Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 2

1.Pain Patterns PAGE Abductor Digiti Minimi 505 Abductor Hallucis 504 Adductor Hallucis 524 Adductor Longus and Adductor Brevis 291 Adductor Magnus 292 Biceps Femoris 317 Coccygeus 112 Deep Intrinsic Foot Muscles 523, 524, 525 Extensor Digitorum Brevis 503 Extensor Digitorum Longus 474 Extensor Hallucis Brevis 503 Extensor Hallucis Longus 474 Flexor Digitorum Brevis 505 Flexor Digitorum Longus 490 Flexor Hallucis Brevis 524 Flexor Hallucis Longus 490 Gastrocnemius 399 Gluteus Maximus 133 Gluteus Medius 151 Gluteus Minimus (Anterior part) 169 Gluteus Minimus (Posterior part) 169 Gracilis 293 Hamstring Muscles 317 Iliopsoas 90 Interossei (of the Foot) 525 Levator Ani 112 Long Extensors of Toes 474 PAGE Long Flexors of Toes 490 Obturator Internus 112 Pectineus 237 Pelvic Floor Muscles 112 Peroneus Longus and Peroneus Brevis 372 Peroneus Tertius 372 Piriformis 188 Plantaris 430 Popliteus 340 Quadratus Lumborum 30 Quadratus Plantae 523 Quadriceps Femoris Group 250,251,252,253 Rectus Femoris 250 Sartorius 227 Semimembranosus and Semitendinosus 317 Soleus 429 Sphincter Ani 112 Superficial Intrinsic Foot Muscles 503,504,505 Tensor Fasciae Latae 218 Tibialis Anterior 356 Tibialis Posterior 461 Vastus Intermedius 252 Vastus Lateralis 253 Vastus Medialis 251

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 experience, 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 upper 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 established and are increasingly being vali- dated by once skeptical clinical investigators. This volume goes beyond and opens up new ground in sensitizing clinicians to the important interfaces between myofascial pain syndromes and articular (somatic) 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 valuable 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 illustrations, 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 concerns the muscles of the lower half of the body as Volume 1 dealt with the muscles of the upper half of the body. This volume 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 practitioners 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 differences between Volume 1 and Volume 2. This volume includes frequent references to related manual medicine diagnoses and treatment. The therapy sections describe alternative treatment techniques that do not require vapocoolant spray, techniques that will serve as a substitute until an environmentally safe vapocoolant 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; however, 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 inequality (often called a short leg) in per- spective and examines in detail radio- graphic techniques for measuring it accurately. 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 distinguishing 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 adductor 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 reviews thoroughly the subject of nocturnal calf cramps and their close relation to trigger points in the gastrocnemius muscle. Chapter 22 on the soleus and plantaris muscles summarizes the current literature on shin splints in relation to trigger points. The subject of postexercise muscle 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 syndromes and who fail to respond to the therapeutic measures that are usually so effective in single-muscle myofascial syndromes. This chapter distinguishes between the chronic myofascial pain syndrome and fibromyalgia. Health professionals, when first exposed to this subject, often ask, "What does it take to become proficient?" The answer is threefold: (a) develop an appreciation 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 muscle 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 expressed 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 author's wife, Lois Statham Simons, P.T., whose spirited discussions helped keep the manuscript on course and whose meticulous 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 recognition for the meticulous care and understanding with which he reviewed every chapter. He is a master of grammatic pre- cision, concise expression, and the resolution of fuzzy statements. Any redun- dancy in this volume surely crept in following 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 myofascial 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 myofascial 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 pelvic floor muscles, based on extensive experience 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 support, 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 understanding 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 opportunity for fruitful discussions of myofascial 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 regional myofascial pain syndromes, and to develop effective clinical methods of treatment and management for these common 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 encourage frequent reference to it, whenever needed. Comments concerning a definition 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 forefoot 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 adduction. Action: The actions of a muscle, as described in this volume, are the anatomical movements produced by contraction of that muscle. To be distinguished from function. 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 voluntary effort to move the body part being tested. Active Myofascial Trigger Point: A focus of hyperirritability in a muscle or its fascia 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 tender, prevents full lengthening of the muscle, weakens the muscle, usually refers pain on direct compression, mediates a local twitch response of its taut muscle fibers when adequately stimulated, causes tenderness in the pain reference zone, and often produces specific referred autonomic 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 midline. For the toes, it is movement toward the midline of the second digit. For the foot, it is movement of the forefoot horizontally inward toward the tibial side of the leg. At the hip, adduction is movement of the thigh toward the midline of the body. Adduction is the opposite of abduction. Agonists: Muscles, or portions of muscles, 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 forward, 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 referred phenomena caused by trigger-point activity in another muscle. Satellite and secondary trigger points are types of associated 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 pattern referred from trigger points in two or more closely adjacent muscles. No distinction is made between the referred pain patterns of the individual muscles. Concentric (contraction): Contraction as the muscle shortens. Contracture: Sustained intrinsic activation of the contractile mechanism of muscle fibers. With contracture, muscle shortening occurs in the absence of motor unit action potentials. This physiological definition, 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 movements are complex. The term eversion is sometimes used as synonymous with pronation.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 includes 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 distinguished 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 distinguished 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 interphalangeal joint of the great toe,2 2 or persistent flexion of the proximal interphalangeal 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 talus. in: Inch, a unit of distance; approximately 2.54 centimeters. Innominate Upslip: An innominate upslip (shear) dysfunction2 8 is characterized by upward displacement of an innominate 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 talus and movement of the forefoot on the hindfoot at the transverse tarsal joint. The term inversion is sometimes used as synonymous with supination.26 To be distinguished from eversion. Involved Muscle: A muscle that has developed one or more active or latent trigger 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 hyperirritability. This action blanches the compressed 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 describe the local twitch response of muscle fibers 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 extended, and the ankle is passively dor- siflexed. Considered indicative of lumbar root or sciatic nerve irritation,20 or of gastrocnemius 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 distinguished. 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 below the brim or superior aperture.1 3 To be distinguished from the greater pelvis. Lewit Technique: At stretch-length of the muscle, postisometric relaxation combined with reflex potentiation of relaxation 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 contraction 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 erroneously 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 anteroposterior curvature of the spine that places the lumbar spine in extension with the convexity of the curve facing anteriorly. 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 anterior surface turned inward toward the midsagittal plane of the body. To be distinguished 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 radiation: 0.001 rad. Muscular Rheumatism (Muskel Rheuma- tismus): Muscular pain and tenderness attributed to "rheumatic" causes (especially 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 component of somatic dysfunction. To be distinguished from fibromyalgia. Myofascial Syndrome: Pain, tenderness, and autonomic phenomena referred from active myofascial trigger points, with associated dysfunction. The specific muscle or muscle group that causes the symptoms should be identified. Myofascial Trigger Point: A hyperirritable 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 phenomena. 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 phenomena, 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 concept that the regions of circumscribed firmness were due to localized gelling of muscle proteins. This concept predates our understanding of sliding filaments as the basis for muscle contraction. Focal tenderness and palpable taut muscle fibers are also characteristic of myofascial trigger points. Most patients diagnosed as having myogelosis would also be diagnosed as having myofascial trigger points. Myotatic Unit: A group of agonist and antagonist muscles, which function together as a unit because they share common spinal reflex responses. The agonist muscles may act together in series, or in parallel. 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 examiner'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 muscle. Orthosis: An orthopaedic appliance intended to correct a deformity1 1 or structural inadequacy. Palpable Band (Taut Band, or Nodule): The group of taut muscle fibers that is associated 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 subject must relax the muscles crossing the joint. Pes Anserinus: The tendinous expansion and attachment of the sartorius, gracilis, and semitendinosus muscles at the medial 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 trigger 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 hyperirritable 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 another muscle of the body. To be distinguished 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 phenomena 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 distance, 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 phenomena, 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 pelvis 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 focus 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 palpation. Secondary Myofascial Trigger Point: A hyperirritable spot in a muscle or its fascia 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 latent 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 contact 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 neutral length or slightly longer. To be distinguished from flat palpation and pincer palpation. Spasm: Increased tension with or without shortening of a muscle due to non- voluntary motor unit action potentials. Spasm cannot be stopped by voluntary relaxation. 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 referred pain from an active trigger point. The spillover zone is indicated by red stip- pling in the pain-pattern figures. To be distinguished 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 consists of inversion and adduction of the foot, causing an elevation of its medial edge. Swing Phase: The swing phase is that period of the gait cycle during which the foot is not in contact with the ground. Synergistic Muscles: In this volume, synergistic 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 hyperirritability 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 autonomic phenomena and distortion of proprioception. Types include myofascial, cutaneous, fascial, ligamentous, and periosteal trigger points. TrP: Trigger point. TrPs: Trigger points. Upslip: See Innominate Upslip. uV: Microvolt, a measure of electrical potential: 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 below 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 chapter: 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 terminology of muscle pain disorders. Another section deals with sacroiliac (SI) joint mobilization. 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 released, 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 already inflicted and the recovery rate of the atmosphere. Vallentyne and Vallentyne have expressed the opinion that the use of Fluori- Methane, a mixture of chlorofluorocarbons, 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 atmosphere.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 several 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 presented in each muscle chapter. The stroking 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 vapocoolant spray. The skin must remain dry, because 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 muscle 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 acting 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 patients for home use. Other Methods With Stretching Any procedure for inactivating myofascial 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 employed by Karel Lewit for release of muscle 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 increased as the sensitivity of the TrP wanes and the tension in its taut band fades. Pressure is released when the clinician feels the TrP tension subside or when the TrP is no longer tender to pressure. 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 effective technique for muscles that are sufficiently superficial to be accessible. This procedure is described as stripping massage on page 88 of Volume l . 9 3 (The term deep-friction massage refers to other techniques, not exactly the method discussed here.) We call it stripping massage because 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 region 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 therapy sessions, but not after the final sessions 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 active motion available in the agonistic pattern. Contract-relax employs contraction and then relaxation of the tight antagonists 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 contraction of the tight muscle and then allow it to relax and lengthen, only incidentally shortening the agonist. As originally described," 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-established neurophysiological principle that can be used to assist a muscle-stretching procedure. To invoke reciprocal inhibition, the agonist (muscle not being stretched) is voluntarily activated during the period of stretch of the involved antagonist muscle (when it needs to be relaxed). Relaxation during exhalation, described 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 exhalation, the patient may reduce TrP irritabil- ity and release associated muscular tension. The muscle should be lengthened to the point of taking up all slack (to the onset 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 patient 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 impact every 5 seconds; the slower rates are likely to be more effective. This procedure may enhance or substitute for intermittent cold with stretch. The senior author 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 compartment leg muscles because of a possible compartment syndrome, if it caused bleeding there. Muscle energy technique involves voluntary 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 technique using some principles from soft tissue technique, from muscle energy technique, and from inherent force cranio- sacral technique. It combines soft tissue changes, faulty body mechanics, and al- tered reflex mechanisms in both diagnosis 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 especially 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 relaxation 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 movement. 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 effective force to "encourage" release of the muscle tension. Postisometric relaxation begins by having the patient perform an isometric contraction of the tense muscle at its initial tolerated length, while the clinician stabi- lizes that part of the body to prevent muscle shortening. Contraction should be slight (10-25% of maximum voluntary contraction). After holding this contraction for 3-10 sec, the patient is instructed to "let go" and to relax the body completely. During this relaxation phase, the clinician gently takes up any slack that develops in the muscle, noting the increase in range of motion. Care is taken to maintain the stretched length of the muscle and not to return it to the neutral position during subsequent cycles of isometric contraction and relaxation.5 5 Respiration The effectiveness of postisometric relaxation is augmented by combining it with phased respiration. Since inhalation encourages contraction of most muscles and exhalation encourages their relaxation, the contraction-relaxation cycle is coordinated with these phases of respiration. The patient slowly inhales during the isometric 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 sitting up straight is associated with inhalation. 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 activation of jaw depressors, this may be an example of overriding reciprocal inhibition. For these jaw elevators, the isometric 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 facilitate 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 magnetic resonance spectroscopy as they relate to an understanding of myofascial TrPs. Algometry, tissue compliance measurement, and thermography are valuable for substantiating clinical observations and as research tools. By themselves they cannot 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 devices specifically designed to measure pressure threshold, pressure tolerance, and tissue compliance in relation to myofascial 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 between 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 tolerance meter is too insensitive to resolve accurately the differences in the sensitivity 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 sensitivity of an electronic strain gauge algometer to perform both pressure threshold measurements and pressure tolerance measurements. 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 fingertip. Inter-rater reliability of their pressure algometer for 14 muscles of the head and neck was consistently higher than the reliability 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 different instruments.2 3 , 7 8 List and associates5 9 found the Fischer algometer reliable and valid for measuring sensitivity (tenderness) in the masseter 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 sensitivity 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 response to passive stretch. Fischer2 8 gave examples of the change in sensitivity observed 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 headache, 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 musculoskeletal 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 applications of the meter.2 6 Jansen and associates4 3 evaluated the reliability of this meter by measuring normal 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 section 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 electronic radiometry or with films of liquid crystal. Recent advances in infrared radiation (electronic) thermography with computer 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 radiometry. Each of these thermographic techniques measures the skin surface temperature 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 superior to these other measures in convenience 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 diameter 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 tenderness at the hot spot could represent referred tenderness 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 eliciting the characteristic referred pain pattern by the application of digital pressure on the spot of maximum tenderness in that band or by eliciting a local 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 reference 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 observed in normal subjects differ significantly from a study of the hot spots observed in myofascial pain patients? Are the tender points in fibromyalgia 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 metabolites reflect sequential steps of muscle energy metabolism. This technique can identify 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 resonance spectroscopy measurements and muscle metabolism, noted that the relative concentrations of these metabolites were measurable with an error of less than 10%. This new technique has provided simple and useful criteria for distinguishing 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 resonance 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 studies can demonstrate diffuse metabolic abnormalities in some forms of fibromyalgia, it seems likely that metabolic abnormalities should be demonstrable in the immediate vicinity of a myofascial TrP, if the area for examination can be adequately 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 controversial diagnostic terms under a new um- brella usually adds only nosological complexity and confusion to the field of muscle pain. It is our opinion that splitting existing diagnoses into more clearly defined component syndromes is more likely to clarify our understanding. Chronic Fatigue (Syndrome):3 4 , 3 9 , 1 0 1 Chronic fatigue is now generally considered a close relative of fibromyalgia, or a partial expression of it. Since myofascial pain syndromes typically cause localized weakness rather than general fatigue, patients with chronic fatigue are more likely to have fibromyalgia than myofascial pain. Chronic Myalgia:5 1 The cited description of chronic myalgia emphasized muscle pain related to static load during repetitive assembly work, which would also be likely to activate TrPs. As defined by Larsson et al., chronic myalgia also included findings characteristic of fibromyalgia. Since the patients studied were not, specifically examined for myofascial syndromes, 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 "localized 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 distinction 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 conditions 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 condition, 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 examination recommended for this condition does not specifically include criteria that would identify myofascial TrPs. There- fore, like fibromyalgia, it could readily include patients with chronic regional myofascial 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 reviewed the history of this term and the concepts that it encompasses, which include 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 syndrome was found to be particularly common among industrial workers who perform stressful repetitive activities, musi- cians, and athletes. Since these patients complained of weakness rather than fatigue, 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 myofascial TrPs, the role of TrPs in the overuse syndrome remains an open question. 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 fibrositis (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 syndrome and also has characteristics suggestive 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 discussed in detail in Chapter 6 of this volume. 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 expanded to include muscles throughout the body. Weichteilrheumatismus:6 2 Literally meaning "soft-tissue rheumatism," this term is generally translated as "nonarticular rheumatism." Since it refers to all soft- tissue structures that may become painful, 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 movement 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 location of the most likely centers of rotation 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 illustrations, 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 numerous authors.8 , 1 3 , 3 7 , 3 8 , 5 3 , 6 0 , 6 9 , 7 5 The following 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 pattern 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, crossing 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 present 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 develop TrP tenderness, including the lower end of the erector spinae, the quadratus lumborum, the three glutei, and the piriformis 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 affected 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 unlikely 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 lumborum muscle have been inactivated; tension of this muscle can hold the SI joint in a malaligned position. For manipulation of the SI joint, as illustrated 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 loosely over the ankle under- neath. The arm beneath is drawn forward out of the way at a right angle with the body. The uppermost arm hangs loosely behind the back. The operator stands in front of the patient with one hand cupping the caudal end of the sacrum. The other hand grasps the front of the patient's upper torso. Si- multaneously, the operator pushes the upper torso backward and the sa

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Myofascial Pain and Dysfunction: The Trigger Point Manual, Volume 2