11/1 Welcome to Our Unit on the Organs of Action

LEGS & ARMS UNIT MODULE 1 1

Welcome to Beyond Trigger Point Seminars Legs and Arms Unit Module 1 on the Quadriceps, Adductors & Hamstrings. In this unit we will be exploring myofascial pain syndromes (MPS) of the upper and lower extremities. Like the heart to the circulation system, the legs and arms are our body’s organs of action. Because a majority of our pain clients are presenting with problems in the low back and neck regions, therapists, I’ve noticed, are often focused on only treating these regions. In this unit, you will become more familiar with the many common pain diagnoses of the legs and arms frequently unrecognized as originating from trigger points (TrPs). We will consider the holding patterns down below which are affecting the alignment up above. We may be treating condition specific, but we will also be looking at the entire structure as well. Specifically, by the end of your online studies, you will have a greater understanding of tennis and golfer’s elbow, carpel tunnel syndrome, heal spurs, plantar fasciitis, shin splints, and runner’s and jumper’s knees to innumerate just a few diagnoses we will encounter.

Before we get started, let’s do a little housekeeping. If you haven’t already listened to the free introductory lecture, it is available at www.AskCathyCohen.com. Though I try reviewing one or two basic concepts of myofascial pain syndromes with each module, by listening to the intro lecture and filling in its study guide, you’ll maximize your learning.

What also helps is setting aside four 60 to 90 minute slots in your appointment book to complete this unit. Go ahead and do this now while you are still thinking about it. Even though you are taking this course at your convenience, prioritize your time so the material is assimilated in steady doses. Pretend you are in a real classroom and act accordingly. For those of you taking a hands-on workshop, completion of all four online modules is a prerequisite.

On page 1 of your student study guide, I’ll begin by reviewing the anatomy of the quadriceps femoris. As the name implies, there are four heads. The quadriceps weight approximately three pounds which makes it the heaviest muscle in the body. The action of all four heads is to extend the knee. All four heads take turns among themselves when slowly straightening the knee. The rectus femoris head is the only piece that also flexes the hip. So again, the rectus femoris crosses BEYOND TRIGGER POINTS SEMINARS WWW.BEYONDTRIGGERPOINTS.COM Putting Your Hands To Better Use © 2009 Cathy Cohen, LMT LEGS & ARMS UNIT MODULE 1 2 two joints, and all four of the heads acting together straightens the knee. Both the vastus medialis and lateralis heads act as stabilizers of the patella bone and the knee joint when the knee is slightly flexed. Balanced tension between the vastus medialis and lateralis maintains normal positioning of the patella. As we shall see, all sorts of biomechanical havoc can be created when the balance is out of kilter. Let me repeat, balanced tension between the vastus medialis and lateralis keeps the patella in its normal position. The role of this balancing act will become more evident as we consider knee pain. Understanding the actions of this muscle will help you predict how it’s injured. Knowing the muscle fiber arrangement and anatomical attachments will help you predict the trigger point locations. You may find it helpful to have one or two anatomy books open while studying this material.

Looking at the rectus femoris on page 2 of the study guide or page 250 of the textbook, Myofascial Pain and Dysfunction the Trigger Point Manual Volume 2, draw where you think the one documented trigger point (TrP) is located near its upper attachment by the anterior inferior iliac spine (aiis). Make your mark onto the body scan on the left of page 1. Now draw its primary pain pattern over the patella with some possible secondary referral into the lower thigh. If are new to the program, the more lightly colored area depicted in the pain pattern picture may or may not be present when you compress exactly over the TrP. What you are memorizing while drawing is the main, solidly colored pain pattern over the patella. So again, you are drawing an “x” right at the level of the pubic synthesis, just underneath the aiis and lateral to the femoral artery. This is often an overlooked and common source of knee pain. Why? Because we sit so much neither the hip joint nor the knee is fully stretched in daily activity. Dr Travell nicknamed the rectus femoris muscle the Two-joint Puzzler because the connection between the TrP in the upper thigh and the pain at the knee often mystifies both practitioner and patient. On page 2 near the rectus femoris picture there is room for you to write the nickname. Often the referred, deep aching pain in the knee isn’t relieved by positional changes until you teach your client to fully stretch the muscle across both its joints. When your client presents with this problem you may observe how they are fidgeting with their leg trying to find a comfortable position for their knee. They may also have a difficult time pointing at where it hurts because the pain is felt deep in BEYOND TRIGGER POINTS SEMINARS WWW.BEYONDTRIGGERPOINTS.COM Putting Your Hands To Better Use © 2009 Cathy Cohen, LMT LEGS & ARMS UNIT MODULE 1 3 the knee joint. They may also report or you may observe a difficulty walking going down stairs.

Deep to the rectus femoris is the vastus intermedius. We can nickname it the Frustrator. It is often misdiagnosed because one has to palpate deep, through the rectus femoris, to find the taut bands harboring the trigger points. The documented one is shown as a proximal attachment trigger point but, if you can gently palpate deep enough, you may find others in the belly.

Let’s consider the vastus medialis shown on page 3 of your study guide and page 251 of the text. Here we see two documented trigger points: one’s an attachment trigger point and the other is more centrally located. Picture B, the picture in the middle, represents the relationship of the two points in the muscle. Picture A and C show the pain patterns for each TrP. Generally, when you see a TrP1 labeled in a picture, it’s the most commonly found location for a TrP to form. So TrP1 is about a thumbs distance up from the patella and refers into the medial side of the knee. TrP2 is more centrally located. Its referral zone is a line of pain extending from the medial knee to half way up the medial thigh. The vastus medialis is nicknamed the, Buckling Knee Syndrome. Have you ever had this happen to yourself, or to your clients? They say, “I was just walking along and my knee just kind of gave out!” Here’s one reason this might happen.

The vastus medialis tends to be overpowered by the vastus lateralis. After only a few weeks or months from the initial TrP formation, the vastus medialis becomes, I quote, “a quitter”. The initial pain phase changes to an inhibition phase. There’s a big tug and pull here between these two heads and often the vastus lateralis wins. Can you visualize what kind of folks present with an overdeveloped vastus lateralis? To name a few: cyclists, joggers and kickers, especially kickers that externally rotate their thighs in their hips, like soccer players. So again the vastus medialis is a muscle that can become inhibited when the vastus lateralis is overdeveloped.

Let’s move now to the vastus lateralis at the bottom of page 3 or page 253 of the text. There is a whole line of legs there like a Rockette chorus line! So, you might just want to start studying the middle picture C where the hornet’s nests of Xs are located. There are nine BEYOND TRIGGER POINTS SEMINARS WWW.BEYONDTRIGGERPOINTS.COM Putting Your Hands To Better Use © 2009 Cathy Cohen, LMT LEGS & ARMS UNIT MODULE 1 4 documented points in all. TrPs 1-5 are all shown on picture C. The vastus lateralis is large. It wraps half way around the thigh. When you palpate for the trigger points, you need to be deep, near the bone.

What TrPs 1-5 have in common are referral zones extending up and down the lateral thigh and knee. So when you ask your client the critical first question on intake, “Where do you hurt and how can I help you?”, from this day forth, if they rub their lateral thigh, think vastus lateralis or gluteus minimus. Range of motion testing, history of onset and simple palpation for taut bands and reproduction of their pain complaint on compression of the TrP will confirm your hunch.

Picture D shows TrP1. Draw two Xs representing TrP1 on the anterior side of the muscle just above the knee. Either TrP may refer pain along the outer side of the knee and throughout the length of the lateral thigh. Take your time to draw those onto the body scan on page 1. When pain from TrP1 is active, it may be difficult for your client to sleep on the affected thigh. Or you might notice your client is limping perhaps because it just plain hurts to walk on that leg. Along with the lateral thigh pain a distinctive feature of TrP1 is a stuck patella. In fact, the nickname for the vastus lateralis is Stuck Patella. In our workshop we examine patellar mobility. Normally the patella can move up, down, left, right and in a medial and lateral circle.

TrP2 shown on picture B has a similar lateral knee and thigh pain pattern as TrP1 but with a possible spillover below the knee. Draw two Xs posterior to TrPs1 just above the knee.

TrP3 shown on the two pictures A is a centrally located spot with a pain pattern extending along the lateral thigh and includes the lateral half of the posterior knee.

On Picture E, TrP4 is shown as a cluster of three spots close to the fascia lata and can produce an intense pain along the lateral thigh, knee and hip.

TrP5 is less commonly found near the superior attachment and lies within its own pain pattern.

I hope you took the time to draw all nine of these documented locations. This muscle in particular will have TrPs found at different layers. Some may be superficial and others will be closer to the bone. Starting tomorrow, see how many different ways you can use your elbow or your forearm to stroke the quadriceps. Once a taut band has been detected, either with a longitudinal or cross fiber stroke, use your elbow to compress any nodule you feel harbored within the taut band. If your client says it reproduces a pain pattern like the ones you just drew, then you know you are on the TrP. Hold your compression for 8-10 seconds. Have your client tell you when the referred pain eases off. Then slowly release your pressure. Please don’t ever use your thumbs on this area! These are some of the heaviest muscles in your body.

I have a case story to share. My client was a postal worker whose job was to stand in a cage on a concrete floor in a cold post office. Her job was lifting mail crates up to a table so she could sort letters. She lifted the crates by doing deep knee bends while probably counting the years to retirement! One day upon arriving home, her golden retriever jumped up on her thigh to kiss her and that’s when her thigh misery started. She presented with pain spreading across the mid-section of her anterior thigh. Can you guess which muscle was involved? I hope you guessed the vastus intermedius because if you did that would be correct. She also had tightness in the other quadriceps femoris muscles that were treated as well.

What I hope this program will instill in you is a deep curiosity and a passion for talking about activating and perpetuating factors with your clients. Most of us are already good technicians. I’ve seen many of you work, you’re fantastic. What I hope to instill is a love for the detective work and the solutions for protecting your clients from repeated injuries. In her autobiography, Office Hours Day and Night, Dr. Travell said she always tried to give her patients something to do. Every time she treated someone she’d give them at least one thing to do on their own, so they felt in control.

From a therapist’s point of view, spending time discussing body mechanics, emotional stress factors and coping strategies is a whole lot easier on us isn’t it? So if you can get out of the mindset of always doing something with your hands, then this is a good way to pad your

BEYOND TRIGGER POINTS SEMINARS WWW.BEYONDTRIGGERPOINTS.COM Putting Your Hands To Better Use © 2009 Cathy Cohen, LMT LEGS & ARMS UNIT MODULE 1 6 treatments with much needed rest periods. For patient handouts to download and copy, visit the resource tab at www.beyondtriggerpoints.com. The educational material found on the resource tab is always available for you and your clients.

Let’s go now to page four of our study guide where we list how the quadriceps femoris group are activated and perpetuated. I’ll name eight. 1. Direct trauma- like the golden retriever jumping on the thigh or repeated injections of insulin for example into the vastus lateralis. 2. Acute overload such as missteps into a hole or off a curb. 3. Chronic overload such as the repetitive deep knee bends we heard about with the postal worker. 4. Sustained overload that is a result of chronically tight hamstrings. I practice Bikram Yoga. The relationship between the hams and the quads became crystal clear to me when I felt how the hamstrings couldn’t fully lengthen until the quads developed strength and flexibility. I don’t think the quadriceps can fully recover from injury until the hamstrings release. If you are treating one, treat the other. 5. Immobilization. Having any muscle in a fixed position for a long time will aggravate it. 6. Degenerative joint disease- here in southwest Florida we see a lot of elderly people with problems in their quadriceps due to faulty hip and knees. 7. Vigorous exercise such as jogging can activate any of the quadriceps muscles and also trauma to the knee joint. 8. Foot pronation-TrPs in the vastus medialis are perpetuated by excessive flattening of the foot. Pronation can be a result of various situations such as muscular imbalance and a Morton’s foot structure. Morton’s foot structure refers to a long second toe configuration. Podiatrist, and others have concluded; this foot configuration causes excessive pronation of the feet. Hyperpronation causes the ankles and the knees to roll-in leading to muscular and postural compensation. Having a long second toe configuration causes the body weight to shift from the heel straight to the protruding head of the longer second metatarsal bone. It’s as if you are walking on an ice skate blade. The foot struggles to maintain balance and the body compensates. The vastus medialis is one of three compensatory muscles with documented involvement when Morton’s foot, also called a Long Second Toe structure, is present. During the next Module on the BEYOND TRIGGER POINTS SEMINARS WWW.BEYONDTRIGGERPOINTS.COM Putting Your Hands To Better Use © 2009 Cathy Cohen, LMT LEGS & ARMS UNIT MODULE 1 7 peroneal muscles we will be discussing the corrective action your client can take to minimize the rolling-in effect this foot structure has on the knee.

Next question: What symptoms might a patient with myofascial involvement in the quadriceps report? I’ll list 3. 1. Thigh and knee pain. In one study involving 85 cases of children with myofascial pain, 35% of them had a TrP in the vastus lateralis. Remember vastus lateralis TrPs typically cause lateral knee and thigh pain. From the same study the second most frequently seen TrPs was the vastus medialis causing pain in the medial knee. It makes me wonder if the pediatrician’s diagnosis of “growing pains” might really be a MPS. My kids were constantly on the move, using their thighs for jumping, kicking, skipping. Seems reasonable children might injure and overuse their legs from time to time.

2. Stiff Knee. Vastus lateralis TrPs, along with their pain patterns to the lateral thigh and knee, may cause the patella bone to move stiffly. Then your clients will walk in with a stiff leg because it’s difficult to bend their knee.

3. Buckling knee. TrPs cause muscle weakness. When the vastus medialis is involved, weakness can produce a buckling of the knee, a so-called trick knee, possibly causing the individual to fall.

In my experience, I have seen a strong bias in the medical community to consider joints before muscles. There are lots of reasons for that. I’ve been on a mission to educate other clinicians about soft tissue because I know how frequently individuals suffer needlessly or undergo invasive protocols when muscles aren’t considered as a primary problem. So I hope you are realizing how many people you can help with the knowledge of MPS due to TrPs. Assure your client that both of you will know after the first treatment if a TrP is causing the source of their problem. Also assure them that within 3-5 treatments, they will be significantly better or not. One reason they might not experience relieve is because a problematic knee may have non-myofascial origins. But at least you will be able to rule out a muscular origin, with two or three weeks of regular massage treatment.

So for your knowledge let’s consider a few of the non-myofascial sources of knee pain on page four of the study guide. I’ll mention common injuries to each of the knee joint’s four different structures; the ligaments, menisci, tendons and bones.

1. Strained and torn ligaments- connecting the femur to the tibia are four ligaments and any of them can be injured. An anterior cruciate ligament tear often occurs during athletic events. The injury typically occurs when the athlete suddenly changes direction by cutting or pivoting. They feel their knee give out from under them and a loud pop is heard. Pain and swelling occurs instantly.

2. Torn menisci-two cartilaginous structures cushion the knee joint. Activity causing a forcefully twist or rotation of the knee, especially when putting the full pressure of the body weight on it, can lead to a torn meniscus. Due to the degenerative changes of the knee as we age, even a minor injury may contribute to a torn meniscus. Symptoms include a popping sensation, swelling or stiffness and pain, especially when twisting, rotating or placing weight on the knee. The feeling of the knee being locked in place may also prevent the knee from straightening fully. 3. Inflammation of the tendons- one of two important tendons is the patellar tendon connecting the patella to the tibia (technically this is a ligament because it connects two bones). Jumpers knee / patellar tendinopathy occurs when the patella tendon comes under a large amount of stress as when extra strain on the knee joint occurs from direction changing and jumping movements. As a result of the repeated strain, micro-tears as well as collagen degeneration may occur in the tendon.

Again, Jumper’s Knee or patellar tendinopathy is more about degeneration of the tendon as opposed to Patella tendonitis which is due to inflammation of the tendon. Jumper’s Knee is often associated with poor vastus medialis function particularly in teenage girls.

4. Finally, the patella bone can develop problems. Runner’s knee, a common name given to Patellofemoral pain syndrome can be caused when any of the bones are slightly out of their correct position. Then the stress from impact won't be evenly distributed through the knee.

Sometimes, you will see how the kneecap itself is out of position. Runner's knee can result from overpronation of the ankles and flat feet. I had a Triathlon diagnosed with patellofemural dysfunction who had severe pain in her anterior knee. She had been training hard on her bicycle and had overdeveloped her lateral thigh. We cleaned up the TrPs in her vastus lateralis. And she went home and properly conditioned her medial and lateral thigh muscles.

So, your job with a runner’s knee is to remove the tension causing the patella to improperly tract. And the client’s job is to strengthen and balance the quadriceps.

Answering the question, “What corrective actions can we take to resolve pain in the quadriceps femoris?” 1. Avoid extended periods of hip flexion or knee extension. Our clients need us to nag them about keeping their bodies in anatomical neutral positions. For the quadriceps group, neutral is positioning the legs so the hip is neither flexed nor the knee extended. For example sitting for extended periods of time in an upright chair with the legs propped on an ottoman should be avoided. A recliner is a better choice with a pillow under the knees. That applies to sitting in bed too. Dr. Travell re-popularized the Boston rocker. She put President Kennedy in one and designed a better seat for his Air Force One plane. Rocking keeps the muscles mobilized because you’re always pushing back and forth with the legs.

2. Avoid kneeling for extended periods of time. Gardeners in particular will benefit by sitting on a stool.

3. Correct the Morton’s foot configuration. We will dive deeply into this corrective during the next module on the peroneus muscles.

4. A home exercise program. In our protocol, we stretch the muscle first and then one or two weeks down the road when the TrP is inactive, a strengthening protocol would begin. On the resource tab of the website, I have exercise material available for you to give your clients if you need ideas. We exercise a lot in the workshops too.

Let’s go now to page five of our student study guide where we’ll answer the question, what’s the action of the adductor muscle? Its

BEYOND TRIGGER POINTS SEMINARS WWW.BEYONDTRIGGERPOINTS.COM Putting Your Hands To Better Use © 2009 Cathy Cohen, LMT LEGS & ARMS UNIT MODULE 1 10 main action, as the name implies is to ADduct the thigh. In addition the adductors play several roles in walking; the adductor magnus initially helps pick the leg up to bring it towards midline, then the other adductors help stabilize the leg. The adductor magnus is large and deep. Its middle fibers function together with the hamstring. As a consequence, I suggest getting in the habit of thinking about the adductor magnus as a functional unit of the hamstrings and treating both muscles together. The gracilis is a long thin muscle crossing both the knee and hip joint thus it may also be functioning to maintain the position of the valgus angulation of the knee. The pectineus is also considered an adductor and flexes the thigh at the hip. It works with the iliopsoas to flex and adduct the thigh as when crossing the leg over when seated. Again, all the adductors bring the leg towards midline. The pectineus also is nicknamed The Fourth Adductor because it adducts and flexes the thigh at the hip.

On page 6 of the study guide, bottom left corner, or page 291 of the text, two documented trigger point locations for the adductor longus and brevis are shown. Our book makes no distinction between the pain patterns caused from TrPs in the adductor longus verses the adductor brevis. When a client presents with groin pain, this group may be the culprit. There is also a spillover pattern down the anteromedial thigh. Draw an essential or primary pattern along the upper medial portion of the knee as well.

In class, palpation of the adductors is accomplished by first finding the pelvic bone, then the quadriceps femoris group and the hamstrings. The adductors are sandwiched in between the two muscles. The longus lies most superficially. The brevis lies underneath. A pincer palpation, squeezing the flesh between your index finger and thumb, can be used to palpate the adductor longus; a deep, flat palpation against the femur bone can be used to palpate the adductor brevis.

On the bottom right of page 6 the adductor magnus muscle with 3 separate TrPs are shown. Picture A shows TrP1 in the midthigh region and its corresponding pain pattern upward into the groin below the inguinal ligament and downward along the medial thigh. On picture C, the more proximal TrP2 region along the attachments to the pubic ramus refers pain into the intrapelvic area. Picture B is a midsagittal BEYOND TRIGGER POINTS SEMINARS WWW.BEYONDTRIGGERPOINTS.COM Putting Your Hands To Better Use © 2009 Cathy Cohen, LMT LEGS & ARMS UNIT MODULE 1 11 view of the intrapelvic region and the pain patterns referred from TrP2. The referred pain is generally described as a shooting pain extending into the vagina, rectum and pubic bone.

Because the adductor magnus lies deep to other big muscles, it’s often difficult to palpate for a taut band. So in class we learn to clean along the attachments and cross fiber friction the area along a narrow window just below the pelvis.

On page 293 of the book, there are two documented trigger points in the gracilis muscle. I haven’t encountered trigger points in this muscle very frequently. I think you will encounter trouble in the other adductors more frequently. But I wanted to present them to you anyway.

Now draw the one pectineus documented trigger point. Its pain pattern is felt as a deep aching pain in the groin. It’s often associated with other adductors as well as the iliopsoas.

On page seven of our student study guide, answering the question “How are the adductors including the pectineus activated and perpetuated?” The adductors nickname is Obvious Troublemaker. There is room for you to write, Obvious Troublemaker on 6. Remember it this way, if a story you hear makes you cringe, an adductor might be involved. For instance, I’ve had two elderly women tell me a story of how they did a split while sliding across their wet kitchen floor. Long after the injury to their hips healed, trigger points in the adductors were unresolved.

Sometimes with adductors, folks may not present with a pain complaint, per say. Instead they may have restricted range of motion only felt during leg abduction as during intercourse. Another example of activation is a broken pubic symphysis. This can happen during child bearing. I had a mother who broke her pubic symphysis giving birth to twins. When I saw her, the bone had healed but the adductors had not. Equestrians too appreciate good adductor work after strenuous horseback riding.

I can admit injuring my adductor lifting my 185 pound hydraulic massage table. Someone was helping me but as I was lifting one end BEYOND TRIGGER POINTS SEMINARS WWW.BEYONDTRIGGERPOINTS.COM Putting Your Hands To Better Use © 2009 Cathy Cohen, LMT LEGS & ARMS UNIT MODULE 1 12 in a deep horse stance, I medially rotated my thigh to push. I thought I had given myself an inguinal hernia. But then I saw my massage therapist, and after treating one TrP in the pectineus muscle and the surrounding muscles, it was 50% better after the first treatment. So I’ll think you will find that TrPs in the adductors, the hamstrings and the quadriceps respond beautifully to our work. Finally, I’ll list 3 corrective actions for the adductors. 1. Place a pillow between the knees if sideline sleeping and keep the legs uncrossed as well. This keeps the legs and the hips in a neutral position.

2. Move around frequently. This might be the most helpful advice you give your clients. Encourage your client to avoid immobility and to get up and move more.

3. Moist heat and stretching. These muscles respond well to both moist heat and stretching.

Finally on page 8 of the study guide, let’s explore the hamstring muscles. The main actions of the hamstrings are to flex the knee and extend the hip when the thigh and leg are free to move. Page 9 or page 317 of the text shows a cluster of 5 TrPs in the medial mid thigh region and 4 more documented TrPs directly lateral in the biceps femoris head. When a semitendinosus or the semimembranosus muscle is involved, your client will show you where it hurts by grabbing underneath the check of their hip. They could also describe some spillover pattern down the posterior thigh and into the medial side of the back of the knee. When a bicep femoris head is involved, your client will describe a deep aching pain behind their knee. Draw those 9 TrPs now. You don’t really have to memorize these locations because your hands will so easily find the taut bands in these muscle fibers. Then it’s just a matter of following the taut band until you find the most sensitive point. If a hypersensitive spot gives rise to referred sensation in the gluteal fold when compressing the semitendinosus or the semimembranosus muscles then bingo, you are on the bull’s eye. If the hypersensitive spot gives rise to referred sensation distally behind the knee, then you have hit a bicep femoris TrP.

Dr. Travell nicknamed the hamstrings the Chair-seat Victims because of trauma caused from compression of a chair seat edge. BEYOND TRIGGER POINTS SEMINARS WWW.BEYONDTRIGGERPOINTS.COM Putting Your Hands To Better Use © 2009 Cathy Cohen, LMT LEGS & ARMS UNIT MODULE 1 13

On page 10, let’s answer the question, “How are the hamstrings activated and perpetuated?” 1. Pressure caused from a high front edge of a chair. I find patio and pool furniture bothersome because the chair seat usually sags and a metal bar across the front causes ischemic compression in the posterior thigh. Placing a child in a highchair without foot support or on a stack of books would compress their little hamstrings too.

2. Improperly positioned bike seats. According to the trainers I’ve talked with, when the ball of the foot is on the pedal at the end of the down stroke, the knee should be almost straight. Less than almost straight cramps the hamstrings.

3. Repetitive flutter kicks in the freestyle stroke or according to one study, inadequate stretching before and after running.

4. Being a man. Joking aside, you’ve seen people, typically men, who are so tight in their back line; they can’t do a pelvic tilt. And the reason they can’t is why? Because they are already in a pelvic tilt from overly tight hamstrings. Some folks will say they just came out of the womb that way. So our job as a massage therapist is to help them touch their toes and show them how to loosen up the whole back line of their body from their ankles to their low back area.

5. TrPs in the quadriceps femoris group and the adductors. As we already discussed, tightness in the other muscle groups cause an imbalance.

6. Articular dysfunctions. For those of you working with chiropractors, L4-5 and L5-S1 vertebral joint immobility is associated with hamstring tightness based on one study.

What are the corrective actions? If there’s too much compression on the hamstrings when seated, especially if your client is height challenged, you could place phone books on the floor to elevate the feet and provide clearance between the thigh and front edge of the chair. An even better correction for the pressure caused from sitting too long is to take frequent stretch breaks. For intense people, setting a timer across the room that rings at prescribed times forces them to get up and turn off the alarm. Or for people who travel from Canada to BEYOND TRIGGER POINTS SEMINARS WWW.BEYONDTRIGGERPOINTS.COM Putting Your Hands To Better Use © 2009 Cathy Cohen, LMT LEGS & ARMS UNIT MODULE 1 14

Florida in 3 days, two hours and 23 minutes, you know the type eh, insist they stop at every rest area just to walk around the car and stretch. Stretching is the number one preventative action.

Well that concludes are module on the thighs. In module 2 we’ll be exploring the actions of the lower leg, ankles and feet. If you have any questions or comments, please feel free to contact me at [email protected]. Stay in touch.