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Trigger Point Chart | Active vs Latent Trigger Points

What is a trigger point chart?

A trigger point is a hypersensitive spot in any muscle that has the ability to cause pain or other clinical manifestations. Trigger points can either be active or latent and can result in muscle shortness, weakness, and reduced range of motion. Let’s take a look at the difference between active and latent trigger points and how a trigger point chart can help diagnose it.

What is an Active Trigger Point?

An active trigger point means that it causes pain. Not only does it cause pain, it causes the muscles to exhibit tautness or shortening, spasm, and weakness relative to its normal state. Once the trigger points are completely eliminated the muscle will once again return to its normal strength. The longer a trigger point remains active, the more weakness occurs and the more dysfunctional the muscle becomes.

Where can I find a trigger point chart?

What is a Latent Trigger Point?

A latent trigger point won’t cause any discomfort unless it is sufficiently compressed. A latent trigger point is basically an active trigger point in waiting. It won’t cause discomfort unless it is activated. Latent trigger points may persist for months, even years, before they become active trigger points. While it might not be noticeable, the latent trigger point will still cause dysfunction, or prevent full motion and normal muscle strength.

Where Can I Find a Trigger Point Chart?

A great way to determine, and help diagnose a trigger point, is with a trigger point chart. If you are looking for trigger point charts, contact us today at Kent Health Systems.

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Postural Analysis | TMJ Dysfunction and Forward Head Posture

What is a postural analysis?

If you suffer from TMJ syndrome you already know some of the more common symptoms. Did you know though, that problems with your TMJ can be directly related to your posture? Believe it or not, the way you sit or stand can have a direct effect on your TMJ. Let’s take a look at the correlation between TMJ dysfunction and forward head posture and how a postural analysis can help remedy it.

How are TMJ syndrome and Bad Posture Connected?

One of the causes of TMJ dysfunction is poor posture. It’s particularly important because many times it’s the last thing we think of. However, the stress put on your body from forward head posture can put pressure on all different parts of your body, including your mouth and jaw. Luckily, out of all the possible causes, this one is the least expensive and easiest to treat.

Who offers postural analysis?

What Causes Forward Head Posture?

A forward-leaning head is caused by constantly being hunched over. In fact, poor posture while sitting, working and walking can lead to a complete change in the curvature of the neck. This can lead to TMJ pain issues like migraines, stress headaches, plus pain in the back and shoulders.

Can a Postural Analysis Help with Forward Head Posture?

There are two main ways to fix forward head posture. You can either go through rehabilitation, or you can use things like a postural analysis to correct the issue. At Kent Health Systems we offer everything you need to give your patients a proper postural analysis. Contact us today to learn more.

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Posture Charts | Importance of Good Posture

Who offers posture charts?

When you were a kid, chances are your mom told you to sit up straight or fix your posture. While you might have thought she was just nagging you, there was a real reason for it too. Having a good posture can prevent back and other medical issues later in life. Let’s take a look at just a few of the reason why a good posture on posture charts is important.

Eliminates Neck and Back Pain

When you have proper posture, your bones and spine can easily and efficiently balance and support your body’s weight. When you have improper posture, muscles, tendons, and ligaments have to constantly work to support that same weight. The extra strain that is put on your back from bad posture can lead to neck pain, back pain, and even headaches.

Improves Memory

Studies have shown that there may be a connection between good posture and memory retention when learning new things. That’s probably why your teacher in school would tell you to sit up straight at your desk. The theory is, good posture enhances your breathing. This allows you to take in more oxygen, and when you take in more oxygen, your cognition improves.

 Where can I find posture charts?

Makes You Look Slimmer

Poor posture can cause your stomach to protrude over your belt line, sometimes referred to as a “beer belly”. Standing up straight will make you look skinnier and taller.

Are You Looking for Posture Charts?

At Kent Health Systems we offer all sorts of charts and training aids for your practice, including posture charts. Contact us today to learn more.

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Trigger Point Chart | Pain Management Without Opioids

Where can I find a trigger point chart?

Trigger points are small areas of spasm inside your muscle. When “struck” trigger points can sometimes cause debilitating pain that can make it difficult or temporarily even impossible to move. For generations, the answer to pain caused by trigger points was opioids. However, with the use of a trigger point chart some hospitals have begun using alternative methods for pain management. Let’s take a look at one of those alternative methods.

Dry Needling

It’s no secret that the country is currently in the middle of an opioid epidemic. It’s also no secret that a hospital ER is the biggest prescriber of opioids in the United States. Some hospitals, like St. Joseph’s University Medical Center in Paterson, N.J. have begun using alternative methods though when treating patients for pain. In fact, the strategy has led to a 58% drop in the ER’s opioid prescriptions in just the first year that the program has been in place.

One of the methods that St. Joseph’s uses is dry needling the trigger point of the pain. Unlike opioids which are rarely actually able to penetrate the spasm and trigger point, a dry needle can break up the muscle tissue and mechanically stop the spasm and the pain. The dry needling is followed with a small injection of a local anesthetic for the soreness caused by the needle.

What is a trigger point chart?

Are You in Need of a Trigger Point Chart?

At Kent Health Systems we offer charts and training aids to better help you serve your patients. Contact us today to learn more about the products and services we offer.

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Back Pain from Gluteus Medius Trigger Points

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By: David Kent, LMT, NCTMB

Each week, I treat several clients who complain of “low back pain.” For many patients, however, the primary cause of pain is not the lower back but the gluteus medius muscle. No matter what kind of massage practice you have, a great deal of your success will depend on how quickly you are able to determine the origin of a patient’s complaint and your ability to produce measurable results. This article will review some ways to identify when the gluteus medius muscle is responsible for causing pain.

Anatomy:

The gluteus medius muscle lies superficial to the gluteus minimus muscle and deep to the gluteus maximus muscle. Proximally, it attaches along the external surface of the ilium between the anterior and posterior gluteal lines. Distally, it attaches to the lateral surface of the greater trochanter of the femur (See Photo 1).

The gluteus medius muscle “abducts the hip joint; the anterior fibers medially rotate and may assist in flexion of the hip joint; [and] the posterior fibers laterally rotate and may assist in extension.”1 It also helps to keep the pelvis level when the opposite leg is raised during activities such as walking, running, or standing on one leg.

Intake and History:

The first step to designing and implementing an effective treatment plan is to understand the client’s medical history and current circumstances. Utilizing health history intake forms will help you gather the appropriate information; they will also reveal important factors that could be relevant to a patient’s condition.

Using pain scales to document a client’s pain patterns are beneficial, as well. Ask the client to color the diagram form illustrating where on the body he/she experiences pain. Then ask the client to add modifiers that adequately describe the pain, followed by a number from 1-10 to rate its intensity (See Photo 2 ). This diagram provides a helpful visual tool that you can reference during the session. You will also see how pain patterns often match common trigger point patterns, which are discussed in more detail below.

Ask the client if any of his/her daily activities are affected by the pain. If the answer is yes, ask the client which muscles hurt, what movements aggravate the pain, and what he/she believes caused the pain. Ask if the client has recently started or modified an exercise program. Answers like walking, running, tennis, aerobics and other types of activities may indicate gluteus medius involvement. Has the client had any falls or sustained any hip injuries? What is the client’s occupation? Does the client place a wallet or tools in a back pocket? All of these questions will help you narrow down the origin of pain. (Read “Questions with Direction,”)

Gait & Postural Analysis:

Observe the client as he/she walks. A painful or “weak gluteus medius muscle forces the client to lurch toward the involved side to place the center of gravity over the hip; such movement is called an abduction, or gluteus medius lurch.”2

Show your client the relationship between posture and pain, and describe how you can help. Just like chiropractors advertise free “spinal exams” to attract new patients, you could provide free postural analysis to attract new clients. Market the postural analysis as a value that you include during the initial visit; then include a second postural analysis taken upon completing a series of treatments. This is a great way to sell packages, and it also demonstrates postural progress. (Read “Getting Comfortable with Postural Analysis,”) When conducting a postural analysis, look for signs of gluteus medius muscle involvement. Shortness of the gluteus medius muscle “may be seen as a lateral pelvic tilt, low on the side of tightness, along with some abduction of the extremity.”3

Trigger Points

“Myofascial trigger points (TrPs) in the gluteus medius are a commonly overlooked source of low back pain.”4 There are three trigger points frequently identified in the gluteus medius muscle. TrP1 (See Photo 1) is located lateral and superior to the posterior superior iliac spine (PSIS) just below the iliac crest. TrP1 refers pain and tenderness over the sacrum, above the iliac crest into the lumbar region, and throughout the gluteal region on the same side of the body as the trigger point.

TrP2 (See Photo 1) is positioned midway between the anterior superior iliac spine (ASIS) and the PSIS just below the iliac crest. “Pain referred from TrP2 is projected more laterally and to the midgluteal region; [and] may extend into the upper thigh posteriorly and laterally.”5

TrP3 (See Photo 1) is rarely present and can be located just posterior to the ASIS and just below the iliac crest. Referred pain is primarily produced over the sacrum bilaterally.

Educate your clients about trigger points. Use wall charts or flip charts to demonstrate their location on the body. Using charts and other aids will not only help the client, but it will also build your credibility with the client. This is also an excellent time to explain how the muscle affects posture.

Pain is a symptom. As massage therapists, our job is to address the cause of the pain and work to prevent its return. Educate your clients. Discuss proper ergonomics, stretching and strengthening. Identifying the gluteus medius as a source of back pain is easy once you have the knowledge.

David Kent, LMT, NCTMB

David Kent, LMT, NCTMB, is an international presenter, product innovator and writer. His clinic, Muscular Pain Relief Center, is in Deltona, Florida, where he receives referrals from various healthcare providers. David is President and Founder of Kent Health Systems which teaches Human Dissection, Deep Tissue Medical Massage and Practice Building seminars, and has developed a line of products, including the Postural Analysis Grid Chart™, Trigger Point Charts, Personalized Essential Office Forms™, and DVD programs. Visit www.KentHealth.com or call (888) 574-5600 for more information.

1, 3 Kendell FP, McCreary, et al. Muscle Testing and Function with Posture and Pain, 5th ed.  Lippincott, Williams and Wilkins: 2005.

2 Hoppenfeld S. Physical Examination of the Spine & Extremities. Appleton & Lange: 1976

4 Simons DG, Travell JG. “Myofascial Origins of Low Back Pain, 3: Pelvic and Lower Extremity Muscles,” Postgrad Med 73:99-108, 1983.

5 Simons DG, Travell JG. Myofascial Pain and Dysfunction, The Trigger Point Manual: The Lower Extremities, 2. Lippincott, Williams and Wilkins: 1992

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Subscapularis: Overlooked and Under Treated

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By: David Kent, LMT, NCTMB

The subscapularis is often neglected and/or undertreated as a cause of posterior shoulder pain with restricted range of motion (ROM). According to Travell and Simons, “differential diagnosis of subscapularis TrPs includes C7 radiculopathy, thoracic outlet syndrome, adhesive capsulitis and ‘impingement’ syndrome.”[1]In this article, I will review how to determine when the subscapularis muscle is responsible for causing shoulder pain and restricted ROM, as well as review its anatomy, function, trigger-point patterns and treatment options.

Intake and health history forms will help you identify some common factors that may contribute to the formation and perpetuation of trigger points, as well as the shortening of the subscapularis muscle. According to Travell and Simons, some of these factors include the following:

  • Repetitive movements that involve medial rotation, such as swimming the overhead stroke, playing tennis or pitching a baseball;
  • Repeatedly lifting boxes or other objects overhead with both arms extended;
  • Reaching backward to break a fall;
  • Soft-tissue stress when the shoulder joint is dislocated;
  • A fracture to the proximal humerus or trauma to the shoulder joint capsule;
  • The immobilization of the shoulder in an adducted and medially rotated position over a long period of time, such as when the arm is in a sling; and
  • Prior surgeries and procedures.[2]

Taking a photo of your client in front of a postural analysis grid chart is an effective method of evaluating, documenting, educating and ultimately showing a client his or her postural progress over a series of treatments. For example, a constant slumped, forward-head, adducted-scapulae posture will perpetuate trigger points and the shortening of muscles, like the subscapularis, by continually keeping the humerus in a position of medial rotation.3 [Photo 1]

 

 

Symptoms

 

Trigger Points: When trigger points are present in the subscapularis muscle, they produce referred pain “in the posterior deltoid area…down the posterior aspect of the arm, and then skip to a band around the wrist.”4 [Photo 2] Remember that referred pain is a symptom; we want to address the cause. So intake forms, postural analysis evaluations, range-of-motion and orthopedic assessments, and being familiar with trigger point patterns are all helpful to designing and implementing a customized therapy plan. But treating a trigger point is only part of the solution. We need to avoid a recurrence in the future. It is therefore necessary to demonstrate to your client which muscles need more lengthening and which ones need more strengthening so that all of the joints are properly aligned and moving through their full range of motion.

Anatomy: The subscapularis is one of four muscles that make up the rotator cuff, along with the supraspinatus, infraspinatous and the teres minor muscles. In my dissection seminars, I always highlight the subscapularis, which is the most anterior of the rotator cuff muscles. [Photo 2] It is a thick triangular muscle that attaches medially on the anterior or costal surface of the scapula on the subscapular fossa; it forms part of posterior wall of the axialla. Laterally it attaches on the lesser tubercle of the humerus and the lower half of the shoulder joint capsule.

Actions: The subscapularis is primarily responsible for medially rotating and adducting the arm. It also helps to hold the humeral head in the glenoid cavity. To check for shortening in the subscapularis it is necessary to evaluate both abduction and external rotation.

Abduction: According to Travell and Simons, when evaluating a shoulder with restricted abduction, it is first necessary to determine if the restriction is being caused by the inability of the scapula to move on the rib cage, the humerus to properly articulate in the shoulder (glenohumeral) joint, or a combination of the two. The difference can be easily determined by placing your hands on the client’s scapula to prevent its movement while asking the client to abduct his/her humerus. [Photo 3] When the subscapularis is involved, it restricts glenohumeral movements like abduction and lateral rotation, but it does not restrict scapular movements on the rib cage. If scapular movements are restricted, it is necessary to evaluate muscles that run from the torso to the scapulae like the pectoralis minor, serratus anterior, trapezius and the rhomboids.5

Lateral Rotation: When checking lateral rotation at the shoulder, adduct the arm by placing the elbow at the side. Bend the elbow 90 degrees to show the amount of rotation at the shoulder joint. [Photo 4] The arm should be able to laterally rotate 90 degrees. In addition to the subscapularis, other synergistic muscles like the teres major, latismus dossi and pectoralis major also adduct and medially rotate the arm. These muscles must also be evaluated and treated. Keep in mind that the antagonistic muscles are weak and over lengthened, so they need strengthening. Muscle movement charts can aid in quickly identifying the muscles involved and show the normal range of motion for the muscles and joints being evaluated. [Photo 5]

Treating the subscapularis: While there are many different approaches to treating the belly of the subscapularis muscle, I find one particularly effective; however, with this method some clients may only be able to tolerate static pressure versus movements, such as with-fiber or cross-fiber techniques.

  1. Place the client in a supine position.
  2. Stand facing the client at level of client’s shoulder.
  3. In the palm of your non-treating hand, cradle the scapula while using your fingertips to secure the vertebral border of the scapula; abduct the scapula.[Photo 6]
  4. Position the fingers of the treating hand against the belly of the subscapularis muscle. [Photo 7]

NOTE: Some clients may be ticklish, but this is easily overcome by using the client’s hand during the treatment. Have the client place his/her hand on the ticklish region while you treat the area between his/her fingers. [Photo 8]

  1. Drape the client’s arm across his/her chest (adduction) to shorten the muscle. [Photo 9]
  2. Press the fingers of your treating hand down toward the table and into the subscapular fossa.

Before the session ends, advise your client that he/she will receive the most benefit from your therapy session by actively engaging in self-care stretching techniques, such as the doorway stretch, which will further help improve muscle length, and create and maintain balance in the shoulder. [Photo 10]

You have now identified several factors associated with subscapularis pain and discomfort with the help of assessment aids and tools like intake forms, charts and postural analysis photos. Continue to study and broaden your skills with hands-on seminars and DVD programs. And to share your tips and experiences in the treatment room, please drop me a line at [email protected]

For more information related to this month’s topic, check out “Charting Your Progress: Visuals for Success” (February 2008) and “Getting Comfortable with Postural Analysis” (July 2008) online at www.massagetoday.com.

David Kent, LMT, NCTMB

 

David Kent, LMT, NCTMB, is an international presenter, product innovator and writer. His clinic, Muscular Pain Relief Center, is in Deltona, Florida, where he receives referrals from various healthcare providers. David teaches Human Dissection, Deep Tissue Medical Massage and Practice Building seminars, and has developed a line of products, including the Postural Analysis Grid Chart™, Trigger Point Charts, Personalized Essential Office Forms™, and DVD programs. Visit www.KentHealth.com or call (888) 574-5600 for more information.


1-5 Simons DG, Travell JG, et al. Myofascial Pain and Dysfunction: The Trigger Point Manual, volume 1, 2nd ed. Williams and Wilkins: 1999.

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