Trigger Points and Muscle Chains in Osteopathy (Complementary Medicine (Thieme Hardcover))

242 Pages·2008·28.06 MB·English

by  Philipp Richter

~~ Trigger Points and Muscle
...(,G,I Chains in Osteopathy
..al!\
Phihpp Richler
Eric Hebgrn
" Thieme
'Thieme
ForAnja and Heike-
without whose patience and support this book would
nat have been possible.
Thank you!
Trigger Points
and Muscle Chains
in Osteopathy
Philipp Richter, DO
Private Practitioner
Assistant Directorofthe InstituteforApplied Osteopathy(!FAD)
Burg Reuland. Belgium
Eric Hebgen, DO, MRO
Private Practitioner
Konigswimer,Germany
263 illustrations
Thieme
Stuttgart· New York
Ubrllry 0/ COlllrn5 CD(lIlogilll-in-PublitDli(lll DoIII is IIVl1illlblr Import.lnl noll': MtdlCme is .In ever-ch.nsHlg SCleMt under
'''1'
/rIIm publis"tr. going conllOuill development. Rtwoifch .nd clinic.l t:l.ptrie'nce
.rt conunu.Uy t:l.poindlOg our kroow~. In poinlCul.r our
kroowltdgeofpropertrt.tmtnl.nddrUJlher.py.Insof.r.iSthis
This book is iln ilulhori~td ilnd revistd lfilnsliltlon of lhe 2nd book menuons .nydOSilgtorolpplicillion. rtoidtrs molY rest .5
Grrmointdlllonpublishedilndtopyrighttd2007byGl'OrgThieme surtd Iholl Ihe.uthors.tditors.•nd publishtrs h.vem.deevery
Verlilg.SluUgiltl.Germany.TilleofIi'll'Germanedllion:Triner tffon 10tnsurtIholl such r('ftrtnces,lre in ilCrordilnceWilh the
punkte und Muskelfunktionskelten In der Osleopoithie und S1ilttofknowltdgeill IhelimeofprocluClionofIhebook.
M,lnuellenTherapit. Neverlheless, lhisdoesnOl involve. imply.orexpressilnygUilr~
olntee or rtsponsibilityon lht pilrt oflhe publishers in rtspecl
10 any dOSolg(' inslrucllOns olnd forms ofdllPllcdlions stdttd in
Translator:SabineWilms.PhD.R,lnchosdeTaos.NewMe~ico.USA lhe book, Every user is requeSltd 10 U,lllline cnerully Ihe
n1olnufolcturers' INfietsdccompolnyingeach drugolnd 10ch~k, if
IIlustr,lIOrs: Malgorzala ,lnd PiOlrGUSlil. Ch,lmpigny sur Marne. necessaryinconSultalionwilh.physicidnorSpeciol!lSI.whether
Funce: Chrisliilne ,lnd Michilel von Solodkoff. N('ckarg('mund. lhedOSilgeschedulesmenliontdthertinorIhecOnlrdindicillions
Germilny sUled byIht milnurilcturersdifferfrllm lhestiltemtnlSmade in
lhe present book. Such eumination is parllcul.rly importilnl
Richter.Phihpp. 1960- wilhdrugsthillilrtelthtrr.relyusedorhilvebeenntwlyreltilsed
ITriggtrpunktt und Muskelfunklionsktlttn in der Ostl'Op.llhie onthemilrkel.EverydOSilgtscheduleoreveryformofilppllc.tion
undManutlltnTher,lpie.Englishl used is tnllrely ., Ihe user's own mil .Inti responsibilily. The
TriggtrpolnlSilndmusclechilinsIIIosll'OpoilhyIPhlhppRichler. ilulhorsilOO publishers rC'qutSltvtry usertorepon tothepub
EricHebstn:Ilrilnslillor.SilbineWilmsl. IishtrsilonydlSCTtpoil'lCltsorinilccurildtsnoIiced.lferrorsinIhls
p. ;cm. worlcilre found"i'Ilftttrpublicillion.~illilwill beposltdoilWWW.
lnc1ucksblbhOIraphiCilI referel'lCts.lnd indtx.. thltme.comon productdtscnpllonp.l&t.
ISBN978-1·11-1450SI~7 (.Ilk.poiptr)
I. Osttop"llhicmedicint.2. Milnlpuliltion{TIItrilptutksl1. Mus
clts-Phys,olOlY. 4. Myof.sciill poiln syndromts-Chlropr.Clic
Utiltment. I.Htbgen.Eric.II.Tille.
[ONLM: I. M.mpuliltion.Osttopoilhic-methods. 2. Myof.sci.ll
Polin Syndromts-Ihtr,lpy. 1. Musclts-physioIOlY. WE 550
RS1612008il)
RZl41.R521)2008
615S)1-dc22
20080)1519
02009Gto'1ThitmeVtrlilJ. Someoftheproduct IIilmts. poilems.ilnd rl"JISlertddeslllnsrr
Riidi&trsu.ssr 14.70469Stultg.r!,Germ.ny ferrtdto10thISbookilreinfilCt registeredlroldtmoirksOfpropnt
hltp://_.lh,tme.de lilryIIilmtseventhou:ghspecirKrtftrencetolh,sfilCtisnoI:illwilYS
ThiemeNewYork.])3~nlhAvenue. moide in the texl.Therefore. the ilpptilrilnceofil rwmewllhout
NewYork.NY 10001.USA dtsi!noillon.sproprie'toiryislIOIlObeconSlrurdilS.re~nlil­
hllp://WWW.lhieme.com lionbyIhepubhsherthillIIisinthepublkdomilJn.
This book. including illl poirts lhereof, is leplly prOltCled by
CO\I'trdesign:ThIemePublishingGroup copyrighl. Any use, eXplotl,llion. or commrrciilliziluon outsidt
TyptsettingbyH,lgtdomKommunilYtion.Viemhtlm.Gtrm,lny Ihe n.rrowlimitssel bycopyrighl ltgislilllOn.wilhoul lhe pub
lisher'sconsem. isiUtg.l ilnd li.ableto proseculion.ThisilppHes
!'rinltdinGtrmilnybyAPP\..prlnl.druck.Wtmding inpoiflicul.rIIIpholosliltrtprodUClion,copying,mimrogTilphing.
prepoirollion of microfilms, olnd el~lronic dillil processing ilnd
ISBN978-3-1)-145051-7 12)456 StOrilgt.
v
Preface
Theidea(orthisbookoriginated molnyyearsolga.Prae litclejohn'smodelofthe ~me<:hanicsofthevertebral
ti(.<l1experiences.readingspecializedliterature,allen column~and the ~Zink P<lnerns~ofthe American os
danceat seminars. and conversations with colleagues teopath Gordon link, DO have inspired us to divide
and specialists from other disciplines showed us the torso skeleton into units of movement. Much ro
time and again the signific,lOce ofthe locomotor sys our surprise, we realized that this division inlo units
tem. of movemenl correlated closely with the division of
Daily clinical routine showed us in {he course of neurologicsupplyofcertain organs and muscles.
years that the same lesion patterns tended to occur Weprovided bothchainswith muscles.understand·
over and over. Years ofintensive observation and in ing that this can only be incomplete and theoretical.
vesfig'llion as well as thorough literature research We ask the reader to keep this in mind. Nevertheless,
confirmed that our observations agree with reality becausetheorganismonly recognizes motorpatterns,
and are notjust wishful thinking. but not individual muscles, this is somewhat irrele
Notonlyosleopaths.butalsoposturologistsandman vant.
ualtherapists.speakofmotorpanerns.usingdifferent In thesecond partofthebook.we presenta number
explanatorymodelsfor thedevelopmentofthesepat of rrearmenl methods for the myofascial structures.
terns. In dcourse on muscle energy techniques. both For this purpose. we describe nigger point therapy
Dr. F.L MirchellJr. dnd Dr. Ph. Greenman referred to a in great detail because it is invaluable in clinic. We
universalpattern.Bothdgreeontheexistenceofauni hewe purposely limited this presentation to the me·
vers.alpdtlern.beCduseintheedseofdysfunctioninthe chanicaIaspect ofosteopathy because it issignific<lnt
motorsystemotherbodYPdrtsdlwdysaddptwithiden for posture and can thereforebeapplied in diagnosis.
tical pdlterns. Similarly. the entire organism follows Forphysiologiccranialdysfunctions,wehavechosen
certain pdllerns in physiology; examplesinclude pro· a mechanical model to attempt an explanation. We
cesseslikewdlkingorbreathing.Thecommonembryo have.however,refrainedfrom presentingvisceraldys·
logicoriginofalltissues.theconnectionsoftheconne<:· functions in detail, in spite ofthe fact that they quite
tivetissue,dndtheorgdnismasahydropneumaticsys clearly follow the Sdme patterns. Structurdl distur
tem all support this theory. The endocrine system is bances manifest in malposture through direct fascial
alsoagood exampleofholistic behavior. trains dnd particularly through viscerosomatic re
The holistic principle. highly prized by the osteo flexes. Following the holistic principle, the orgdns
path,aswellasembryologic.physiologic.and neurolo adapt to the "container,M the motor system. in the
gicaxiomsoffersexplanationsfor theoriginofcertain same way that postural disturbances affect the loca
patterns. In our opinion. the nervous system and the tionclnd function oftheorgans(adaptationoffunction
myofascial structures play key roles in this process as to structure). .; ....... , .;. ."
organizerand as executing organ respectively. Ourmodelofmusclechai!)s'isonlyaworkingmodel,
We have compared different models of muscle justlikem.myothers: wedbnotlayclaimtocomplete
chains and different osteopathic working models. ness. We were able to realize in clinic, however, that
looking for commonalities. Consequently. we have diagnosisaswell astreatmentofpalientscan become
realized that all these models share a basic premise. much more rationalandeffectivewhen theyoriginate
but from different perspectives. inthisperspective.Thisappliesinparticulartochronic
In this book, we present a model of muscle chains and therapy-resistant cases.
that is based on the two motor pdtternsofcranial os
teopathy, namely flexion and extension. Because the
organism consists of two halves. it has two corre Philipp Richrer
spondingchainsofflexion and extension. EricHebgen
VI
List of Abbreviations
ABO Abduction OAAcomplex OCCipitoatlantOdxial complex
Alcholin Anterolateral chain OM sutUff' OCCipitomastoid sulure
ASIS Anterior superior iliac spine OAjoint OCCiput~atlasjoint
AilS Anteriorinferioriliacspine ORl Otorhinolaryngology
ATP Adenosine triphosphate PA-APchain Posteroanterior-anteroposterior
CCP Commoncompensatory p.lttern chain
CNS (eoual nervoussystem PLchain Poslerolateral chain
esc Cervical spinal column PNF Proprioceptive neuromuscular
CSF Cerebrospin.al nuid facilitation
CT] Cervicothoracicjunction PR' Poslisometric relaxation
CVB Cervical vertebral body PRM Primary respiratory mechanism
EMG Electromyography PSIS POSleriorsuperior iliacspine
ERS Extension-fota[ion-sidebendiog SAT Specific adjusting technique
FRS Flexion-rotation-sidebeodiog SBl Superficial back line
ILA [nferolateral angle SBS Sphenobasilarsynchondrosis
ISj lIiosi!craljoint SCM Sternocleidomastoideus/
LSC lumbarspinal column sternocleidomastoid muscle
LS] lumbosacraljunction SFe Superficial fronl line
lTA Lower thoracicaperture TI'l Tensor fasciae lalae
MET Muscle energy technique nj Thoracolumbarjunction
MTPjoint MetatarsophalangeaIjoi01 TSC Thoracic spinal column
NCP Non~compensated pattern TVB Thoracic vertebral body
NMT Neuromuscular technique UCCP Uncommon compensatory pattern
NSR Neutral position-sidebend-rotiltion UTA Upperthoracicaperture
Picture Credits
Figs.2.6, 2.7,.tnd 2.8 from: Chaitow L: MuscleEnergy Fig. 14.3 from: Oespopoulos A, Silbernagel S: Color
Techniques. 2nd ed. Edinburgh: Churchill Living Atlas ofPhysiology. 5th ed. Stuttgart; Thieme: 2003
stone; 2001 Fig. 14.4 from: Rehabilitation Medicine, edited by
Figs. 3.1, 3.2, 3.3, and 10.12 from: Mitchell FL Jr., Goodgold J. Chapter 45: Simons DG: Myofasdal
Mitchell PKG: The Muscle Energy Manual. Vols 1-2. pain syndrome due to trigger points. Mosby Year
Eastlansing: METPress: 2004 Book. Sf. Louis; 1988. pp. 686-732
Figs. 3.4 and 3.5 from: Brokmeier A: Kursbuch Ma
nuel/eTherapie.3rded.Stuttgart: Hippokrates; 2001 The anatomical illustrations in Parf BTrigger Points
Figs.4.2,4.~,)nd c,4.901 and b, 4.11.01 from: liemT: and ,heirTreorment are taken from: Schuenke M: To
Kraniosakrale Osteopathie. 3rd ed. Stuttgart: Hippo pagraphie und Funktion des Bt>wegungssySftms. Stutt·
krates; 2001 gart: Thieme; 2000; Schuenke et 011.: THIEMEAlias of
Figs. 5.7,) and b from: liem/Dobler: Leirfaden Osreo Anafomy, Vol I: General AnalOmyand Musculaskpletal
pathie. 2nd ed. Munich: (l 2005 Elsevier GmbH. System. Illustrations by Wesker Kand Vall M.. Stult
Urban & FischerVerlag gart: Thieme Publishers; 2006; and SchweglerJ: Der
Fig. 14.1 from: Schmidt RF.ThewsG(editors): Physia Mensch-Anaromip und Physi%gie. 3rd ed. Stuugart:
logiedesMenschen. 29th ed. Berlin: Springer; 2004 Thieme: 2002. The photos were taken by Ullrich +
Figs. 14.2. 15.1. and 15.2 from: Travell J. Simons 0: Company. Renningen.
Myofascial Pain and Dysfunction. The Trigger Point
Manual. Vols I-II. 2nd ed. Philadelphia: lippincott
Williams&Wilkins; 1999
VII
Contents
Preface. ..................•.•. ••.•... V 3.2 SupplyoftheConnectiveTissue 28
listofAbbreviations .....•....•.••.•... VI Diffusion. ........................ 28
PictureCredits. . . . .. . . .. . . ..••. ••. •. . . VI Osmosis............. 29
3.3 The "Creep"Phenomenon. . . . .••. . . . . 29
3.4 The Muscle. . .. . . . . .. .. . . . . .. . . . . . 29
Part A Muscle Chains 3.5 The Fasciae . . .. . . . . .. .. . . . . . .. . . . . 30
PhilippRichter Functionsofthe Fasciae. ............. 30
M.tnifestationsofFascial Disorders. ..... 30
EvaluationofFascialTensions. ......... 31
1 Introduction. .................... 2
Causes ofMusculoskeletal Dysfunctions.. 31
1.1 TheSlgnlncanceofMusde Chains GenesisofMyofascial Disorders ........ 31
IntMOrganism 2 PallernsofPain .................... 32
1.2 TheOst@OpilithyofDr. Still 2 3.6 Vegetative InnenraUon oftheOrgans. . . 34
1,] Scientific Evidence 4 3.1 Inrln M. Korr . . .. . . . . . . .. . . . . . . .. . . 34
SignificanceofaSomatic Dysfunction in the
1.4 Mobllltyand Stability. .. . . . .. . . . .. . . 5
SpinalColumn for the Entire Organism. .. 34
1.5 TheOrganism ilSa Unit. . . . . .. . . . .. . . 6
SignificanceoftheSpinal Cord. ........ 3S
1.6 Interrelation ofStructureilnd Function. . 7 SignificanceoftheAutonomous Nervous
1.7 BlomechanlaoftheSpinal Column and System 35
the Loc:omotorSystem 7 Significanceofthe Nerves forTrophism .. 35
3.8 SirCharlesSherrlngton . . . . . .. . . . . . .. 36
1.8 TheSignificanceofHomeostasis . . . . .. . 8
Inhibition oftheAntagonist orReciprocal
1.9 TheNenrousSystem as Control Center .. 8
Innervation(orInhibition) ............ 36
1.10 DifferentModelsofMuscleChains 8 Post-isometric Relaxation. ............ 36
1.11 InThis Book 9 TemporarySummation dnd locdl.
SpatialSummation. ................. 36
Successive Induction 36
2 ModelsofMyofasclal Chains. . . .. . . . . 10
3.9 Harrison H. Fryette . . . . .. . . . . .. . . . . . 37
2.1 Herman Kabat 1950: Lovett's laws. ..................... 37
ProprioceptiveNeuromuscularFacll1tatlon 10 Fryette's laws ..................... 38
Motion Patterns. .............. 10 3.10 TheCaltasa Clobal Functional Motion
Application Modalities..... ..... ..... 11 Pattern. . . . . . .. . . . . . . .. . . . . . .. . . . 39
Observations. ..................... 11 Gait Analysis. ..................... 39
2.2 Godelleve5truyff.Denys 11 MuscleActivityduringWdlking ........ 41
Classific;lIion ofthe Five Muscle Chains.. 12 Conclusion. ................. 44
2.3 Thomas W. Myers........ 15
~Anatomy Trains~-Myofasdal Meridians
4 The Craniosacral Model. . .. . . . . . 4S
(Chains}...................... 15
Myofascial Chdins According toT. Myers.. 15 4.1 WilliamC. Sutherland. . . . .. . . . . . .. .. 45
2.4 leopold Busquet . .. . . . .. . . .. . . . .. . . 18 4.2 Blomechanlu ofthe Craniosacral System 46
The MuscleChains. ................. 18 4.3 TheMovementsand Dysfunctions ofthe
Myofasdal ChainsAccording to Busquet. 19 Craniosacral Mechanism .. 49
Functionsofthe Myofascial Muscle Chains 25
Flexion and Extension. .............. 49
2.5 Paul Chauffour: le lien MecanlqueenOsteo Torsion 50
pathle(TheMechanical linkIn Osteopathy) 25 Sidebending Rotation. ............... 52
Powl Chauffour's Biomechanical Chains. .. 25 Vertical Strainand lateral Strain 53
2.6 Conclusion onthe Different Modelsof Compression Dysfunction in the
MyofasclalChains . . .. . . . .. . . .. . . . . . 26 SphenobasilarSynchondrosis. ......... 53
Intraossal Dysfunction. .............. 53
Sacral Dysfunctions ................. 56
3 Physiology. . . . .. . . . .. . .. . . . . .. . . . 27
4.4 The Innuence of(ranlal Dysfunctions
3.1 Componentsofthe ConnectiveTIssue. . . 27 and Malposturesonthe Periphery ..... 56
TheCells. ........................ 27
The IntercelluldrSubstance 27
The BasicSubstance. ...........••... 27
VIII Contents
5 TheBlomechanlcal Model ofJohn Martin 9 Posture ,.. , . 9.
9.
Littlejohn-The Mechanics oftheSpine 58 9.1 HingeZones .............•.. , .
5.1 History . 58 9.2 Posture ~d Balance . 95
5.2 The "MechanicsoftheSpine" and the 9.3 Leg Length Differences . 97
Force Linesofthe Body . 58 Posturdl Chdnges in the Pelvis and Spinal
TheCentrdl Grdvity!Jne . 59 Column from leg length Differences .... 97
The Anterior Body Une . 59 Effectson the Musculoskeletal Systemand
TheAnteroposteriorline . 60 Symptomsofleg length Difference . 97
5.3 The Force Polygon . 61 Diagnosisofa leglength Difference . 98
5.' Arches, Pivots,~ndDoubleArches . 62 Should WeCorrect leg length Differences? 99
Pivots . 62 Conclusion . 100
DoubleArches . 63
5.5 SpecificAdjustmentT«hnlqueAccording 10 Diagnosis ............•........... 101
to Dummer . 64
10.1 Medical History.......•....••...... 101
History . 64
10.2 Examination ..............•..•.... 101
Procedure . 65
TheThree Units . 65 Observdtion ...............•..•.... 101
Pdlpdtion.................•....... 101
MotionTests ,. _•..•.... 101
6 Postural Muscles. Phasic Muscles. and ..
Crossed Syndrome (VladimirJanda's
11 Therapy . 106
Contribution to Myofasdal Treatment
11.t Musde EnergyTechniques . 106
Methods) .
Definition . 106
6.1 Posture . 66
Indicdtionsand Contraindications . 107
6.2 Motoria . 66 Prerequisites forOptimal Muscle Energy
6.3 Skeletal MusdefiberTypes.......•... 67 TechniqueApplication . 107
6.4 CrossedSyndrome . 69 Technicdl Prerequisitesand Enhancers
for Muscle EnergyTechniques . 107
The UpperCrossed Syndrome . 69
VariationsofMuscle EnergyTechniques 108
The lowerCrossed Syndrome . 70
11.2 Myofasclal ReleaseTechniques . 109
6.5 Practical Consequences . 70
11.3 NeuromuscularTechnique . 110
11.4 Myofasclal ReleaseTechniquewith
7 The link Patterns . 71
IschemicCompression . 110
7.1 The Composition oftheZink Patterns . 72
Occiput-AtIds-Axis . 72
UpperThordcic Aperture . 73
7. Part B Trigger Points and
lowerThoracic Aperture .
7. Their Treatment
Pelvis .
7.2 Practical Application oftheZink Patterns 75 EricHebgen
Occiput-Atlas-Axis . 75
UpperThoracicAperture . 75 12 Definition . 112
lowerThoracicAperture ........•.... 75
Pelvis . 75
13 Classification ofTrigger Points . 113
13.1 Activeand LatentTrigger Points . 113
8 Myofasdal Chalns-A Model . 77
t3.2 Trigger PointSymptomsand Supporting
8.1 Muscle Chains . 78 Factors . 113
Flexion Chain . 80 Symptoms . "3
Extension Chain . 84 Supporting Factors . 113
8.2 SummaryandConclusions ofthe Flexion
and Extension Chains . 85 ".
Flexion Chain . 85 14 Pathophysiology ofTriggerPoints ....
Extension Chdin . 86 14.1 Locally IncreasedTension InTriggerPoints
II.
8.3 Torsion . 86 and Referred Pain .
8.'
SpecificChar~cterlstlcsofSomeMuscles 14.2 tauses ofLocallyInueasedTension
II.
orMuscleGroups . 87 InTriggerPointsand Referred Pain .
Sternocleidomastoid Muscle . 87 Convergence Projection . 11.
SCalene Muscles..............•.•... 87 Convergence Facilitation . 115
Diaphrdgm _ . 88 Axonal Ramificcuions . 115
Iliopsoas .....................•... 91 SympatheticNerves . 115
Hip Rotators ...........•......•... 92 Metdbolic Derailment . 115
MuscleStretchingAffects Muscle
Metabolism . 115
Contents IX
The Hypertonic Palpdble MuscleSpindle.. 115 19.3 MusclesofElbOW-FingerPain . 156
MuscularWeaknessand FastTiring ..... 117 Brachioradialis Muscle and Wrist Extensors 156
11. Brachioradialis Muscle . 156
15 Diagnosis _ . ExtensorCarpiRadialislongusMuscle . 150
Extl'nsorCarpi RadialisBrevisMuscle . 157
15.1 Detailed Medical History . 118
ExtensorCarpi UlnorisMusdl' ........•. 158
15.2 Chilrtlng Pain Pillterns . 118 ExtensorOigitorum and Indicis Muscles .. 158
15.3 Examining MusclesIn Activity . 118 Extl'nsorDigitorum Muscle .........•.. 158
ExtensorIndidsMuscle ....•......... 159
15.4 Looking forTriggerPoints . "'
Supinator Muscle . 160
Palmaris LongusMuscle . 161
'0 Trigger PointTherapy . '2' AexorCarpi Radialisand Ulnaris. Flexor
Digitorum Superficialisand Profundus.
16.1 5tretc!t-and-SprayTechnique . 121
Flexor Pollicis Longus. and Pron.uorTeres
ApplyingCoolingSpray . 121
Muscles . 162
PassiveStretch . 121
FlexorCarpiRadialisMuscle . 162
ActiveStretch . 121
FlexorCarpiUlnarisMuscle . 162
16.2 PostisometricRelaxation/Muscle Energy
FlexorDigitorumSuperficialis Muscle . 163
Technlque/Myofasclal Release . 122
FlexorDigitorum ProfundusMuscll' . 163
16.3 IschemicCompression/Manual Inhibition. 122 F/exorPollicislongusMuscle . 163
16.4 Deep Friction Massage . 122 PronatorTeres Muscle . 164
Adductorand Opponens Pollicis Muscles 164
AdductorPollicisMuscle . 164
17 TriggerPoint-Sustaining Factors 123 OpponensPo/licisMuscle . 166
AbductorDigiti Minimi Muscle . 167
18 The FacilitatedSegment . 124 Interosseous Muscles . 168
Dorsa/InterosseousMuscles . 168
1. PolmorInterosseousMuscles . 170
TheTrigger Points . 125 19.4 Muscles ofUpperTorso Pain . 170
19.1 MusclesofHeadand NeckPain . 125 Pectoralis Major Muscle . 170
Trapezius Muscle . 125 Pectoralis Minor Muscle . 172
Sternocleidomastoid Muscle . 127 Subclavius Muscle . 172
MasseterMuscle . 128 Sternalis Muscle . 174
Temporalis Muscle . 130 Serratus PosteriorSuperior Muscle . 174
lc1teral Pterygoid Muscle . 131 Serratus Posterior InferiorMuscle . 175
Medial Pterygoid Muscle . JJ2 SerrdtusAnteriorMuscle . 176
Digaslric Muscle . 132 ErectorSpinae Muscles . J77
OrbicularisOculi.Zygomaticus Major, lIiocostolMuscle . J77
and Platysma Muscles . 133 longissimusMuscle . 178
Orbicularisoculi . 133 SpinalisMuscle. . . . . . . . 178
ZygomaticusMajorMuscle . 134 Rectus Abdominis.Abdominal Imernal and
Platysma Muscle . 135 External Oblique,TransversusAbdominis.
Occipitofrontalis Muscle . 135 and Pyramidalis Muscles . 179
SpleniusCapitis and Cervicis Muscles . 136 RectusAbdOl1linis Mllscle . 179
SemispinalisCapitisand Cervids Muscles. AbdominalInternalObliqueMuscle . 179
Multifidus Muscles (Transversospinalis) .. 138 AbdominalExrernalObliqueMuscle . 180
RectusCapitis PosteriorMajorand Minor TransversusAbdominisMuscle . 180
Muscles.ObliquusCapitis Inferiorand PyramidalisMuscle . 181
SuperiorMuscles . 139 AbdominalMuscll's ..............•... 181
19.2 MusclesofUpperThorax Pain and 19.5 Muscles ofLowerTorso Pain . 182
Shoulder-Ann Pain . 140 QUddrdtus Lumborum Muscle . 182
LevatorScapulae Muscle . 140 Iliopsoas Muscle . 183
ScaleneMuscles.............•...... 142 IliacusMuscll' . 183
SupraspinatusMuscle . 143 PsoasMajorMuscll' ...•........••... 183
InfraspinatusMuscle . 144 PsoasMinorMuscle .............•... 184
Teres MinorMuscle ........•........ 145 Muscles ofthe Pelvic Floor . 185
Teres Major Muscle ........•.••.•... 146 ObruratorIntl'rnusMuscle . 185
lc1tissimus Dorsi Muscle.....•.••..... 140 ExternalAnalSphincIl'rMuscle . 185
SubscapularisMuscle.......•..•..... 147 levatorAniMuscle .._......•........ 185
Rhomboid Muscle .........•..•..... 148 CoccygeusMuscle ...............•... 180
Deltoid Muscle ...........•..•..... 149 Gluleus Maximus Muscle . 180
Cordcobrachialis Muscle.....•..•..... 151 Gluleus Medius Muscle . 187
Biceps Brachii Muscle ......•.••..... 152 Gluteus MinimusMuscle . 188
Brachialis Muscle .........•..•... 153 Piriformis Muscle . 189
Triceps Brachii Muscle ......•..•..... 154 19.6 Muscles ofHip. Thigh. and Knee Pain . 191
Anconeus Muscle .........•..•..... 155 Tensor Fasciae Latae Muscle . 191