiseasesHandbooks, manuals, etc. 3. Fasciae
(Anatomy)DiseasesHandbooks, manuals, etc. 4. Myofascial pain
syndrome. 5. Mus- cles. I. Simons, David G. II. Trigger point
manual. III. Title. RC925.5.T7 1983 616.7'4 82-8555 ISBN
0-683-08366-X (v. 1) ISBN 0-683-08367-8 (v. 2) Lippincott Williams
& Wilkins 5 3 0 W a l n u t Street Philadelphia, PA 1 9 1 0 6
00 01 10 11 12
7. TO Lois Statham Simons whose contributions enriched this
book and with whom it became a rewarding way of life
8. Foreword John V. Basmajian Superlatives come easily in
considering what Drs. Travell and Simons have done in rounding out
their epoch-making and highly successful Trigger Point Manual with
this Volume 2. Many must have thought that producing the excellent
Vol- ume 1 was so exhausting that the authors were not going to be
able to produce a fit- ting sequel. Such fans will be as delighted
as I (who was impatient, not pessimistic). The pessimists were
completely wrong. I believe this volume is even better than the
other because it reflects an enormous new recharging of energy that
further ex- perience, interaction, and thought have stimulated.
Thus, Volume 2 has become much more than it originally promised to
be; i.e., it was to be a rounding out of practical considerations
in the anatomical sense of dealing with the lower half of the body.
Volume 1, indeed, dealt with the up- per half of the body, but it
also laid out the important principles of the myofascial pain
syndromes (MPS) and hands-on techniques that were state-of-the-art
then. This new volume has the distinction of going considerably
beyond those areas to discuss rationale, new principles arising
from a ground-swell of experience, and the unique place of MPS in
the spectrum of musculoskeletal disorders. No book, not even Volume
1, has attempted this broad view before, and probably no other
authors now could do it as well-if at all. Myofascial trigger
points and their sig- nificance in painful conditions are no longer
the rather controversial subject they were before Volume 1
appeared, nor are the treatment methods taught by Drs. Travell and
Simons. These are firmly es- tablished and are increasingly being
vali- dated by once skeptical clinical investiga- tors. This volume
goes beyond and opens up new ground in sensitizing clinicians to
the important interfaces between myo- fascial pain syndromes and
articular (so- matic) dysfunctions on the one hand and fibromyalgia
(fibrositis) on the other hand. I applaud the wise manner in which
these issues are addressed, as- sessed, and integrated. When I
first began to learn that Fluori- Methane spray had a deleterious
effect on the ozone layer, I was dismayed and dis- heartened for
both my two friends and the many patients who would be denied the
spray-and-stretch treatments. It is so heartwarming and exciting to
see these innovators fully recognizing the environ- mental risks
and acting with firmness. In- stead of making excuses and
persisting in the use of fluorocarbons, they have found adequate
alternative techniques and are actively seeking adequate
substitutes. My instincts assure me that they will suc- ceed.
Meanwhile, it is important that the chemical coolants are only the
means to an end that can be achieved by following the lessons to be
learned in Volume 2. There are a multitude of clinically valu- able
gems throughout this volume. Some are boldly displayed (e.g.,
postisometric relaxation and cautions for patients with
hypermobility); others are scattered liber- ally throughout the
text and may be over- looked by the inexperienced reader. Of
course, on seeing the eloquent illus- trations, casual browsers
will be deeply impressed. I predict that they will soon be at risk
of becoming serious and devoted readers. The drawings are not
approxi- mate renderings by a clever artist of what the authors
"want." They are exactly what the authors require, carefully
integrated vii
9. viii Foreword with the text by a close authorartist rela
tionship. Rarely have I seen such a perfect match. The chapters on
individual muscles below thewaistwere,ofcourse,supposedtobethe
reasonforVolume 2. Alone,theycouldmakethe
bookanimportantaidforclinicians.Butonce again, they go far beyond
the How To ap proach implied by the title Manual. They embody the
stateoftheart of dealing with
paininandaroundtheindividualmusclesina way that I have never before
seen for those muscles. Morphology, function, and commonsense
approaches are melded with greatstyleandclarity. In short, I am
greatly honored and pleased to have had the opportunity to write
this Foreword. It is a volume that has set a very
highmarkforallauthorsinthisfieldtotryto reach.Itisthe
bookforitstime,andaninstant classic formanyyearstocome.
JohnV.Basmajian,M.D.,FRCPC, FACA,FACRM(Australia),FSBM, FABMR
ProfessorEmeritus,McMaster University Hamilton,Ontario Canada
10. Preface Volume 2 of The Trigger Point Manual con- cerns the
muscles of the lower half of the body as Volume 1 dealt with the
muscles of the upper half of the body. This vol- ume follows the
same format with the same careful attention to detail found in
Volume 1 and, again, reflects the close collaboration and
interdependence of the coauthors who bring to it, respectively,
their clinical expertise and insatiable cu- riosity as to how and
why. Preparation of this volume has been spurred by the broad
acceptance of Vol- ume 1. The first volume has now sold over 50,000
copies, partly because practi- tioners who have learned to use it
have brought relief to their patients, and partly because
practitioners became aware of it through the slides of all of its
figures, eco- nomically supplied by the illustrator, Bar- bara D.
Cummings. Volume 1 has been printed in English, Russian, and
Italian and is scheduled to appear in German, French, and Japanese.
Patients suffering from myofascial pain will benefit greatly as the
recognition and management of myofascial pain syndromes are
incorpo- rated into the curricula of medical schools and physical
therapy schools. The reader will notice several differ- ences
between Volume 1 and Volume 2. This volume includes frequent
references to related manual medicine diagnoses and treatment. The
therapy sections de- scribe alternative treatment techniques that
do not require vapocoolant spray, techniques that will serve as a
substitute until an environmentally safe vapocool- ant is
available. These other treatment techniques are summarized in
Chapter 2. Paragraphs set in smaller type indicate material that
may not be essential to the management of patients' symptoms; how-
ever, this material cites the details and references on which
summary statements are based. The supplementary references at the
end of each anatomy section are provided primarily for the benefit
of teachers and advanced students. This volume includes unique
features and reviews of special topics that are not available
elsewhere. The chapter on the quadratus lumborum muscle contains an
extensive review of the causes of func- tional scoliosis and how to
identify them clinically. It puts lower limb-length ine- quality
(often called a short leg) in per- spective and examines in detail
radio- graphic techniques for measuring it accu- rately. Chapter 6,
Pelvic Floor Muscles, provides an unprecedented description of how
to examine intrapelvic muscles for trigger points. A practical
three-tone topo- graphical guide (Fig. 8.5) simplifies dis-
tinguishing the three gluteal muscles and the piriformis muscle
when palpating trigger points. The piriformis chapter, Chapter 10,
presents a new understanding of the muscular origin of pain in
sciatic, gluteal, and perineal distributions. The adductor chapter
(Chapter 15) examines the remarkable complexity of the ad- ductor
magnus muscle, wbich helps ex- plain why its importance is easily
over- looked. The amply illustrated review of the recognition and
correction of the Mor- ton foot structure appears in Chapter 20 on
the peroneal muscles. Chapter 21 re- views thoroughly the subject
of nocturnal calf cramps and their close relation to trigger points
in the gastrocnemius mus- cle. Chapter 22 on the soleus and
plantaris muscles summarizes the current litera- ture on shin
splints in relation to trigger points. The subject of postexercise
mus- cle soreness is reviewed in the Appendix. The review shows
that this phenomenon ix
11. x Preface is now well understood. In summary, it is
unlikely that either condition is closely associated with trigger
points. The last chapter (Chapter 28), Manage- ment of Chronic
Myofascial Pain Syn- drome, concerns the care of patients who have
developed multiple myofascial syn- dromes and who fail to respond
to the therapeutic measures that are usually so effective in
single-muscle myofascial syn- dromes. This chapter distinguishes
be- tween the chronic myofascial pain syn- drome and fibromyalgia.
Health professionals, when first ex- posed to this subject, often
ask, "What does it take to become proficient?" The answer is
threefold: (a) develop an appre- ciation of the ubiquity and
characteristics of referred pain, (b) become intimately fa- miliar
with muscle anatomy, and (c) learn to palpate taut bands, locate
trigger points, and elicit local twitch responses. To achieve the
first, listen to and believe the patient. For the second, keep The
Trig- ger Point Manual in the examining room to show a patient the
illustration of the mus- cle most likely to be causing the pain
(while the examiner reviews its anatomy). The third requires a
motor skill that must be learned, like any other motor skill, by
diligent practice. During this volume's 8 years of gesta- tion,
many individuals have contributed to the final product in many
helpful ways. The heavy burden was frequently made bearable by the
enthusiasm ex- pressed by practitioners for the value of Volume 1
to their patients and by their in- sistent need for Volume 2.
Through most, if not all, of this period, five individuals formed
the essential team: the coauthors; the artist, Barbara D. Cummings,
whose steadfast dedication and blossoming skills account for all of
the original illustrations; the second au- thor's wife, Lois
Statham Simons, P.T., whose spirited discussions helped keep the
manuscript on course and whose me- ticulous editing of every
chapter polished it and ensured that it was correct and made sense;
and the second author's faithful secretary, Barbara Zastrow, who
typed and processed the seven (or more) drafts of each chapter and
never lost her sense of humor. Michael D. Reynolds, M.D., a rheu-
matologist, deserves outstanding recogni- tion for the meticulous
care and under- standing with which he reviewed every chapter. He
is a master of grammatic pre- cision, concise expression, and the
reso- lution of fuzzy statements. Any redun- dancy in this volume
surely crept in fol- lowing his review! We owe a deep debt of
gratitude to Robert Gerwin, M.D. for screening most of the chapters
with a keen appreciation of the interface between neurology and
myo- fascial trigger-point phenomena. Mary Maloney, P.T., enriched
many chapters with her comments based on years of combining manual
medicine skills with a thorough clinical knowledge of myofas- cial
trigger points. Dannie Smith, P.T., and Ann Anderson, P.T.,
contributed knowledgeable reviews and suggestions for several
chapters. Jay Goldstein, M.D., critically reviewed Chapter 6 on the
pel- vic floor muscles, based on extensive ex- perience with
patients whose pain came from intrapelvic muscles that harbored
trigger points. The authors are grateful to A.J. Nielsen, P.T., for
his enthusiastic sup- port, which included willing participa- tion
as the subject in pictures from which many of the drawings were
made and for access to the Physical Therapy Anatomy Laboratory.
Stimulating discussions with Prof. MUDr. Karel Lewit of
Czechoslovakia greatly enriched the second author's un- derstanding
of the importance of the in- teractions between articular
dysfunctions and myofascial trigger points. Herbert Kent, M.D., as
Chief, Rehabili- tation Medicine Service at the Veterans Medical
Center, Long Beach, California, and Professors Jerome Tobis, M.D.,
and Jen Yu, M.D., as successive Chairmen of the Department of
Physical Medicine and Rehabilitation at the University of Califor-
nia, Irvine, have been most supportive, for which we are deeply
grateful. Earle Davis, M.D., enthusiastically extended privileges
for anatomical dissections at the same University and contributed
helpful discussions. The second author's friend and colleague,
Chang-Zern (John) Hong, M.D., has provided an ongoing op- portunity
for fruitful discussions of myo- fascial pain problems based on his
out-
12. Preface xi standing clinical competence and extensive
researchexperience. The librarians who provided the second author
with the many references used in this
volumewereofinestimablehelp.Theyinclude
KarenVogelandUteM.Schultzintheearlier
yearsand,later,SusanRussell,directorofthe Medical Center Library of
the University of California, Irvine; Marge Linton, also of that
library;LindaLauMurphy,whohelpedmake Melvyl Medline available on
the second authors home computer through the library; and the
interlibrary loan librarians, Chris Ashen, Jody Hammond Oppelt, and
Linda Weinberger,whoobtainedworkingcopiesof references. The
references on the piriformis
syndromecollectedbyLeRoyP.W.Froetscher,
M.D.,whenhewasaresidenthelpedgreatlyin thepreparationofChapter10.
JohnButler,ourExecutiveEditoratWilliams & Wilkins, has earned
our deep gratitude for his persistent support, patience, and
understanding. Lastbutnotleast,weexpressappreciationto
inquiringmedicalstudentsandresidentsandto
ourdeterminedcriticsandskeptics,whokeep
askingdifficultandstimulatingquestions. DavidG.Simons,M.D.
JanetG.Travell,M.D.
13. Acknowledgment To my coauthor, David G. Simons, I ex- tend
my deepest appreciation for his un- tiring and pioneering effort in
the writing of Volume 2 of our text, Myofascial Pain and
Dysfunction: The Trigger Point Manual. I wish to acknowledge that
he has made the major contribution to the authorship of this Volume
2. I am proud to have had the privilege of working with Dr. Simons
for about thirty years in order to elucidate the basic
neurophysiologic mechanisms of the re- gional myofascial pain
syndromes, and to develop effective clinical methods of treatment
and management for these com- mon complex pain problems. Janet G.
Travell, M.D. xiii
14. Contents for Volume 1 CHAPTER 5 Head and Neck
Pain-and-Muscle Guide, Introduction to Masticatory Muscles 165 C H
A P T E R 6 Trapezius Muscle 1 8 3 C H A P T E R 7
Sternocleidomastoid Muscle 2 0 2 C H A P T E R 8 Masseter Muscle 2
1 9 C H A P T E R 9 Temporalis Muscle 2 3 6 C H A P T E R 10 Medial
(Internal) Pterygoid Muscle 2 4 9 C H A P T E R 11 Lateral
(External) Pterygoid Muscle 2 6 0 C H A P T E R 12 Digastric Muscle
2 7 3 C H A P T E R 1 3 Cutaneous-I: Facial Muscles Orbicularis
Oculi, Zygomaticus Major and Platysma 2 8 2 C H A P T E R 1 4
Cutaneous-ll: Occipitofrontalis 2 9 0 C H A P T E R 1 5 Splenius
Capitis and Splenius Cervicis Muscles 2 9 5 C H A P T E R 1 6
Posterior Cervical Muscles Semispinalis Capitis, Semispinalis
Cervicis, and Multifidi . . . . 3 0 5 C H A P T E R 1 7
Suboccipital Muscles Recti Capitis Posterior Major and Minor,
Obliqi Inferior and Superior 3 2 1 X V Foreword by Rene Cailliet
vii Foreword by Parker E. Mahan ix Preface xi C H A P T E R 1
Glossary 1 C H A P T E R 2 Background and Principles 5 C H A P T E
R 3 Apropos Of All Muscles 4 5 C H A P T E R 4 Perpetuating Factors
1 0 3 PART 1 PART 2 CHAPTER 18 Upper Back, Shoulder and Arm
Pain-and-Muscle Guide 331 C H A P T E R 1 9 Levator Scapulae Muscle
3 3 4 C H A P T E R 20 Scalene Muscles 3 4 4 C H A P T E R 21
Supraspinatus Muscle 3 6 8 C H A P T E R 22 Infraspinatus Muscle 3
7 7 C H A P T E R 2 3 Teres Minor Muscle 3 8 7 C H A P T E R 2 4
Latissimus Dorsi Muscle 3 9 3
15. xvi Contents for Volume 1 C H A P T E R 33 Elbow to Finger
Pain-and-Muscle Guide 477 C H A P T E R 3 4 Hand Extensor and
Brachioradialis Muscles 4 8 0 C H A P T E R 3 5 Finger Extensor
Muscles Extensor Digitorum and Extensor Indicis 4 9 7 C H A P T E R
3 6 Supinator Muscle 5 1 0 C H A P T E R 3 7 Palmaris Longus Muscle
5 2 3 C H A P T E R 3 8 Hand and Finger Flexors in the Forearm
Flexores Carpi Radialis and Ulnaris, Flexores Digitorum
Superficialis and Profundus, Flexor Pollicis Longus (Pronator
Teres) 531 C H A P T E R 3 9 Adductor and Opponens Pollicis
Muscles; Trigger Thumb . . 5 4 8 C H A P T E R 4 0 Interrosseous
Muscles of the Hand 5 5 9 Index 6 8 5 C H A P T E R 2 5 Teres Major
Muscle 4 0 3 C H A P T E R 2 6 S u b s c a p u l a r s Muscle 4 1 0
C H A P T E R 2 7 Rhomboideus Major and Minor Muscles 4 2 5 C H A P
T E R 2 8 Deltoid Muscle 4 3 1 C H A P T E R 29 Coracobrachialis
Muscle 4 4 0 C H A P T E R 3 0 Biceps Brachii Muscle 4 4 7 C H A P
T E R 3 1 Brachialis Muscle 4 5 6 C H A P T E R 3 2 Triceps Brachii
Muscle (Anconeus) 4 6 2 PART 3 PART 4 CHAPTER 41 Torso
Pain-and-Muscle Guide 5 7 3 C H A P T E R 4 2 Pectoralis Major
Muscle (Subclavius Muscles) 5 7 6 C H A P T E R 4 3 Pectoralis
Minor Muscle 5 9 8 C H A P T E R 4 4 Sternalis Muscle 6 0 9 C H A P
T E R 4 5 Serratus Posterior Superior Muscle 6 1 4 C H A P T E R 4
6 Serratus Anterior Muscle 6 2 2 C H A P T E R 4 7 Serratus
Posterior Inferior Muscle 6 3 1 C H A P T E R 4 8 Thoracolumbar
Paraspinal Muscles 6 3 6 C H A P T E R 4 9 Abdominal Muscles 6 6
0
16. Contents to Volume 2 CHAPTER 11 Hip, Thigh, and Knee
Pain-and-Muscle Guide 215 C H A P T E R 1 2 Tensor Fasciae Latae
Muscle and Sartorius Muscle 217 C H A P T E R 1 3 Pectineus Muscle
236 C H A P T E R 1 4 Quadriceps Femoris Group Rectus Femoris,
Vastus Medialis, Vastus Intermedius, and Vastus Lateralis 248 C H A
P T E R 1 5 Adductor Muscles of the Hip Adductor Longus, Adductor
Brevis, Adductor Magnus, and Gracilis 289 C H A P T E R 1 6
Hamstring Muscles Biceps Femoris, Semitendinosus, and
Semimembranosus 315 C H A P T E R 1 7 Popliteus Muscle 339 xvii
PART 1 Foreword by John V. Basmajian vii Preface ix Acknowledgment
xiii C H A P T E R 1 Glossary 1 C H A P T E R 2 General Issues 8
PART 2 CHAPTER 3 Lower Torso Pain-and-Muscle Guide 23 C H A P T E R
4 Quadratus Lumborum Muscle 28 C H A P T E R 5 Iliopsoas Muscle 89
C H A P T E R 6 Pelvic Floor Muscles Bulbospongiosus,
Ischiocavernosus, Transversus Perinei, Sphincter Ani, Levator Ani,
Coccygeus, and Obturator Internus 110 C H A P T E R 7 Gluteus
Maximus Muscle 132 C H A P T E R 8 Gluteus Medius Muscle 150 C H A
P T E R 9 Gluteus Minimus Muscle 168 C H A P T E R 10 Piriformis
and Other Short Lateral Rotators Gemelli, Quadratus Femoris,
Obturator Internus, and Obturator Externus Muscles 186
17. xviii Contents to Volume 2 PART 3 CHAPTER 18 Leg, Ankle,
and Foot Pain-and-Muscle Guide..................................
351 CHAPTER 19 Tibialis Anterior
Muscle......................................................................................
355 CHAPTER 20 Peroneal Muscles Peroneus Longus, Peroneus Brevis,
Peroneus Tertius..................................... 370 CHAPTER
21 Gastrocnemius Muscle
.....................................................................................
397 CHAPTER 22 Soleus Muscle and Plantaris
Muscle.................................................................
427 CHAPTER 23 Tibialis Posterior Muscle
....................................................................................
460 CHAPTER 24 Long Extensors of Toes Extensor Digitorum Longus and
Extensor Hallucis Longus............................... 473 CHAPTER
25 Long Flexor Muscles of Toes Flexor Digitorum Longus and Flexor
Hallucis Longus ....................................... 488 CHAPTER
26 Superficial Intrinsic Foot Muscles Extensor Digitorum Brevis,
Extensor Hallucis Brevis, Abductor Hallucis, Flexor Digitorum
Brevis, Abductor Digiti Minimi..................................
501 CHAPTER 27 Deep Intrinsic Foot Muscles Quadratus Plantae and
Lumbricals, Flexor Hallucis Brevis, Adductor Hallucis, Flexor
Digiti Minimi Brevis, and Interossei
.......................................... 522 CHAPTER 28
Management of Chronic Myofascial Pain
Syndrome......................................... 541
AppendixPostexercise Muscle
Soreness....................................................... 552
Index to Volume 1
...........................................................................................
559 Index to Volume 2
.............................................................................................
589
18. C H A P T E R 1 Glossary The glossary comes first to assure
that the reader knows what a term means as it is used in this
manual, and to help the reader become acquainted with unfamil- iar
terms. The glossary is in front to en- courage frequent reference
to it, whenever needed. Comments concerning a defini- tion appear
in italics. Abduction: Movement away from the midline. For the
toes, it is movement away from the midline of the second toe. For
the foot, it is movement of the fore- foot horizontally outward
toward the fib- ular side of the leg. For the thigh, it is movement
away from the midline of the body. Abduction is the opposite of
adduc- tion. Action: The actions of a muscle, as de- scribed in
this volume, are the anatomical movements produced by contraction
of that muscle. To be distinguished from func- tion. Active Range
of Motion: The extent of movement (usually expressed in degrees) of
an anatomical segment at a joint. The movement should be caused
only by vol- untary effort to move the body part being tested.
Active Myofascial Trigger Point: A focus of hyperirritability in a
muscle or its fas- cia that is symptomatic with respect to pain; it
causes a pattern of referred pain at rest and/or on motion that is
specific for that muscle. An active trigger point is ten- der,
prevents full lengthening of the mus- cle, weakens the muscle,
usually refers pain on direct compression, mediates a local twitch
response of its taut muscle fi- bers when adequately stimulated,
causes tenderness in the pain reference zone, and often produces
specific referred auto- nomic phenomena, generally in its pain
reference zone. To be distinguished from a latent myofascial
trigger point. Acute: Of recent onset (hours, days, or a few
weeks). Adduction: Movement toward the mid- line. For the toes, it
is movement toward the midline of the second digit. For the foot,
it is movement of the forefoot hori- zontally inward toward the
tibial side of the leg. At the hip, adduction is move- ment of the
thigh toward the midline of the body. Adduction is the opposite of
ab- duction. Agonists: Muscles, or portions of mus- cles, so
attached anatomically that when they contract, they develop forces
that re- inforce each other. Anatomical Position: The erect
position of the body with the face directed for- ward, each arm at
the side and the palms of the hands facing forward, feet together
with the toes directed forward. The terms posterior, anterior,
lateral, medial, etc., are applied to the body parts as they relate
to each other and to the axis of the body when in this anatomical
position.16 Antagonists: Muscles, or portions of muscles, so
attached anatomically that when they contract, they develop forces
that oppose each other. Antalgic Gait: A gait resulting from pain
on weight bearing. Characteristically, the stance phase of gait is
shortened on the affected side.4 Anterior Tilt (of the pelvis):
Anterior tilt rocks the cephalad portion of the pelvis (crest of
the ilium) anteriorly, tending to increase lumbar lordosis.
Associated Myofascial Trigger Point: A myofascial trigger point in
one muscle that develops in response to compensa- 1
19. 2 Myofascial Pain and Dysfunction: Trigger Point Manual
tory overload, shortened position, or re- ferred phenomena caused
by trigger-point activity in another muscle. Satellite and
secondary trigger points are types of associ- ated trigger points.
Chronic: Long-standing (months or years), but NOT necessarily
irreversible. Symptoms may be mild or severe. ck: creatine kinase
Composite Pain Pattern: Total pain pat- tern referred from trigger
points in two or more closely adjacent muscles. No distinc- tion is
made between the referred pain pat- terns of the individual
muscles. Concentric (contraction): Contraction as the muscle
shortens. Contracture: Sustained intrinsic activa- tion of the
contractile mechanism of mus- cle fibers. With contracture, muscle
short- ening occurs in the absence of motor unit action potentials.
This physiological defini- tion, as used in this manual, must be
differen- tiated from the clinical definition, which is shortening
due to fibrosis. Contracture also must be distinguished from spasm.
Coronal Plane: A frontal (vertical) plane that divides the body
into anterior and posterior portions.1 5 Dorsiflexion: Turning of
the foot or the toes upward.2 Eccentric (contraction): Contraction
as the muscle lengthens. EMG: Electromyographic. Essential Pain
Zone (Area): The region of referred pain (indicated by solid red
areas in pain-pattern figures) that is present in nearly every
patient when the trigger point is active. To be distinguished from
a spillover pain zone. Eversion: Eversion of the foot is outward
(lateral) turning of the entire foot on the talus and of the
forefoot on the hindfoot at the transverse tarsal joint. The move-
ments are complex. The term eversion is sometimes used as
synonymous with prona- tion.26 To be distinguished from inversion.
Extrinsic Foot Muscles: Muscles that originate outside the foot and
attach onto structures in the foot. Fibromyalgia: Fibromyalgia is
identified by widespread pain of at least 3 months' duration in
combination with tenderness at 11 or more of the 18 specified
tender point sites.3 4 Fibrositis: A term with multiple mean- ings.
In publications prior to 1977, it was often used to identify a
,condition with palpable taut bands strongly suggestive of
myofascial trigger points. Subsequently,3 0 fibrositis is
frequently used as essentially synonymous with the condition now
known as fibromyalgia.3 4 First Ray: The first ray of the foot in-
cludes tbe first metatarsal bone and the bones (two phalanges) of
the great toe. The second, third, fourth, and fifth rays comprise
the corresponding sequential bones (metatarsal and phalangeal)
across the foot. Flat Palpation: Examination by finger pressure
that proceeds across the muscle fibers at a right angle to their
length, while compressing them against a firm underlying structure,
such as bone. It is used to detect taut bands and trigger points.
To be distinguished from pincer palpation and snapping palpation.
Forefoot: The forefoot is that part of the foot anterior to the
transverse tarsal joint. The location of the transverse tarsal
joint is between the navicular and the cuboid in front, and the
talus and the calcaneus behind.2 5 Function: The function of a
muscle, as used in this volume, concerns when and how the muscle
contributes to the posture and activities of the individual. To be
dis- tinguished from action. Gait Cycle: The gait cycle during
ambula- tion is the entire period from heel-strike of one foot to
the next heel-strike of the same foot. Greater Pelvis (Pelvis
Major, Large Pel- vis, False Pelvis): The expanded portion of the
pelvis above the brim.1 2 , 27 To be dis- tinguished from the
lesser pelvis. Groin: The groin, as used in this volume, includes
the inguinal region, not just the anterior crease at the junction
of the thigh with the trunk.5 h: Hour, a unit of time.
20. Hallux Valgus: Deviation of the first toe toward the lesser
four toes.6 Hallux Varus: Deviation of the first toe away from the
lesser four toes.6 Hammer Toe: Persistent flexion at the in-
terphalangeal joint of the great toe,2 2 or persistent flexion of
the proximal in- terphalangeal joint with extension of the distal
interphalangeal joint of one of the four lesser toes. Hindfoot: The
hindfoot is that part of the foot posterior to the transverse
tarsal joint; it includes the calcaneus and the ta- lus. in: Inch,
a unit of distance; approxi- mately 2.54 centimeters. Innominate
Upslip: An innominate up- slip (shear) dysfunction2 8 is
characterized by upward displacement of an innomi- nate bone in
relation to the sacrum.2 9 Intrinsic Foot Muscles: Both ends of an
intrinsic foot muscle attach within the foot. Inversion: Inversion
of the foot is inward (medial) turning of the foot, including
movement of the entire foot about the ta- lus and movement of the
forefoot on the hindfoot at the transverse tarsal joint. The term
inversion is sometimes used as synony- mous with supination.26 To
be distinguished from eversion. Involved Muscle: A muscle that has
de- veloped one or more active or latent trig- ger points. IP
Joint: Interphalangeal joint. Ischemic Compression: (also Acupres-
sure, Myotherapy, Shiatzu, "Thumb" Therapy): Application of
progressively stronger, painful pressure on a trigger point for the
purpose of eliminating the trigger point's tenderness and hyperir-
ritability. This action blanches the com- pressed tissues, which
usually become hy- peremic (flushed) on release of the pressure.
Jump Sign: A general involuntary pain response of the patient, who
winces, may cry out, and may withdraw in response to pressure
applied on a trigger point. At one time, we erroneously used this
term to de- scribe the local twitch response of muscle fi- bers to
trigger-point stimulation. Chapter 1 / Glossary 3 kg: Kilogram, a
unit of weight equal to 1,000 grams; approximately 2.2 pounds.
kg/cm2 : Kilogram per square centimeter, a unit of weight or force
per unit area. LaSegue's Sign: Pain or muscle spasm in the
posterior thigh when the patient lies supine with the hip flexed
and knee ex- tended, and the ankle is passively dor- siflexed.
Considered indicative of lumbar root or sciatic nerve irritation,20
or of gastroc- nemius muscle tightness. Latent Myofascial Trigger
Point: A focus of hyperirritability in muscle or its fascia that is
clinically quiescent with respect to spontaneous pain: it is
painful only when palpated. A latent trigger point may have all the
other clinical characteristics of an active trigger point, from
which it is to be distin- guished. Lateral Rotation (External
Rotation, Ro- tation Outward): Lateral rotation of the thigh at the
hip or of the leg at the knee is rotation of the anterior surface
outward from the midsagittal plane of the body. To be distinguished
from medial rotation. Lateral Tilt: Lateral tilt of the pelvis in-
clines the pelvis toward the lower side in a frontal (coronal)
plane. Leg: In this volume, the leg includes only that part of the
lower limb between the knee and the ankle, not the entire lower
limb. Lesser Pelvis (Pelvis Minor, Small Pelvis, True Pelvis): The
cavity of the pelvis be- low the brim or superior aperture.1 3 To
be distinguished from the greater pelvis. Lewit Technique: At
stretch-length of the muscle, postisometric relaxation com- bined
with reflex potentiation of relaxa- tion using coordinated
respiration and eye movements, as described in Chapter 2, pages
10-11, of this volume. LLLI: lower limb-length inequality. Local
Twitch Response: Transient con- traction of the group of muscle
fibers (usually a palpable band) that contains a trigger point. The
contraction of the fibers is in response to stimulation (usually by
snapping palpation or needling) of the trigger point, or sometimes
of a nearby
21. 4 Myofascial Pain and Dysfunction: Trigger Point Manual
trigger point. The local twitch response er- roneously has been
called a jump sign. Long Sitting Position: Sitting upright with the
hips flexed and the knees straight (extended). Lordosis: Lumbar
lordosis is an antero- posterior curvature of the spine that places
the lumbar spine in extension with the convexity of the curve
facing anteri- orly. Lotus Position: An erect sitting posture with
the legs crossed, so that each foot, sole upturned, rests on the
upper part of the thigh of the opposite leg.3 2 Lumbago: Pain in
the mid and lower back; a descriptive term not specifying cause.7
m: Meter, a defined measure of distance; equivalent to
approximately 39 inches. Medial Rotation (Internal Rotation, Rota-
tion Inward): Rotation of the thigh at the hip or of the leg at the
knee with the ante- rior surface turned inward toward the
midsagittal plane of the body. To be distin- guished from lateral
rotation. mm: Millimeter, a measure of distance equal to l/l,000th
of a meter or l/10th of a centimeter; approximately 1/25th of an
inch. MP (MTP) Joint: Metatarsophalangeal joint. mrad: Millirad, a
measure of ionizing ra- diation: 0.001 rad. Muscular Rheumatism
(Muskel Rheuma- tismus): Muscular pain and tenderness at- tributed
to "rheumatic" causes (espe- cially exposure to cold), as
distinguished from articular rheumatism. Often used as synonymous
with myofascial trigger-point syndromes. Myalgia: Pain in a muscle
or muscles.8 Myalgia is used in two ways, to signify: (1) diffusely
aching muscles due to systemic dis- ease, such as a viral
infection; and (2) the spot tenderness of a muscle or muscles as in
myofascial trigger points. The reader must distinguish which use an
author has in mind. Myofascial Pain Syndrome: Synony- mous with
Myofascial Syndrome and with Myofascitis. Often a significant com-
ponent of somatic dysfunction. To be distin- guished from
fibromyalgia. Myofascial Syndrome: Pain, tenderness, and autonomic
phenomena referred from active myofascial trigger points, with as-
sociated dysfunction. The specific muscle or muscle group that
causes the symptoms should be identified. Myofascial Trigger Point:
A hyperir- ritable spot, usually within a taut band of skeletal
muscle or in the muscle's fascia. The spot is painful on
compression and can give rise to characteristic referred pain,
tenderness, and autonomic phe- nomena. A myofascial trigger point
is to be distinguished from cutaneous, ligamentous, periosteal, and
nonmuscular fascial trigger points. Types include active, latent,
primary, associated, satellite, and secondary. Myofascitis:
(Myofasciitis, Myositis Fi- brosa, Interstitial Myositis): As used
in this text, myofascitis is the syndrome of pain, tenderness,
other referred phenom- ena, and the dysfunction attributed to
myofascial trigger points.9 , 1 0 Myogelosis: Circumscribed
firmness and tenderness to palpation in a muscle or muscles. The
name is derived from the con- cept that the regions of
circumscribed firm- ness were due to localized gelling of muscle
proteins. This concept predates our under- standing of sliding
filaments as the basis for muscle contraction. Focal tenderness and
palpable taut muscle fibers are also charac- teristic of myofascial
trigger points. Most pa- tients diagnosed as having myogelosis
would also be diagnosed as having myofas- cial trigger points.
Myotatic Unit: A group of agonist and antagonist muscles, which
function to- gether as a unit because they share com- mon spinal
reflex responses. The agonist muscles may act together in series,
or in par- allel. Ober's Test: With the patient lying on the left
side and with the left leg and thigh flexed, the examiner holds the
patient's right lower limb abducted and extended. If, on the sudden
withdrawal of the exam- iner's support, the right lower limb stays
up instead of dropping down, there is contraction of the tensor
fasciae femoris1
22. Chapter 1 / Glossary 5 or shortening of the tensor fasciae
latae mus- cle. Orthosis: An orthopaedic appliance in- tended to
correct a deformity1 1 or structural inadequacy. Palpable Band
(Taut Band, or Nodule): The group of taut muscle fibers that is as-
sociated with a myofascial trigger point and is identifiable by
tactile examination of the muscle. An evoked contraction of the
muscle fibers in this band produces the local twitch response.
Passive Range of Motion: The extent of movement (usually tested in
a given plane) of an anatomical segment at a joint when movement is
produced by an outside force without voluntary assist- ance or
resistance by the subject. The sub- ject must relax the muscles
crossing the joint. Pes Anserinus: The tendinous expansion and
attachment of the sartorius, gracilis, and semitendinosus muscles
at the me- dial border of the tuberosity of the tibia.1 4 Pincer
Palpation: Examination of a part by holding it in a pincer grasp
between the thumb and fingers. Groups of muscle fibers are rolled
between the tips of the digits to detect taut bands of fibers, to
identify trig- ger points in the muscle, and to elicit local twitch
responses. To be distinguished from flat palpation and snapping
palpation. Plantar Flexion: Turning the foot or toes downward.3
Posterior Tilt: Posterior tilt of the pelvis rocks the cephalad
portion of the pelvis (crest of the ilium) posteriorly, tending to
flatten the lumbar spine (decrease the lumbar lordosis). Primary
Myofascial Trigger Point: A hy- perirritable focus within a taut
band of skeletal muscle. The hyperirritability was activated by
acute or chronic overload (mechanical strain) of the muscle in
which it occurs, and was not activated as the result of
trigger-point activity in an- other muscle of the body. To be
distin- guished from secondary and satellite trigger points.
Pronation: Pronation of the foot consists of eversion and abduction
of the foot, causing a lowering of its medial edge.1 7 Reactive
Cramp: See Shortening Activa- tion. Rearfoot: See Hindfoot. Term
hindfoot is preferable. Reference Zone: See Zone of Reference
Referred Autonomic Phenomena: Vaso- constriction (blanching),
coldness, sweat- ing, pilomotor response, vasodilatation, and
hypersecretion caused by activity of a trigger point but occurring
in a region separate from the trigger point. The phe- nomena
usually appear in the general area to which that trigger point
refers pain. Referred (Trigger-Point) Pain: Pain that arises in a
trigger point, but is felt at a dis- tance, often entirely remote
from its source. The pattern of referred pain is reproducibly
related to its site of origin. The distribution of referred
trigger-point pain rarely coincides with the entire distribution of
a peripheral nerve or dermatomal segment. Referred (Trigger-Point)
Phenomena: Sensory, motor, and autonomic phenom- ena, such as pain,
tenderness, increased motor unit activity (spasm), vasoconstric-
tion, vasodilatation, and hypersecretion caused by a trigger point,
which usually occur at a distance from the trigger point. Rotation,
Pelvic: Rotation of the pelvis occurs in the transverse plane
around the long axis of the body. Rotation of the pel- vis toward
the right moves the anterior part of the pelvis toward the right
and the posterior part toward the left. Sagittal Plane: A vertical
anteroposterior plane that divides the body into right and left
parts, or any plane parallel to it. To be distinguished from the
unique midsagittal plane, which divides the body into right and
left halves. Satellite Myofascial Trigger Point: A fo- cus of
hyperirritability in a muscle or its fascia that became active
because the muscle was located within the zone of reference of
another active trigger point. To be distinguished from a secondary
trigger point. Sciatica: Pain in the lower back and hip radiating
down the back of the thigh into the calf, cause not specified.1
8
23. 6 Myofascial Pain and Dysfunction: Trigger Point Manual
Scoliosis: Lateral curvature of the spine.1 9 Screening Palpation:
Digital examination of a muscle to determine the absence, or
presence, of palpable bands and tender trigger points using flat
and/or pincer pal- pation. Secondary Myofascial Trigger Point: A
hyperirritable spot in a muscle or its fas- cia that became active
because its muscle was overloaded as a synergist substituting for,
or as an antagonist countering the forces of, the muscle that
contained the primary trigger point. To be distinguished from a
satellite trigger point. Shortening Activation: Activation of la-
tent myofascial trigger points by unaccus- tomed sudden shortening
of the muscle during stretch therapy of its antagonist. The
activated latent trigger points increase tension in the shortened
muscle and can cause severe referred pain. SI: Sacroiliac (joint).
Snapping Palpation: A fingertip is placed on the tender spot in a
taut band of muscle at right angles to the direction of the band
and suddenly presses down while drawing the finger back so as to
roll the underlying fibers transversely under the finger. The
motion is similar to that used to pluck a guitar string, except
that firm con- tact with the surface is maintained. To most
effectively elicit a local twitch response, the band is palpated
and snapped transversely at the trigger point, with the muscle at a
neu- tral length or slightly longer. To be distin- guished from
flat palpation and pincer palpa- tion. Spasm: Increased tension
with or with- out shortening of a muscle due to non- voluntary
motor unit action potentials. Spasm cannot be stopped by voluntary
re- laxation. Spasm should be distinguished from contracture.
Tightness of a muscle may or may not be caused by spasm. Spillover
Pain Zone (Area): The region beyond the essential pain zone where
some, but not all, patients experience re- ferred pain from an
active trigger point. The spillover zone is indicated by red stip-
pling in the pain-pattern figures. To be distin- guished from an
essential pain zone. Square Brackets [ ]: In this volume, square
brackets set off comments or inter- pretations by the authors.
Stance Phase: The stance phase of gait is that portion of the gait
cycle during which the foot is in contact with the ground.
Stripping Massage (Deep-stroking Mas- sage): As described on pages
26 and 88 in Volume l 3 1 and on page 9 in Chapter 2 of this
volume. Supination: Supination of the foot con- sists of inversion
and adduction of the foot, causing an elevation of its medial edge.
Swing Phase: The swing phase is that pe- riod of the gait cycle
during which the foot is not in contact with the ground.
Synergistic Muscles: In this volume, syn- ergistic muscles are
defined as muscles that assist each other in an action when they
contract. Toe (of shoe): That part of the shoe that covers the
toes. Triceps Surae: The gastrocnemius and soleus muscles
considered together. Trigger Point (Trigger Zone, Trigger Spot,
Trigger Area): A focus of hyperirritabil- ity in a tissue that,
when compressed, is locally tender and, if sufficiently hyper-
sensitive, gives rise to referred pain and tenderness, and
sometimes to referred au- tonomic phenomena and distortion of
proprioception. Types include myofas- cial, cutaneous, fascial,
ligamentous, and periosteal trigger points. TrP: Trigger point.
TrPs: Trigger points. Upslip: See Innominate Upslip. uV: Microvolt,
a measure of electrical po- tential: 1 0 - 6 volt, or 0.000001
volt. Valgus: Used in this volume in accor- dance with accepted
orthopaedic usage, the part distal to the structure named is bent
or twisted outward: genu valgum (knock-kneed)2 3 or talipes valgus
(foot be- low the talus is turned outward).2 1
24. Chapter 1 / Glossary 7 Vamp:Thevampisthatpartofabootorshoe
thatcoverstheinstepandtoesofthefoot.33
Varus:Usedinthisvolumeinaccordancewith accepted orthopedic usage,
the part distal to thestructurenamedisbentortwistedinward: genu
varum (bowlegged)24 or talipes varus
(footbelowthetalusisturnedinward).21 Zone of Reference: The
specific region of the bodyatadistancefromatriggerpoint,where the
referred phenomena (sensory, motor,
autonomic)thatitcausesareobserved. References 1. Agnew LRC, et al.:
Dorland's Illustrated Medical Dictionary,
24thEd.W.B.Saunders,Philadelphia,1965(p. 1546). 2.
BasmajianTV,etal.:Stedman's Medical Dictionary, 24th
Ed.Williams&Wilkins,Baltimore,1982(p.421). 3. Ibid. (p.540). 4.
Ibid. (p.569). 5. Ibid. (p.608). 6. Ibid. (p.618). 7. Ibid.
(p.811). 8. Ibid. (p.913). 9. Ibid. (p.920). 10. Ibid. (p.922). 11.
Ibid. (p.997). 12. Ibid. (p.1046). 13. Ibid. (p.1047). 14. Ibid.
(p.1062). 15. Ibid. (p.1093). 16. Ibid. (p.1126). 17. Ibid.
(p.1148). 18. Ibid. (p.1262). 19. Ibid. (p.1265). 20. Ibid.
(p.1288). 21. Ibid. (p.1408). 22. Ibid. (p.1458). 23. Ibid.
(p.1530). 24. Ibid. (p.1534). 25. BasmajianJV,SloneckerCE:Grant's
Method of Anatomy, 11th Ed. Williams & Wilkins, Baltimore, 1989
(pp. 316317). 26. Ibid. (p.332). 27. Clemente CD: Gray's Anatomy of
the Human Body, AmericanEd.30.Lea&Febiger,Philadelphia,1985(pp.
270271). 28. Greenman PE: Innominate shear dysfunction in the
sacroiliacsyndrome.Manual Medicine 2:114121,1986. 29. GreenmanPE:
Principles of Manual Medicine. Williams
&Wilkins,Baltimore,1989(pp.234,236,246). 30. Smythe HA,
Moldofsky H: Two contributions to
understandingofthefibrositissyndrome.Bull Rheum Dis 28:928931,1977.
31. Travell JG, Simons DG: Myofascial Pain and Dys- function: The
Trigger Point Manual. Williams&Wilkins, Baltimore,1983. 32.
Webster N, McKechnie JL: Webster's Unabridged Dictionary, 2nd Ed.
Dorset & Baber/New World Dictionaries/Simon and Schuster, New
York, 1979 (p. 1069). 33. Ibid. (p.2018). 34. Wolfe F, Smythe HA,
Yunus MB, et al.: American College of Rheumatology 1990 criteria
for the classification of fibromyalgia: report of the multicenter
criteriacommittee.Arth Rheum 33: 160172,1990.
25. CHAPTER 2 General Issues OUTLINE OF CHAPTER 1.
Fluori-Methane Spray: The Problem 8 2. Alternative Treatment
Techniques ... 9 3. Lewit Technique 10 4. New Measurement
Techniques 11 5. Current Terminology of Muscle Pain Disorders 14 6.
Mobilization of the Sacroiliac Joint ... 16 7. Hypermobility
Syndrome 18 8. Shortening Activation 19 9. Injection Technique 19
10. Head-forward Posture 20 This introductory chapter is not
intended to cover the material previously presented in the
introductory chapters (Chapters 2 4) of Volume l . 9 3 It addresses
new issues or issues that represent major progress in previously
discussed areas. It omits a number of updates, including new preva-
lence data and new understanding of the neurophysiology of referred
pain, which will be covered in the forthcoming revi- sion of Volume
1. Only updates of clinical issues of immediate concern are
included here. Five topics that are new to The Trigger Point Manual
are addressed in this chap- ter: the hazard posed by Fluori-Methane
spray to the upper atmosphere ozone layer; alternative treatment
techniques; the Lewit technique; new methods of measurement
applicable to myofascial trigger points (TrPs); and current termi-
nology of muscle pain disorders. Another section deals with
sacroiliac (SI) joint mo- bilization. Four additional sections en-
large on topics previously addressed:9 3 the hypermobility
syndrome; shortening activation; injection technique; and the
head-forward posture. 1. FLUORI-METHANE SPRAY: THE PROBLEM The fact
that the ozone layer of the upper atmosphere is being destroyed by
envi- ronmental contaminants including the 8 chlorofluorocarbons is
widely known. Since it may be a decade or more until we can fully
assess the damage that will be done by chlorofluorocarbons already
re- leased, it is of utmost importance that their release into the
atmosphere be ter- minated quickly. Then we will have time to
determine the extent of the damage al- ready inflicted and the
recovery rate of the atmosphere. Vallentyne and Vallentyne have ex-
pressed the opinion that the use of Fluori- Methane, a mixture of
chlorofluoro- carbons, should be stopped.9 8 Although medical use
of chlorofluorocarbons re- leases minuscule amounts of fluoro-
carbon compared to those released by the refrigeration industry, we
agree that ev- eryone should cooperate fully in the elim- ination
of this hazard to our atmos- phere.8 4 , 8 5 Fortunately,
alternative techniques can substitute for the method of spray and
stretch using Fluori-Methane.6 5 , 7 2 , 8 4 , 8 5 Mean- while, a
major research effort is under- way to find a suitable replacement
for Fluori-Methane, but that may take sev- eral years. The
intermittent cold effect of the vapocoolant can be obtained in
other ways and for that reason, in this volume, the term spray and
stretch has been re- placed by the term intermittent cold with
stretch. Some stretching techniques used
26. Chapter 2 / General Issues 9 alone, without intermittent
cold, also can be effective. 2. ALTERNATIVE TREATMENT TECHNIQUES
Intermittent Cold The sensory and reflex effects of a jet stream of
vapocoolant spray (such as Fluori-Methane) can also be obtained to
a considerable degree by stroking with ice. Water frozen in a
plastic or paper cup is a convenient form of ice. A stirring stick
in- serted in the cup before freezing the water provides a
convenient handle to hold the ice. The ice is exposed by tearing
back part of the cup and is then covered with thin plastic to
prevent melting ice from making direct contact and wetting the
skin. An edge of the plastic-covered ice is applied in
unidirectional parallel strokes, which follow the spray patterns
pre- sented in each muscle chapter. The strok- ing movements
progress slowly, at the same rate as the spray: 10 cm (4 in)/sec.
This application of the sharp, dry edge of ice simulates the jet
stream of vapocool- ant spray. The skin must remain dry, be- cause
dampness reduces the rate of the change in skin temperature
produced by the ice-stroking. Wetness also prolongs and diffuses
the cooling effect, which de- lays rewarming of the skin. The
clinician must avoid cooling the underlying mus- cle when stroking
with ice, just as when applying vapocoolant spray.6 5 , 7 6 , 9 3
Although some health professionals still use ethyl chloride spray,
we do not recommend its use as a vapocoolant for several reasons
(see Volume l 9 4 ) . It is too cold as usually applied, it is a
rapidly act- ing general anesthetic with a very narrow safety
margin, and it has been responsible for accidental death. It is
flammable, and potentially explosive when the vapor is mixed with
air. It is not safe to give to pa- tients for home use. Other
Methods With Stretching Any procedure for inactivating myofas- cial
TrPs is facilitated if the muscle is passively lengthened to the
point of resistance during the procedure, and if, following the
procedure, it is actively and slowly moved from the fully shortened
to the fully lengthened position (if muscle mechanics and anatomy
permit). Distrac- tion of the joint or joints crossed by the muscle
while it is being stretched can also facilitate release of tension
due to myofascial TrPs. The combination of techniques em- ployed by
Karel Lewit for release of mus- cle tension is particularly
effective and is described in detail in Section 3 of this chapter.
Ischemic compression consists of the application of sustained
digital pressure to a TrP for a period of about 20 seconds to a
minute. Pressure is gradually in- creased as the sensitivity of the
TrP wanes and the tension in its taut band fades. Pressure is
released when the clini- cian feels the TrP tension subside or when
the TrP is no longer tender to pres- sure. This technique is
illustrated on pages 26 and 87-88 of Volume l , 9 3 and numerous
examples are presented throughout the book. Sustained pressure
should not be applied to blood vessels or a nerve; it may induce
numbness and tin- gling. Ischemic compression should be followed by
lengthening of the muscle, except when stretching is contraindi-
cated, as in hypermobility. Deep-stroking massage is another effec-
tive technique for muscles that are suffi- ciently superficial to
be accessible. This procedure is described as stripping mas- sage
on page 88 of Volume l . 9 3 (The term deep-friction massage refers
to other tech- niques, not exactly the method discussed here.) We
call it stripping massage be- cause of the milking effect it
produces. Stripping massage is performed by lubri- cating the skin
and/or hands and applying firm pressure progressively along the
length of the taut band, through the re- gion of the TrP.
Danneskiold-Sams0e and co-workers1 0 , 1 1 found that application
of this technique to the tender "nodules" of "fibrositis" or
"myofascial pain" relieved the signs and symptoms of most patients
after 10 massage sessions. Those respond- ing had a transient
elevation of serum my- oglobin levels following the initial ther-
apy sessions, but not after the final ses- sions when symptoms had
been relieved. Contract-relax, as taught by Voss and associates,9 9
is recommended for patients presenting with marked limitation of
the
27. 10 Myofascial Pain and Dysfunction: Trigger Point Manual
range of passive motion and with no ac- tive motion available in
the agonistic pat- tern. Contract-relax employs contraction and
then relaxation of the tight antago- nists to permit active
shortening of the weak agonist. This same technique can be used to
inactivate myofascial TrPs, and to augment relaxation for the
purpose of stretching the involved antagonist. In this case, the
emphasis is on trying to lengthen the tight antagonist by having
the patient perform an isometric contrac- tion of the tight muscle
and then allow it to relax and lengthen, only incidentally
shortening the agonist. As originally de- scribed," the patient is
instructed to make a maximum contraction effort of the tight
antagonist muscle and then relax it. (In contrast, Lewit recommends
for his postisometric relaxation technique that the contraction
phase be limited to a mild voluntary contraction of between 10% and
25% of maximum effort.5 8 ) Reciprocal inhibition is a well-estab-
lished neurophysiological principle that can be used to assist a
muscle-stretching procedure. To invoke reciprocal inhibi- tion, the
agonist (muscle not being stretched) is voluntarily activated
during the period of stretch of the involved an- tagonist muscle
(when it needs to be re- laxed). Relaxation during exhalation, de-
scribed in the next section as part of the Lewit technique, can be
useful by itself. By breathing deeply and slowly, and con-
centrating on relaxation during exhala- tion, the patient may
reduce TrP irritabil- ity and release associated muscular ten-
sion. The muscle should be lengthened to the point of taking up all
slack (to the on- set of resistance) especially before and also
during each cycle of this procedure. Percussion and stretch starts
with the muscle lengthened to the point of onset of passive
resistance. The clinician or pa- tient uses a hard rubber mallet or
reflex hammer to hit the TrP at precisely the same place about 10
times. This should be done at a slow rate of no more than one
impact per second but, at least, one im- pact every 5 seconds; the
slower rates are likely to be more effective. This proce- dure may
enhance or substitute for inter- mittent cold with stretch. The
senior au- thor considers it particularly applicable to the
quadratus lumborum (self-applied), brachioradialis, long finger
extensors, and to the peroneus longus and brevis. It is nor applied
to anterior or posterior compart- ment leg muscles because of a
possible compartment syndrome, if it caused bleeding there. Muscle
energy technique involves vol- untary muscle contractions by the
patient against a specific counterforce provided by a clinician,
whereby the patient, not the clinician, provides the corrective
force. This technique has been applied to joint mobilization and
can be used to lengthen a tense muscle and stretch its fasciae as
well.3 7 , 6 9 Myofascial release is a combined tech- nique using
some principles from soft tis- sue technique, from muscle energy
tech- nique, and from inherent force cranio- sacral technique. It
combines soft tissue changes, faulty body mechanics, and al- tered
reflex mechanisms in both diagno- sis and treatment.3 7 The use of
ultrasound for the inactiva- tion of TrPs was discussed on pages 89
and 90 of Volume l . 9 3 This method is es- pecially useful for
deeply placed muscles that are not accessible to manual therapy.
Examples of the use of high voltage pulsed galvanic stimulation
appear in Section 12 of Chapter 6, Pelvic Muscles. 3. LEWIT
TECHNIQUE The concept of applying postisometric re- laxation in the
treatment of myofascial pain was presented for the first time in a
North American journal in 1984.5 8 Com- bining this technique with
reflex augmen- tation of relaxation5 5 , 5 7 greatly enhances its
effectiveness. Enhancements include the use of gravity to take up
the slack in the muscle and the use of coordinated respiration and
eye movements. For this technique to be effective, the patient must
be relaxed and the body well supported. The muscle is passively and
gently lengthened to the point of taking up the slack (reaching the
barrier or the point of initial resistance). If this initial
positioning causes pain, either the extent of the movement has been
excessive or the patient has actively resisted the move- ment.
28. Chapter 2 / General Issues 11 Postisometric Relaxation The
process of postisometric relaxation is to contract the tense muscle
isometrically against resistance and then to encourage it to
lengthen during a period of complete voluntary relaxation. Gravity
is an effec- tive force to "encourage" release of the muscle
tension. Postisometric relaxation begins by hav- ing the patient
perform an isometric con- traction of the tense muscle at its
initial tolerated length, while the clinician stabi- lizes that
part of the body to prevent mus- cle shortening. Contraction should
be slight (10-25% of maximum voluntary contraction). After holding
this contrac- tion for 3-10 sec, the patient is instructed to "let
go" and to relax the body com- pletely. During this relaxation
phase, the clinician gently takes up any slack that develops in the
muscle, noting the in- crease in range of motion. Care is taken to
maintain the stretched length of the mus- cle and not to return it
to the neutral posi- tion during subsequent cycles of isomet- ric
contraction and relaxation.5 5 Respiration The effectiveness of
postisometric relaxa- tion is augmented by combining it with phased
respiration. Since inhalation en- courages contraction of most
muscles and exhalation encourages their relaxation, the
contraction-relaxation cycle is coordi- nated with these phases of
respiration. The patient slowly inhales during the iso- metric
contraction phase and then slowly exhales during the relaxation
phase. These breaths should be deep. Patients who have difficulty
using such a slow re- spiratory pattern are helped by pausing,
breathing naturally several times, and re- laxing between each
cycle. For the torso, inhalation facilitates moving toward the
neutral erect position. Leaning forward is naturally associated
with exhalation and relaxation. From the forward-flexed position,
standing or sit- ting up straight is associated with inhala- tion.
Similarly, when one is in a retro- flexed (bent-back) position,
inhalation again facilitates straightening up toward the erect
position; exhalation facilitates further backward extension. The
jaw elevator muscles have a respi- ratory reflex response opposite
to that of most muscles. The elevators are reflexly relaxed during
the inhalation associated with a yawn. Since yawning requires acti-
vation of jaw depressors, this may be an example of overriding
reciprocal inhibi- tion. For these jaw elevators, the isomet- ric
contraction phase is coordinated with exhalation, and the
relaxation (stretch) phase is coordinated with inhalation (the
patient is instructed to yawn or imagine yawning). Eye Movements In
general, eye movements facilitate the movement of the head and
trunk in the direction of the patient's gaze and inhibit movement
in the opposite direction. This holds true for lifting the head and
torso as well as for stooping and rotation. Eye movement (gaze)
does not facilitate side bending, however. Looking up does facili-
tate straightening up from the side-bent position. These eye
movements should not be exaggerated, because a maximum- effort
movement may have an inhibitory effect.5 5 , 5 7 4. NEW MEASUREMENT
TECHNIQUES This section will consider new develop- ments in
algometry, tissue compliance measurement, thermography, and mag-
netic resonance spectroscopy as they re- late to an understanding
of myofascial TrPs. Algometry, tissue compliance measure- ment, and
thermography are valuable for substantiating clinical observations
and as research tools. By themselves they can- not be used for
diagnosing myofascial TrPs. Algometry There are two types of
algometers, a mechanical spring-operated force gauge and an
electrical strain gauge. Spring-operated Algometers Pressure
algometry is not new,6 6 but de- vices specifically designed to
measure pressure threshold, pressure tolerance, and tissue
compliance in relation to myo- fascial TrPs are new.2 9
29. 12 Myofascial Pain and Dysfunction: Trigger Point Manual
The pressure threshold is that pressure which is first perceived as
painful by the subject as increasing pressure is applied. Fischer2
8 , 2 9 described a spring-operated pressure threshold meter that
records forces up to 11 kg. This force gauge has a 1-cm2 circular
rubber tip. The scale reads the pressure applied to the TrP
directly in kg/cm2 . This device is usually sensitive enough at the
low end of the scale to identify differences in sensitivity be-
tween active TrPs, yet remains on scale when measuring the higher
pressure threshold of normal muscles.2 0 , 2 3 , 2 9 The companion
pressure tolerance meter2 9 measures the maximum pressure a.subject
can tolerate over muscles and bones, up to 17 kg. Normally,
pressure tolerance is greater over muscle than over bone. Reversal
of this relative sensitivity suggests the presence of a generalized
myopathy.2 2 The reason for having two similar instruments is that
the threshold meter often goes off scale if one attempts to use it
to measure tolerance, and the tol- erance meter is too insensitive
to resolve accurately the differences in the sensitiv- ity of
active TrPs. Tunks and associates9 7 developed a spring-operated
algometer that was adapted from the Preston pinch gauge. The hemi-
spheric tip of the instrument has an area of contact of 2 cm2 . The
unit was designed to simulate the pressure applied by the thumb
when examining a patient for the tender points of fibromyalgia.
Strain Gauge Algometers The user can rapidly rescale the sensitiv-
ity of an electronic strain gauge algometer to perform both
pressure threshold meas- urements and pressure tolerance meas-
urements. Strain gauge algometers also permit direct recording and
computer in- put. Ohrbach and Gale7 1 designed a strain gauge
pressure tolerance meter for testing tender spots in masticatory
muscles. It had a tip area of only 0.5 cm2 . Jensen and associates4
4 developed a strain gauge pressure algometer for measurement of
sensitivity in the temporal region to study patients with headache.
Schiffman and co-workers7 8 developed a strain gauge pressure
algometer especially designed to transmit the feeling that one has
when palpating a taut band. Its bluntly pointed plastic tip
simulates the shape of a finger- tip. Inter-rater reliability of
their pressure algometer for 14 muscles of the head and neck was
consistently higher than the re- liability of palpation.
Applications Using the Fischer pressure threshold meter,2 0 2 3
comparison of normal values with those obtained at corresponding
TrP sites showed that a difference between right and left sides in
excess of 2 kg/cm2 represents abnormal sensitivity. More- over, any
pressure threshold at a muscle site in excess of 3 kg/cm2 was
considered abnormal.2 0 , 2 3 The muscles of females were more
sensitive to pressure than were those of males in two studies using
differ- ent instruments.2 3 , 7 8 List and associates5 9 found the
Fischer algometer reliable and valid for measur- ing sensitivity
(tenderness) in the masse- ter muscle. A well-controlled study by
Reeves and co-workers7 7 demonstrated that the same meter provided
a reliable measure of myofascial TrP sensitivity in five
masticatory and neck muscles. They also found significantly
increased sensi- tivity at the TrP compared with that of the muscle
2 cm away from the clinically de- termined spot of maximum
tenderness. Jaeger and Reeves4 1 demonstrated that myofascial TrP
sensitivity decreases in re- sponse to passive stretch. Fischer2 8
gave examples of the change in sensitivity ob- served following
different therapies. Applying the Jensen instrument to the study of
migraine patients, investigators4 5 concluded that myofascial TrPs
appear to be a significant factor in migraine head- ache,
contributing particularly to interval headaches between migraine
attacks. Thomas and Aidinis8 9 objectively and quantitatively
measured the threshold for grimacing and movement responses by
pressure algometry in a patient with mus- culoskeletal pain
syndrome during light Pentothal anesthesia. A pressure threshold
meter provides an objective measure of the effectiveness of
treatment.2 0 , 2 7 , 2 9 The meter itself does not identify the
cause of the tenderness being measured.
30. Chapter 2 / General Issues 13 Tissue Compliance Measurement
Fischer2 4 , 2 9 described and illustrated a tissue compliance
meter that measures the relative hardness of the subcutane- ous
tissue by the distance a particular pressure indents the skin. He
concluded that a difference of more than 2 mm of penetration at
corresponding bilateral sites indicates the presence of local
muscle spasm, the taut band of a TrP, normal tendon or aponeurosis,
or scar tissue.2 5 He later reported clinical appli- cations of the
meter.2 6 Jansen and associates4 3 evaluated the reliability of
this meter by measuring nor- mal paraspinal tissue compliance. They
were unable to reproduce results at 26% of the sites after a
10-minute interval. Moreover, 85% of these normal subjects
displayed at least one right vs. left side difference large enough
to qualify as path- ological by Fischer's criteria. On the other
hand, Airaksinen and Pontinen1 found that correlations for
within-experimenter and between-experimenter reliabilities for this
same meter ranged from 0.63-0.98 at different force levels. Of the
instruments mentioned above, to our knowledge, only the Fischer
devices are commercially available at this time. (They are
obtainable from Pain Diagnos- tics and Thermography, 17 Wooley Lane
East, Great Neck, New York 11021.) The algometers described in this
sec- tion afford an opportunity to do quantita- tive studies of
myofascial TrP phenomena that have only begun to be explored. Their
reliable use requires training and skill. Thermography Thermograms
can be recorded by elec- tronic radiometry or with films of liquid
crystal. Recent advances in infrared radia- tion (electronic)
thermography with com- puter analysis provide a powerful new tool
for the rapid visualization of skin temperature changes. This
technique can demonstrate cutaneous reflex phenomena characteristic
of myofascial TrPs. The less expensive contact sheets of liquid
crystal have limitations that make reliable inter- pretation of the
findings considerably more difficult than with electronic radi-
ometry. Each of these thermographic tech- niques measures the skin
surface temper- ature to a depth of only a few millimeters. The
temperature changes correspond to changes in the circulation
within, but not beneath, the skin. The endogenous cause of these
temperature changes is usually sympathetic nervous system activity.
The thermogram, therefore, is comparable in meaning to changes in
skin resistance or changes in sweat production. However, electronic
infrared thermography is supe- rior to these other measures in
conven- ience and in spatial as well as temporal resolution. At
this time, thermography alone is NOT sufficient to establish the
diagnosis of myofascial TrPs. However, it can help to substantiate
the presence of myofascial TrPs that have previously been
identified by history and physical examination. It also offers a
wealth of experimental op- portunities. Early thermographic studies
of myofascial pain demonstrated circular hot spots 5 - 1 0 cm in
diam- eter located over the TrP.1 7 Diakow1 2 studied a TrP
(identified by physical examination) in the upper trapezius muscle
of one patient and a TrP in the supraspinatus muscle of another. In
each case, the specific TrP area had a hot spot approximately 2 cm
in diameter overlying it. In both cases, an area within the
expected referred pain zone also exhib- ited increased warmth, but
of less intensity than at the TrP. Whether the increased heat
radiation observed was over a referred pain zone or over a TrP is
un- clear in most of the studies to date. Two papers1 8 , 2 1
asserted that a reduced pressure threshold reading at the hot spot
proved it to be a TrP. We question that firm conclusion since the
observed tender- ness at the hot spot could represent referred ten-
derness and not tenderness of the TrP itself. To date, the presence
of a TrP can be established con- clusively only by palpating a taut
band and elicit- ing the characteristic referred pain pattern by
the application of digital pressure on the spot of maxi- mum
tenderness in that band or by eliciting a lo- cal twitch response.
Other papers specifically related the hot spots of myofascial pain
to the areas in which pain is felt.1 7 , 1 9 The painful area is
usually the pain refer- ence zone, not the location of the TrP. The
referred pain zone has been variously described as hot,1 2 , 1 9
hot or cold,1 7 and cold.9 3 Failure to differentiate clearly
whether the observed thermal changes are
31. 14 Myofascial Pain and Dysfunction: Trigger Point Manual
present over the TrP itself or in its referred pain zone is a
potential source of confusion for the in- terpretation of
thermographic findings. The literature to date fails to address a
number of critical questions concerning thermographic changes
associated with TrPs. Was the TrP active or latent? Was the patient
having pain at the time of examination? If so, where? Is the
thermogram different when the patient is not having pain? What
happens to the thermal pattern while the TrP is palpated to augment
referred pain? Would a controlled study comparing the hot spots ob-
served in normal subjects differ significantly from a study of the
hot spots observed in myofascial pain patients? Are the tender
points in fibromy- algia patients associated with similar hot
spots? The question may arise whether increased skin temperature is
due to underlying muscle spasm. This question can be answered by
needle electro- myography. Spontaneous electrical activity of a
relaxed muscle indicates muscle spasm, and a muscle that is
electrically silent is not in spasm. Magnetic Resonance
Spectroscopy 3 1 P magnetic resonance spectroscopy can measure the
relative concentration of phosphorus-containing metabolites within
a selected volume of muscle. These metab- olites reflect sequential
steps of muscle en- ergy metabolism. This technique can iden- tify
the relative concentration of sugar phosphates, inorganic
phosphate, phos- phocreatine, and three forms of adenine
triphosphate (ATP).1 4 Kushmerick,5 0 in an extensive review of the
relation between 3 1 P magnetic reso- nance spectroscopy
measurements and muscle metabolism, noted that the rela- tive
concentrations of these metabolites were measurable with an error
of less than 10%. This new technique has pro- vided simple and
useful criteria for dis- tinguishing muscle enzyme deficien- cies,1
4 has revealed abnormal changes in metabolite distribution
following re- peated lengthening contractions designed to result in
mild muscle injury,6 4 and has demonstrated characteristic changes
due to muscle fatigue.6 7 , 6 8 Kushmerick5 0 concluded that such a
dynamic stress test is needed to reveal metabolic abnormalities in
muscles of fibromyalgia patients. Two magnetic reso- nance
spectroscopy studies did report several abnormal changes in
metabolite distribution with exercise in some of the fibromyalgia
patients studied.4 6 , 6 3 If 3 1 P nuclear magnetic resonance
stud- ies can demonstrate diffuse metabolic ab- normalities in some
forms of fibromy- algia, it seems likely that metabolic ab-
normalities should be demonstrable in the immediate vicinity of a
myofascial TrP, if the area for examination can be ad- equately
localized. 5. CURRENT TERMINOLOGY OF MUSCLE PAIN DISORDERS The
following terms are in current use and appear to relate in various
ways to myofascial pain caused by TrPs. In many cases, this
relation is not made clear by the respective authors or is
controversial. The result can be confusion as much as
enlightenment. The terms are arranged al- phabetically and a
reference is cited for each term. This list is by no means
complete, but represents a sample of the many terms currently in
vogue. Terms that were used in the past appear on pages 911 of Vol-
ume l , 9 3 and additional terms have been noted.8 1 Lumping
several confusing and contro- versial diagnostic terms under a new
um- brella usually adds only nosological com- plexity and confusion
to the field of mus- cle pain. It is our opinion that splitting
existing diagnoses into more clearly de- fined component syndromes
is more likely to clarify our understanding. Chronic Fatigue
(Syndrome):3 4 , 3 9 , 1 0 1 Chronic fatigue is now generally
consid- ered a close relative of fibromyalgia, or a partial
expression of it. Since myofascial pain syndromes typically cause
localized weakness rather than general fatigue, pa- tients with
chronic fatigue are more likely to have fibromyalgia than
myofascial pain. Chronic Myalgia:5 1 The cited descrip- tion of
chronic myalgia emphasized mus- cle pain related to static load
during re- petitive assembly work, which would also be likely to
activate TrPs. As defined by Larsson et al., chronic myalgia also
in- cluded findings characteristic of fibromy- algia. Since the
patients studied were not, specifically examined for myofascial
syn- dromes, what contribution active TrPs
32. Chapter 2 / General Issues 15 made to the patients'
conditions is not known. Chronic Myofascial Pain:7 3 The cited
authors characterize patients with chronic myofascial pain as
having "local- ized sites of deep myofascial tenderness (i.e.,
trigger points) with normal joint examination and negative
serological screen." There is no indication that the patients were
examined for signs that would distinguish myofascial TrPs from the
tender points of fibromyalgia. For that reason, one cannot assume
that this term was used by these authors in the same sense in which
we use it. In an effort to prevent confusion, we define the terms
chronic myofascial pain83 and chronic regional myofascial pain syn-
drome81 in Chapter 28 of this volume and distinguish them from
acute myofascial pain and fibromyalgia. Fibromyalgia:1 0 3 As
currently defined, fibromyalgia is a widespread, painful condition
of at least 3 months' duration that is identified by finding at
least 11 tender points at 18 prescribed locations on the body.
Since the diagnostic distinc- tion between chronic regional
myofascial pain syndrome and fibromyalgia can be difficult, the
relation between the two conditions has recently been the subject
of a major international symposium.3 0 Distinguishing features of
the two condi- tions were discussed in detail by Simons8 1 and by
Bennett.5 By definition, all active TrPs at these prescribed tender
point sites are also tender points, but not all tender points are
TrPs. Generalized tendomyopathy: This con- dition, known in German
as Generalisierte tendomyopathie,52,70 is frequently equated with
fibromyalgia, but is described as usually beginning at a single
site and de- veloping into generalized pain over months or years.
The physical examina- tion recommended for this condition does not
specifically include criteria that would identify myofascial TrPs.
There- fore, like fibromyalgia, it could readily in- clude patients
with chronic regional myo- fascial pain syndromes. Neuromyelopathic
Pain Syndrome:6 1 Patients with the neuromyelopathic pain syndrome
characteristically have chronic pain that is refractory to ordinary
therapy, and mild but often widespread neurologi- cal deficits.
They frequently also have TrPs. Many of the characteristics of
these patients are similar to those of patients whom we identify as
having post-trau- matic hyperirritability syndrome,8 2 which is
described in Chapter 28 of this volume. Nonarticular Rheumatism:6
The author of the cited article defines nonarticular rheumatism as
including myofascial pain syndrome, fibromyalgia syndrome, ten-
dinitis, and bursitis. This diagnostic term is often equated with
the German Weich- teilrheumatismus (see below). Osteochondrosis:7 4
Popelianskii re- viewed the history of this term and the concepts
that it encompasses, which in- clude both myofascial pain syndromes
and entrapment syndromes of spinal nerves. An extensive Russian
literature employs this term. Overuse Syndrome:2 , 3 2 , 3 3 This
syn- drome was found to be particularly com- mon among industrial
workers who per- form stressful repetitive activities, musi- cians,
and athletes. Since these patients complained of weakness rather
than fa- tigue, and reported initiating factors that are commonly
associated with myofascial TrPs, we suspect that many of them may
have had myofascial TrPs as one cause of their symptoms. Since the
cited reports did not indicate that the muscles of the patients
were examined for signs of myo- fascial TrPs, the role of TrPs in
the overuse syndrome remains an open ques- tion. Regional
Myofascial Pain:7 9 Sheon7 9 uses the term regional myofascial pain
in essentially the same way that we use the term chronic myofascial
pain syndrome. It is a condition caused by myofascial TrPs, which
needs to be distinguished from fi- brositis (fibromyalgia). Chronic
regional myofascial pain syndromes have three distinct phases
(degrees of severity), as described by the senior author.9 2
Repetitive Strain Injury:4 0 , 8 0 Repetitive strain injury is
similar to the overuse syn- drome and also has characteristics sug-
gestive of the myofascial pain syndrome. The patients may have
suffered from myofascial pain syndromes that went un- recognized,
since there was no indication that their muscles were examined for
that condition.
33. 16 Myofascial Pain and Dysfunction: Trigger Point Manual
Tension Myalgia:8 6 , 8 8 , 9 0 This term originated in the
Physical Medicine De- partment of the Mayo Clinic and was first
used in 1977 to describe painful tension of the muscles of the
pelvic floor.8 8 The probable relation of tension myalgia of the
pelvic floor to myofascial TrPs is dis- cussed in detail in Chapter
6 of this vol- ume. The 1990 publication from the Mayo Clinic on
this subject9 0 lumps the diagnoses of myofascial pain syndrome,
fibrositis, and fibromyalgia into one term, tension myalgia, which
now has ex- panded to include muscles throughout the body.
Weichteilrheumatismus:6 2 Literally meaning "soft-tissue
rheumatism," this term is generally translated as "nonarticu- lar
rheumatism." Since it refers to all soft- tissue structures that
may become pain- ful, some authors6 2 suggest that the proper
translation is "reactive myotendopathy." It clearly encompasses
myofascial pain syndromes along with numerous other conditions. 6.
MOBILIZATION OF THE SACROILIAC JOINT (Fig. 2.1) Despite earlier
controversy, it is now well established that the sacroiliac (SI)
joint normally has mobility that decreases with advancing age.3 6
Mobility is less in males than in females and the joint usually be-
comes ankylosed in elderly men.3 6 , 1 0 0 Frigerio and associates3
1 demonstrated several centimeters of rotational move- ment of the
innominate bones relative to the sacrum. However, Weisl1 0 0
pointed out that the concept of an axis of rotation in the SI joint
is meaningless; the two op- posing surfaces of the SI joint are so
un- even that there is much scatter in the lo- cation of the most
likely centers of rota- tion in the frontal and sagittal planes.
For this reason, and because of the energy that would be needed to
separate the joint surfaces as they are held together by the
surrounding ligaments, Wilder and asso- ciates1 0 2 concluded that
the SI joint func- tions primarily as a shock absorber. According
to Lewit,5 6 the SI joint is one of three joints in the body for
which movement can neither be caused by, nor opposed by, muscles.
However, abnormal muscle tension can help to hold the joint in a
displaced position. (The other two such joints are the
acromioclavicular and the tibiofibular.5 6 ) Porterfield7 5
presents an outstanding description, with illustra- tions, of the
examination of a patient for pelvic articular dysfunction in
relation to muscle function. Egund and associates1 5 described the
diagnostic value of stereo- scopic visualization of the pelvic
bones for the identification of SI joint displace- ments. Diagnosis
and treatment of dysfunction of the SI joint have been described by
nu- merous authors.8 , 1 3 , 3 7 , 3 8 , 5 3 , 6 0 , 6 9 , 7 5 The
follow- ing sections on diagnosis and treatment describe a method
that the senior author has employed successfully. Diagnosis The
patient has experienced a sudden or a gradual onset of pain in the
region of one or, occasionally, both SI joints. The pain may be
felt at both SI joints even when only one is displaced, but is
usually worse on the side of the affected joint. Onset commonly is
related to a simple motion that combines bending forward, tilting
the pelvis, and twisting the trunk, such as a short golf swing,
shoveling snow, stooping and reaching sideways to pick up an object
on the floor, or getting up sideways out of a soft chair. The pain
may also be initiated by a slight fall, preg- nancy, or improper
positioning during general anesthesia. Occasionally, severe pain in
a sciatic distribution may be the chief symptom of SI joint
dysfunction and may so predominate that the patient makes no
mention of pain in the back. Some degree of pain radiation to the
lower limb is common. The variable pat- tern of pain referred from
the SI joint may include the lumbar region, the lateral as- pect of
the thigh, the gluteal region, the sacrum, the iliac crest, and a
sciatic nerve distribution.9 5 , 9 6 Limitation of mobility is
variable and may be wholly incapacitat- ing or trivial. Pain may be
aggravated by bending forward, putting on shoes, cross- ing one
thigh over the other, rising from a chair, and turning over in bed.
Steinbrocker and associates8 7 injected 0.2-0.5 ml of 6% sodium
chloride solution into the SI
34. Chapter 2 / General Issues 17 Figure 2.1. Technique for
manipulation of the right the lowermost ilium, which is stabilized
by the patient's sacroiliac joint. The patient lies on the affected
side, weight. With the other hand, the operator exerts The right
hand exerts a smooth forceful thrust against counter pressure
against the upper thorax. (After the sacrum with a corkscrew motion
upward and for- Travell and Travell,9 5 p. 224.) ward, to produce a
rotary movement of the sacrum on joint and observed pain that
radiated both upward and downward to the knee. Tenderness to
pressure is always pres- ent directly over the superior or inferior
posterior iliac spine on the affected side. The diagnosis of SI
joint dysfunction is in doubt if this tenderness is not present. In
addition, muscles in the SI region de- velop TrP tenderness,
including the lower end of the erector spinae, the quadratus
lumborum, the three glutei, and the piri- formis muscle. These
muscles may be more tender than the posterior margin of the joint
itself; this finding can be a source of confusion and misdiagnosis.
Routine X-ray films of the pelvis and lumbar spine rarely show
malalignment of the SI joints. On examination, straight-leg raising
is usually limited. In more severe cases, limitation of flexion of
the thigh against the abdomen is often present on the af- fected
side. The lumbar curve is usually flattened and the pelvis is
tilted upward on the affected side, causing a promi- nence of the
hip on that side. When pain is severe, the patient walks with a
distinct stoop and limps, sparing the limb on the side of the
displaced SI joint.9 5 , 9 6 The left SI joint is tested for
restriction by having the patient lie supine with the examiner
facing the right side of the body. The right thigh is placed in
full abduction and external rotation with the knee bent, foot
beside the other knee, as illustrated in Figure 15.14. The right
knee is gently moved up and down, using the thigh as a lever to
rock the left SI joint, which is where the patient usually feels
discomfort if that joint is abnormal. Sometimes pain is also
induced in the SI joint on the same side as the limb being moved.
If this test is not positive, SI joint dysfunction is un- likely to
be present.9 5 , 9 6 Treatment The first author of this manual has
de- scribed9 1 how she learned from her physi- cian father the
value of, and a technique for, manipulation of the SI joint. A 1942
photograph of her father9 5 shows him demonstrating this technique,
which was later used by Bierman7 and designated "the Travell
maneuver." Before manipulating the SI joint, it is important to
treat first any lumbar spinal joint dysfunction that is present.
One should also ensure that any TrPs that cause shortening of the
quadratus lum- borum muscle have been inactivated; ten- sion of
this muscle can hold the SI joint in a malaligned position. For
manipulation of the SI joint, as il- lustrated in Figure 2.1, the
patient lies on the affected (right) side with the right
35. 18 Myofascial Pain and Dysfunction: Trigger Point Manual
lower limb extended at the hip and the knee straight. The uppermost
lower limb is allowed to fall into a natural position with the knee
slightly bent and the foot hooked l