Musculoskeletal Manual Medicine: Diagnosis and Treatment

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uccessor tl) the renowned Manual Medicine: Diagnostics and Manual Medicine: ·Inerapy. this richly illustrated. logically organized book. while clinically oriented. presents both the theory and practice of the expanding field of musculoskeletal medicine. Its aim is to fully integrate and coordinate the relatively young firld of manual medicine with classic medical school teaching, based on currenL biomechanical and evidence-based knowledge. Without pleJudice the book includes the posillve aspects of osteopathic and chiropractic examination and treatment tpchnique within the context of a functionally meaningful musculoskeletal managpment approach. _

Whllt> the particular examination and related treatment techniques are described in detail. tile layour facl1itate both a quick overview and sufficient detaJi, when needed. The accom­ panying text describes and correlates possible pathologic findings. Other chapters cover the history of manual medi ine, examination and Lreatment principles. and the application of biomechanics and muscle physiology La the variolls non-surgical hands-on approaches, including myofascial trigger point treatmtnt. Emphasis is given to anatomical descriptions of muscles Jnd their palpatory assessment as well as techniques to treat shortened muscles. The concept of muscle imbalance is presented. Relationships between pain and specific variables are juxtaposed Jnd graphically represented. Rarionaltreatmenl approaches are deScribed. ranging from "wait-and-see" recommendations to further medical work-up and indications for surgery. SpecifiC musculoskeletal disorders Jre reViewed in detail.

Highlights: •

•

•

•

•

•

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Systematic presentation, from three-dimensional anatomy to function and pain Over 1000 illustrations. dispenslllg with [he need for lengthy text passages LogICal presentation of speCific disorders "Action" photographs for examination and treatment Full-color drawings and photographs with superimposed graphics clearly depicting lhe joints and areas of each body region Physiological explanations and further requirements substanliclting the use of m;mipulative medicine Well arranged examination techlllques for the entire person

Muscu/oskeleral Manual Medicine will be indispensable to professionals who treat the person

with acute and chronic musculoskeletal problems, providing access to the broadest possible cumamentarium based on today's knowledge and insights.

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Important note: Medicine is an ever-Changing science undergoing

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continual development. Research and clinical experience are contin­ ually expanding our knowledge. in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application. readers may rest assured that the authors. editors. and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Parts of this book are an authorized and revised translation of the 5th German edition of Manuelle Medizin: Diagnostik and the 3rd German edition of Manuelle Medizin: Therapie. published and copyrighted 1997 by Georg Thieme Verlag. Stuttgart. Germany. This book also includes revised and updated material taken from the 1 st edition of Manual Medicine: Therapy and the 2nd edition of Manual Medicine: Diagnostics. published and copyrighted 1988 and 1990. respectively. by Georg Thieme Verlag. Stuttgart. Germany.

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IV

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List of Contributors Hubert Baumgartner, MD

Carl Granger, MD

Former Chief of Rheumatology

Professor of Rehabilitation Medicine

Schulthess Clinic

University at Buffalo

Zurich, Switzerland

School of Medicine and Biomedical Sciences

Daniel Buehler

Uniform Data System for Medical Rehabilitation

Physiotherapist

Amherst

Fluntern High School Sports Center

New York, USA

Executive Director

Department of Physiotherapy Zurich, Switzerland

Dieter Grob, MD

Douglas Chang MD, PhD

Head of Spine Surgery

Professor ,

Assistant Professor

Schulthess Clinic

Chief, Physical Medicine and Rehabilitation

Zurich, Switzerland

Department of Orthopedic Surgery University of California, San Diego San Diego, CA, USA

Norbert Gschwend, MD Professor and Former Chief Surgeon and Chairman Schulthess Clinic

Jill Chomiak, MD, PhD

Zurich, Switzerland

Associate Professor Head of Pediatric Orthopedic Department

Jochen F. Loehr, MD, FRCSC

University Hospital IPVZ and 1 st Medical

Professor of Orthopedics

Faculty of Charles University

ENDO-Clinic

Hospital Na Bulovce

Hamburg, Germany

Prague, Czech Republic Chetan Malik, MBBS Beat Dejung, MD, PhD

Clinical Instructor

Physical Medicine Specialist

Rehabilitation Medicine

Rehabilitation and Rheumatic Diseases

Department of Physical Medicine and Rehabilitation

FMH Swiss Medical Association

University at Buffalo

Winterthur, Switzerland

School of Medicine and Biomedical Sciences

Tomas Drobny, MD

Amherst

Orthopedic Surgeon, Lower Extremity

New York, USA

Uniform Data System for Medical Rehabilitation

Schulthess Clinic Zurich, Switzerland

Anne Frances Mannion, MD, PhD

Toni Graf-Baumann, MD, PhD

Research and Development

Professor

Schulthess Clinic

Managing and Scientific Director

Zurich, Switzerland

Head of Department

German Society of Musculoskeletal Medicine Managing Director

Urs Munzinger, MD

German Society for the Study of Pain

Orthopedic Surgeon FMH

German Pain Society

Head of Orthopedic Surgery. Lower Extremities

Teningen. Germany

SChulthess Clinic Zurich, Switzerland

Copyrighted Material

v

Manohar M. Panjabi, PhD

Wolfgang Trautmann

Professor Emeritus

Physiotherapist

Former Director Biomechanics Research

Director of Physiotherapy

Yale University School of Medicine

Sports Medical Center Bern

New Haven, Connecticut, USA

Permanence Clinic Bern-Hirslanden Bern, Switzerland

Bogdan P. Radanov, MD Professor

Beat Waelchli, MD, DC

Head of Pain Center

PRISMA Spine Surgery Zolliltu- )

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Time

Fig,2.26 Mobilization-without-impulse technique. Distance-time diagram,

18

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Treatment Principles of Various Manual Medicine Techniques

Mobilization- with-Impulse Technique

Joints of the limbs

(MWITH) (Classic Thrust Technique,

•

The affected peripheral joint (limb joint) is guided to its

•

The operator's hands are placed as close to the joint as

"Manipulation")

present neutral (resting) position.

The mobilization-with-impulse technique is also known as

possible. Usually it is the proximal joint partner that is

the classic "thrust" technique, often referred to in the liter­

fixed (held stationary). The direction of impulse force is

ature simply as a "manipulation."

perpendicular to the plane of treatment.

The following principles apply to the mobilization-with­

•

The mobilization-with-impulse technique progresses from level II mobilization to level III mobilization.

impulse technique (MWITH).

Spine (Apophyseal or Facet Joints)

The force-time diagram (Fig.2.28) demonstrates that dur­

•

Slack is taken up in the facet joints above and below the

ing the positioning of a synovial joint. the forces introduced

incriminated vertebral segment; that is, the spinal seg­

to the particular joint are relatively small.

ments adjoining the restricted spinal segment are car­ ried to their respective barriers. •

The distance-time diagram (Fig.2.29) demonstrates that the mobilization-with-impulse techniques involve

Positioning of the patient and preparation for the tech­

very brief but precise maneuvers (high-velocity, low­

nique should be performed carefully so as not to intro­

amplitude) in which the applied force moves the joint

duce or exacerbate the patient's pain.

beyond its particular or actual pathologic barrier but with­

•

Mobilization proceeds in the pain-free direction.

out exceeding the anatomic barrier.

•

The direction of the mobilization forces is determined by carefully dosed provocation testing. The direction of mobilization is that in which the patient-reported pain and the nociceptive reactions decrease (Fig.2.11 a, b,

Zl

Fig.2.27). •

The mobilization-with-impulse technique in which the spinous process or the articular process of the inferior

\

partner of the spinal segment is utilized will introduce vertebral rotation in the same direction as the irritation zone. •

Thus, the inferior vertebra undergoes rotation away from the irritation zone. The opposite is true for the superior vertebral partner, which undergoes a rotation toward the irritation zone (Fig.2.27).

•

Z

+0Y

The force of the impulse should be carefully dosed so as

+0Y --�-------+--�---+�- X --

not to introduce motion beyond the anatomic barrier (mobilization level III. Fig.2.13). •

Mobilization-with-impulse should be performed care­ fully and with great caution so as not to exacerbate the patient's pain in the incriminated joint, or spinal region.

•

When using the mobilization-with-impulse technique, the affected segment should be treated no more than once during the treatment session. Fig.2.27 Mobilization-with-impulse (MWITH). MWITH-via the superior vertebra MWITH-via the inferior vertebra x', Z1

+0Y

=

Pathologic motion barrier

=

Pathologic rotation to the left of the superior

=

Irritation zone

vertebral joint partner

IZ

Copyrighted Material

19

Definitions and Principles of Manual Medicine Diagnosis and Treatment

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Distance gain

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many patients revealed an increased rotation to the left.

lia. demyelinating diseases. spondylitis, and prevertebral

which may be an indication of a lesion of the right alar

soft-tissue abnormalities such as abscesses, the MRI study

ligaments. Patients who demonstrated paradoxical rota-

is superior to conventional computed tomography.

tion exhibited a greater rotation to the contralateral side.

The MRI study allows specific measurements of the

A paradoxical rotation means that the more superior seg­

width as well as the overall diameter of the cervical spinal

ments rotate less than the inferior segments. Again. this

canal. The cranial migration distance determines the dis­

may be a result of loss of normal ligamentous function.

tance between the axis to the occiput, i. e., the foramen magnum (Fig. 13.23). The tip of the occiput and the clivus are connected by

Magnetic Resonance Imaging

drawing a line between these two structures. A line per­

The MRI of the cervical spine is particularly well suited for

the axis. The average value of the cranial migration distance

pendicular to this line is then directed to the lower edge of evaluation of the soft tissues, the spinal cord, and nerve

(( MD) is 38.7 mm (standard deviation 2.9 mm, range

roots. This allows the evaluation of potential compression

33-46 mm) (Dvorak, 1989). A superior migration distance

due to a space-occupying lesion. Disk herniations are also

of less than 31.5 mm is indicative of cranial migration of the

usually well demonstrated with MRI. When there is suspi­

axis or basilar impression.

cion of extradural or intramedullary tumors. syringomye­

199

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Imaging Studies of the Spine

performed with the head being passively guided to max­ imal flexion and then extension. The extreme positions are supported with specific wedges. The extreme positions are delimited only as far as the patient allows them to be Clivus

Occiput _ _

;r

_

achieved without much pain or other symptomatology. Axial cuts for a functional MRI study are performed only

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when there is suspected spinal cord compression as deter­ mined in the sagittal views. The duration of the functional

-- Redtund-Johnett

Rectus capitis posterior major Rectus capitis posterior minor

641

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Functional Examination and Treatment of Muscles

is palpated superoposteriorly in the direction of the tip of

Obliquus Capitis Superior Muscle

the transverse process of the atlas (Fig. 17.66).

Origin

This muscle originates from the transverse process of the atlas, in thick tendinous fibers from the posterior corner

SRS Correlation

The posterior cervical intertransverse muscles and the ob­

and the lateral segment of the C1 transverse process

liquus capitis superior muscle play an important role in the

(Figs, 17,67),

spondylogenic event. Even though the obJiquus capitis superior muscle be­ longs anatomically to the posterior cervical intertransverse

Insertion

muscle group, it has been reported that it is spondylogeni­

Inserts into the occipital bone at the superior to the lateral

cally and reflexogenically correlated with the sacroiliac

third of the inferior nuchal line (Fig, 17,65).

joint.

Innervation

Obliquus Capitis Inferior Muscle

Dorsal rami of C1.

Origin Action

The spinous process of the axis.

Bilateral contraction results in extension of the head. Uni­ lateral contraction results in Side-bending of the head to­ ward the side of the contracted muscle.

Insertion

The transverse process of the atlas, along the inferior and posterior surface.

Palpatory Approach

The origin is palpated inferiorly, below the most lateral insertion of the semispinalis capitis muscle (about 3 cm

Course and Relations

lateral to the external occipital protuberance). The origin

Refer to Figures 17.63 and 17.67.

Fig. 17.65 Muscle attachments at the occiput (see Fig.17.62 for

Fig. 17.66 Palpation of the obliquus capitis superior.

specific muscles).

642

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Muscles of the Posterior Regions of the Neck and Back

Innervation Dorsal rami of the spinal nerves (1 and (2.

Action Rotation of the head to the side of the contracted muscle.

Palpatory Technique The origin is palpated laterally at the spinous process of (2 according to the direction of the muscle fibers. The inser­ tion, at the transverse process of the atlas, is palpated medioinferiorly. To evaluate the muscle origin and inser­ tion, it is important to be at the correct palpatory depth. It is very difficult to distinguish tendinosis of the insertion from the zone of irritation. Myotendinotic changes in the muscle belly (i.e., hard, palpable band) appear in the sub­ occipital soft tissues as a perpendicular, laterosuperiorly

Fig. 17 .67 Suboccipital muscles.

1

Obliquus capitis inferior

2 3

Rectus capitis posterior major

4

Rectus capitis posterior minor

Obliquus capitis superior

directed spindle.

SRS Correlation The entire muscle is correlated with the sacroiliac joint as a single myotenone.

length Testing of the Suboccipital Muscles

Examination Procedure The patient is in the supine position. The examiner cradles the patient's head by placing one palm over the patient's occiput while the other embraces the forehead. The exam­ iner then carefully introduces flexion to the upper cervical spine, specifically inclination to the upper cervical spinal

Fig. 17.68 Length testing of the suboccipital muscles.

segments, while at the same time applying traction. The axis of rotation is hypothetica Ily placed through both mas­ toid processes (Fig. 17.G8).

Positive Findings 1. Loss of inclination motion with soft end-feel indicates shortening of the suboccipital muscles. 2. Loss of inclination motion with hard end-feel indicates degenerative joint changes.

643

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Functional Examination and Treatment of Muscles

Transversospinalis Muscle Group (Semispinalis, Multifidus, Rotatores) Semispinalis Muscle - Overview Spanning from the sacrum to the upper cervical spine, the semispinalis muscle is a long and rather flat muscle that is made up of many divergent fascicles. From superior to inferior, the muscular units overlap each other in a roof­ tile manner. Starting at the axis and going inferior, the characteristic feature of the transversospinal muscle sys­ tem is determined by the muscle's shape and varying length: the muscle fibers originate from an individual transverse process but then the various muscle slips fan out to attach at several spinous processes. which explains the different lengths. The superficial portions are the longer muscle sections with the fibers running nearly vertically. The deeper muscle portions are the shorter components of the muscle with the fibers extending in a transverse direction (Figs. 17.69, 17.70).

Semispinalis lumborum Muscle Origin

The muscle arises by a strong fascia from the mamillary

Fig. 17.69 Semispinalis muscle.

processes of 51, LS, and L2. At L1 and Tl2, the muscles originate directly from the vertebra'S mamillary processes.

Insertion

It inserts as long tendons at the inferior portions of the two spinous processes that are positioned six and seven seg­ ments superior to the vertebra from which the myotenone originates. The anatomic muscle unit of the semispinalis muscle described here is identical to the spondylogenic unit, the myotenone.

Semispinalis Thoracis and Cervicis Muscles Origin

From the superior edge of the transverse processes. •

Thoracic portion: superior margin of the transverse

processes ofT6 through TlO. •

Cervical portion: the superior margin of the transverse

processes of upper thoracic vertebrae, T2 through TS (Fig. 1 7.71 ).

Fig. 17.70 Semispinalis muscle-course and relations.

1

Semispinalis capitis

2

Semispinalis cervicis

3

Semispinalis thoracis

4

Spinalis

5

Longissimus. thoracic region

644

Copyrighted Material

Muscles of the Posterior Regions of the Neck and Back

inserts via three fascicles. The semispinalis muscle extends

Insertion

from one vertebra to the sixth above and inserts via two

The structure of the myotenone remains the same as de­

fascicles. When a painful superior margin of the mamillary

scribed previousl y. The insertions are found at the spinous

bodies is located, all seven spinous processes must be

processes, which are six to seven segmental levels higher

palpated from their lateral aspect to the root in order to

than the vertebra from which the myotenone originates.

eliminate the rotatores muscles and the multifidus muscle

The insertion tendinosis is most prominent at the medial

as the source of the dysfunction and pain.

and posterior margin of the muscle (Figs. 17.69, 17.71).

The origin tendinosis is determined to belong to the semispinalis muscle when the insertion is on opposite poles and lies six to seven segmental levels above the roots

Course and Relations

of the spinous process. The myotendinosis of the individual

All three semispinalis muscles are positioned at the same

muscle fibers can normally be palpated as a thin matchlike

level. The superior surface is covered by the longissimus

band.

muscle and the spinalis muscle, and partially by the semi­ spinalis capitis muscle (Fig. 17.70). A thin connective-tissue layer demarcates this muscle from the multifidus muscle below, which is important for palpation. Differentiation

SRS Correlation The spondylogenic unit, the myotenone, is represented in

from the multifidus muscle is facilitated by recalling that

Fig. 17.72. The 17 myotenones of the semispinalis muscle

the longest portions of the multifidus muscle skip two

are correlated with the spinal segments CO through T9.

fewer vertebrae than the semispinalis muscle.

Innervation Dorsal rami of the spinal nerves.

Action Bilateral contraction results in extension of the vertebral column. Unilateral contraction results in contralateral ro­ tation of the vertebral column.

Palpatory Approach Due to its frequent spondylogenic participation, exact pal­ pation of the transversospinal system is extremely impor­ tant. As a result of the close anatomical arrangement at the mamillary or transverse processes, it is difficult to distin­ guish between a tendinosis at the origin of the semispinalis muscle, and other muscles including the multifidus muscle

Fig. 17.71 Muscle attachments at the

Fig. 17,72 Spondylo­

transverse process of the thoracic

geniC unit (myotenone)

vertebra.

1

1

Short rotator

and the rotator muscles. Only when the attachment tendi­

2

Long rotator

2

noses are present at both poles of the muscle is differ­

3 4

Multifidus

3

entiation possible. The rotator muscles pass from one vertebra to the first or second above (be aware of the difference between the anatomical and

spondylogenic

units).

The multifidus

muscle passes from one vertebra to the third above and

5

Semispinalis thoracis

Semispinalis thoracis Multifidus Short and long rotator muscles

Longissimus capitis and cervicis

6 7 8

Semispinalis capitis Longissimus thoracicis Levator costae

645

Copyrighted Material

Functional Examination and Treatment of Muscles

Semispinalis Capitis Muscle Origin The transverse processes of (3 through (6. The origin of the semispinalis capitis muscle is in close proximity to the insertions of the posterior scalene muscles, the levator scapulae muscle, the splenius cervicis muscle, the iliocos­ talis cervicis muscle, the longissimus cervicis muscle, the longissimus capitis muscle, and the posterior cervical in­ tertransverse muscles. Further origins include the tip of the transverse pro­ cesses of

(7, T1 through T8, and posterosuperiorly from

the planum nuchale (Figs. 17.73 and

Fig. 17.73 Muscle attachments at the transverse process of the

17.74).

thoracic vertebra.

1 2 3

Multifidus

5 6

Semispinalis capitis

Insertion

Semispinalis cervicis

7

Levator costae

The squama of the occipital bone directly lateral to the

4

Longissimus capitis et

Rotatores

Longissimus thoracis

cervicis

midline. The insertion has a characteristic shape (see dia­ gram in Fig. 17.75) and lies between the superior and infe­ rior nuchal lines. In the transverse direction it measures about 3 cm, in the sagittal direction about 2 cm (Figs. 17.75,

17.76).

Course and Relations The semispinalis capitis muscle lies lateral to the nuchal Iigament. It overlies the bifurcated spinous processes of the cervical spine, including that of

(7. Further inferior, it is

imbedded superficially in a bony and ligamentous groove formed by the spinous processes, vertebral arches, apophy­ seal joints, and transverse processes. In the thoracic region, it is situated lateral to the thoracic spinous processes. The muscle itself is flat and superficial in the medial neck portion. In the cervical region, it is covered by the splenius capitis muscle and the trapezius muscle only. The semi­ spinalis capitis muscle covers the semispinalis cervicis muscle, as well as a portion of the semispinalis thoracis muscle. As a result, when palpating, the examiner perceives the semispinalis capitis muscle as a round bundle. It bor­ ders the longissimus capitis muscle laterally (Fig.

17.76).

Fig. 17.74 Course of semispinalis capitis muscl.e.

Innervation Dorsal rami of the cervical nerves

Palpatory Approach

(1-(4.

A general impression of the muscle can be obtained in the cervical region at the (3 level, where it has a cylindrical

Action

appearance. By palpating from medial to lateral (perpen­

Bilateral contraction results in extension of the head and

dicular to the fiber direction), the examiner can detect

the cervical spine. Unilateral contraction results in rotation

possible myotendinosis. When the semispinalis capitis

of the head and the cervical spine to the opposite side.

muscle is palpated

following the arch, the examiner

reaches the deep articular and transverse processes. The

646

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Muscles of the Posterior Regions of the Neck and Back

Myotenone Superior ....... . .. .... . .. ... nuchal line

SRS

..

..

.

SRS T4 TS

[4

T6

C5

17

C6

T8

C7

T9

T1

no

T2

line

' .'

nl

T3

T12

T4

LI

T5

L2

T6

L3

T7

L4

T8

..... .

.

.

'

Fig. 17.75 Spondylogenic reflex system (SRS) correlation (after Sutter).

Fig. 17.76 Semispinalis capitis muscle-:

The characteristic pain pattern is referred anterolater­ ally at the level of the mid-thorax. The pain may also

.:..

project to the region between the shoulder blades, usually between the inferior angle of the scapula and the lower cenlical region (a). •

____

__ __

__ __

______ ______ ____

________ L____

I

a

Motion restriction and provocation testing: Quite fre­

quently scapular motion is restricted due to the associ­ ated myofascial restrictions. Hyperabduction of the arms or bringing the elbows together behind the back may elicit the characteristic pain pattern. •

Palpatory localization: The trigger points are palpated

under the scapula at the attachment of the individual muscle slips to the respective ribs. The palpatory as­ sessment further helps determine the extent and se­ verity of potential fascial restrictions ("adhesions") be­ tween the thorax and scapUla.

Patient Positioning and Set-Up •

b

Variation 1: The patient is in the side-lying position

(lateral Sims position) with the involved side facing away from the table. The physician stands behind the patient •

(b).

Variation 2: The patient can also be treated in the supine

position. Here. the physician stands next to the patient on the same side as the incriminated muscle. The physician elevates the patient's arm

(e).

c

738

Copyrighted Material

Myofascial Trigger Point Treatment

Technique N: Myofascial release ("fascial separation").

Treatment Procedure

Myofascial release addressing the fascia between the sub­

Technique I: Active, repetitive muscle contraction and

scapularis and serratus anterior muscles is performed. The

relaxation. The trigger point is carefully compressed by the

patient. under careful guidance by the physician, is re­

physician while the patient is instructed to actively and

quested to perform all shoulder motions that are possible

repetitively protract and relax his shoulder.

from this position. When discovering a very painful trigger

Technique II: Stroking massage of connective tissue.

to switch to technique I.

point while performing this technique, it is recommended After introducing an adequate preparatory stretch to the incriminated muscle (the muscle that harbors the trigger point is carefully stretched within the patient's pain toler­ ance), the physician performs a deep stroking type of mas­

Comments

Technique IV is a very effective maneuver for treating the

sage applied to the muscle fibers at their insertion to the

scapular fascial restrictions. The serratus anterior and three

correspond ing rib.

other trunk muscles, namely, the middle scalene muscle, the fourth-layer rotator muscles of the thoracic spine, and

Technique III: "Fascial release." Generalized stretching of

the superior portion of the abdominal muscles, are the

the fascia associated with the lateral muscular slips.

major culprits for posterior thoracic pain.

739

Copyrighted Material

Myo(asdal Trigger Point Treatment

Quadratus Lumborum Muscle (Figs. 118.9a-c) Indications •

Pain referral pattern:

The pain is usually reported by the

patient as a "deep low back pain." Trigger points located in proximity to the spine are usually "deep" and project the pain distally in an inferior direction toward the sacrum and the ischial tuberosity. The superficial trigger points, which are generally located more laterally, characteristically refer the pain toward the side of the pelvis and in particular the region of the iliac crest and the greater trochanter, as well as the superior groin, especially when the point is more proximal/superior.

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Pain arising from the superficial, more superiorly lo­ cated points may also be projected to the lower abdo­

a

men (a). •

Motion restriction and provocation testing:

Motion test­

ing reveals reduced contralateral side-bending motion due to shortening of the incriminated muscle. Side-bending motion with the patient either sitting or standing (e.g., loaded positions) may exacerbate or precipitate the patient's presenting pain, while unload­ ing the spine may reduce the pain. Particular lumbo­ sacral movements such as simultaneous trunk rotation/ side-bending toward one side and forward flexion may exacerbate the pain, as this may have been the initial precipitating motion. •

Palpatory localization: The physician is seated behind the patient. Starting laterally from the iliocostalis muscle, the quadratus lumborum muscle is approached by moving medially until the trigger point is encoun­ tered. This may require that the physician introduce

b

some side-bending, either toward the side of the in­ criminated trigger point (for easier access) or to the opposite side in order to introduce additional stretch, depending on the individual situation. The lateral (superficial) trigger points are located just below the 12th rib or directly above the iliac crest. The deep (medial) trigger points lie in close proximity to the transverse processes of the lumbar vertebrae (b).

Patient Positioning and Set-Up •

The patient is seated on a stable stool with his legs supported on the floor,

or

may sit astride the examina­

tion table. •

Alternatively, the patient may be positioned prone. c

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Myofascia/ Trigger Point Treatment

Technique III: "Fascial release." This technique may not

Treatment Procedure

always be possible since the space between the 12rh rib and

Technique I: Active, repetitive muscle contraction and relaxation. While slight

pressure

(e. g.,

the pelvic crest may be too narrow for access.

appropriately

dosed compressive force) is applied to the localized trigger

Technique IV: Myofascial release ("fascial separation").

point by the physician, the patient is requested side-bend

This technique can be utilized especially when addressing

his trunk alternately toward and away from the muscle that

the fascial structures between the iliocostalis and quadra­

harbors the trigger point (c).

tus lumborum muscles.

Technique II: Strol