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.