TRIGGER POINTS

RELEASE
THROUGH SCALP
ACUPUNCTURE
Lecture by: M.K. Sastry
Aims of today
 Learn the theory of a trigger point
 Learn the theory of trigger point therapy
 Practice the trigger point technique to muscle
groups
 Use other soft tissue release techniques along
side TP release
WHAT DO YOU KNOW ABOUT
TRIGGER POINT THERAPY?
Questions
1. Name a type of Trigger Point?
2. How would patients describe trigger
point pain?
3. Name some indications for Trigger Point
Therapy?
4. Name 5 benefits of Trigger Point Therapy
5. Where are the Rhomboid muscles
located?
Questions
6. Name the muscles in the Hamstring
group.
7. Name 5 contraindications of Trigger
point therapy
8. Name some related symptoms to trigger
points in the Sternocleomastoid muscle
Theory: Trigger Point
Therapy
What are trigger points?
 Trigger points are hyperirritable areas of
contracted muscle fibres that form a palatable
nodule
 On a microscopic level, the contracted muscle
fibres accumulate into a small thickened area
causing the rest of the fibre to stretch
 The areas of contracted muscle restrict blood
flow within the tissue causing an accumulation
of waste products and reduced levels of
nutrients available.
Different types of trigger
points
• Trigger points are described according to location, tenderness
and chronicity as central (or primary), satellite (or secondary),
attachment, diffuse, inactive (or latent) and active
• The main types of trigger points are:

 Central/ primary trigger points

 Satellite/ secondary trigger points

 Active trigger points

 Latent trigger points
Central/ primary trigger points

• These are the most well-established and painful points

• Pain is felt by the individual when they are active, and are usually
what people refer to when they talk about trigger points

• Central trigger points exist at a neuromuscular point, which is the

meeting place of a nerve and muscle
 Satellite/ secondary trigger
points
• These trigger points are “created” as a response to the central
trigger point in neighbouring muscles that lie within the referred
pain zone.

• Form in response to central trigger points within the pain referral

patterns

• The primary trigger point is still the key to trigger pointing

intervention: the satellite trigger points often resolve once the
primary point has been effectively rendered inactive.

• Satellite points may also prove resilient to treatment until the

primary central focus is weakened; such is often the case in the
paraspinal and/or abdominal muscles.
Active trigger points
• This can apply to central and satellite trigger points.

• A variety of stimulants, such as forcing muscular activity

through pain, can activate an inactive trigger point.

• This situation is common when activity is increased after trauma

i.e a road traffic accident, where multiple and diffuse trigger
points may have developed.

• This trigger point is both tender to palpation and elicits a referred

pain pattern.

• Pain can limit range of movement

Latent trigger points
• This applies to lumps and nodules that feel like trigger points. These can
develop anywhere in the body and are often secondary.

• These trigger points are not painful, and do not elicit a referred pain
pathway.

• The presence of inactive trigger points within muscles may lead to

increased muscular stiffness and tension. They can build up for years.

• It has been suggested that these points are more common in those who
live a sedentary lifestyle (Starlanyl & Copeland 2001)

• These points are “potential” trigger points and may reactivate if the
central or primary trigger point is (re)stimulated

• Reactivation may occur following trauma and injury

Symptoms of Trigger Points
 Active trigger point referral symptoms

• Dull ache
• Deep
• Pressing pain
• “Stabbing”
• Burning
• Referred pain
• Common reports of headaches,
dizziness and pins and needles
Referral Pain Guide
 Sternocleomastoid and Masseter
Referral Pain Guide
 Trapezuis
Referral Pain Guide
 Pectorals
Referral Pain Guide
 Quadratus Lumborum
Referral Pain Guide
 Piriformis
Referral Pain Guide
 Glute maximus, medius and minimus
Referral Pain Guide
 TFL
Referral Pain Guide
 Vastus Lateralis
Referral Pain Guide
 Hamstrings
Other Symptoms
A sensation of:

• Numbness
• Fatigue
• Weakness

A loss of:

• Flexibility
• Range of movement
• Muscular power and strength
Why are they present?
 Repetitive overuse injuries
(using the same body parts in
the same way hundreds of times
on a daily basis) from activities
such as typing/mousing,
handheld electronics, gardening,
home improvement projects,
work environments, etc.

 Sustained loading e.g heavy

lifting, carrying babies,
briefcases, boxes or lifting
bedridden patients.
Why are they present?
 Poor posture due to our sedentary lifestyles,
de- conditioning, poorly designed furniture and
technology.
 Muscle clenching and tensing due to mental /
emotional stress.
 Direct injury such as a strain, break, twist or tear
e.g car accidents, sports injuries, falling down
stairs.
 Trigger points can even develop due to inactivity
such as prolonged bed rest or sitting.
The Trigger Point Complex
How are they formed?

• Within the muscle structure trigger points

lye within a single muscle fibre
• They are located within each
sarcomere which is where muscle
contraction takes place
• Sarcomeres often get overstimulated and
become difficult to release their
contraction
• Each segment of sarcomeres becomes
longer and shorter which stretches the rest
of the fibres in the band
The Trigger Point Complex
How are they formed?
• Multiple sarcomere knots form trigger points

• Stretched segments of fibres give increased tension to the taut band of

fibres.

• Blood flow is restricted in these fibres which reduces oxygenation and

accumulative of waste products which irritate trigger points

• The body responds by sending out pain signals

• The brain stimulates decreased movement into these muscles which

further tightens the structure
The Trigger Point Complex
The Trigger Point Theories
“Integrated trigger point hypothesis”

 Injury or overuse can stimulate release of acetylcholine (ACh).

 This stimulates the release of calcium from the
sarcoplasmic retinaculum.
 The presence of calcium can allow muscular contraction through
the sliding filament theory.
 Prolongs muscular contraction and reduces blood circulation which
prevents the calcium pump receiving the energy needed to withdraw
the calcium.
 Muscles stay contracted.
The Trigger Point Theories

 “Muscle spindle hypothesis”

 Proposes inflamed muscle spindles cause trigger points.

 Sustained muscular overload causes fatigue, muscular spasm

and restricted blood flow.

 Causes muscle spindles to be surrounded by waste products

e.g. lactic acid, potassium ions and inflammatory chemicals
such as histamine.

 This results in inflammation of the muscle spindle and spasm

of the extrafusal muscle fibres, forming the taunt band that
we can palpate.
Indications and Outcome
Measures
Indications Outcome measures

Pain VAS scale & subjective symptoms

Reduced AROM Active range of movement

High muscle tension and tone

Muscle testing

Muscle tightness
Palpation

Muscle weakness
 Outcome measure: VAS/
Numeric Pain Scale
• Simple and easy

• Before, during and after massage

• Record change

• Use with patient to see reduction in pain over

the progression of treatments
 Outcome measure: Range of
movement

• Pre and post measurements

• Goniometer or visual
• Standardise to produce reliable results
• Review each session
• Used to distinguish areas to treat and
techniques types
• Valuable in the success of treatment
 Outcome measure:
Muscle testing

• Measure nerve conduction, muscle recruitment

to determine a deficit

• Test uninjured side for norm

• Patient will see and feel a progression

• Strengthening exercises needs to be used along

side massage
 Outcome measure: Palpation
• Use palpation as a measure
• “the four T’s”
Temperature
Tissue may be hot or cold, indicating inflammation or
ischaemia

Texture
Swelling (acute-hard, chronic – “boggy”,
congested) healthy tissues should have an even
texture Adhesions feel like tissues are “stuck” and
less mobile “audible crunching”
 Outcome measure:
Palpation
Tenderness
Pain can be indicated through response/ use vas
scores Structures that are too painful to palpate

Tone
Tissues may be hypertonic or
hypotonic Use to compare
 Theory:
Trigger Pointing Therapy
How to treat a Trigger Point
Assessment

 Find the most painful TP using patient response and

Numeric Rating Scale or (VAS)
 Treat the highest rated point and radiate out from this point
 Once the points are found – a good amount of pressure is
applied (perform with precaution - keep communication
with patient)
 Initial pain is stimulated and you hold the pressure until the
pain has eased completely or in some cases reduced slightly
 Reapply pressure onto the same point until the pain eases
off quicker or it isn’t felt anymore
 Thumbs/elbows or tools can be used
How to treat a Trigger Point
Guidelines
 Application of direct pressure onto the trigger points for around 30
seconds or until the patient’s pain has decreased to at least 3/10 VAS
score.
 The applied pressure help breakup the adhesive fibre connections
within the trigger points and push out blood containing waste
products and toxins.
 After 30 seconds the pressure is released allowing a rush of fresh blood
containing nutrients to circulate the trigger point.
 Repeat 3 times in conjunction with deep massage strokes.
 This can depend on the severity of pain/ how deep or superficial the TP is
– subjective and variable to each patient
The Benefits
• Reduced pain
• Increased range of motion
• Decreased muscle stiffness
and tension
• Reduction in headaches
• Improved flexibility
• Improved circulation
• Fewer muscle spasms
Precautions
• High pain scales
• Patient Anxiety
• Acute/ Inflammatory stage of healing
• Hypersensitivity
• Pregnancy
• Epilepsy
• Asthma
• Hypertension
• Prescribed medication
Contraindications
General Local
Acute conditions requiring medical attention Acute flare-up of inflammatory arthritides

Acute pneumonia Aneurysms deemed life-threatening (may be

general contraindication depending
on location)

Advanced kidney, respiratory or liver failure Local contagious condition

Diabetes with complications such as gangrene,

advanced heart or kidney disease or very Local irritable skin condition
unstable or high blood pressure

Hemorrhage Malignancy

Severe atherosclerosis Open wound or sore

Severe and unstable hypertension Recent burn
Shock Undiagnosed lump

Systemic contagious or infectious condition

Manual Handling and Body
Position
• Posture
– Bed height
– Stance
– Patient position

• Use different parts of your hands/ arms to apply pressure

• Keep arms straight to utilise body weight when applying
pressure/resistance.
• Move from the hips and knees as much as possible
• Oil (or cream)- only needs to be a little bit, if any.

Look after yourself before you look after the patient!

 Post Treatment Irritation

Very common for people to experience irritation for up to 72

hours after treatment.

Side effects can include:

• Bruising
• Redness
• Tenderness/Increased Sensitivity
• Increased symptoms
• Aching similar to DOMS
 Post Treatment Irritation
Causes

• The release of toxins/waste products from

muscular tissue
• Neurological sensitisation
• Increased blood flow and micro trauma can lead
to bruising and redness

Advice

• Reassure the patient it's a normal

response to be sore after soft
tissue treatment
• Recommend they drink water to keep hydrated
Sternocleomastoid
Anatomical Highlights:

• Each SCM group has two divisions that originate off the mastoid
process behind the ear. The sternal division runs diagonally
downward to attach to the sternum, while the clavicular division
attaches right behind it on the medial clavicle.

• Acting unilaterally, contraction of the SCM muscle turns the head

towards the opposite side, while bilateral contraction flexes the
neck and head forward.

• The most important function of the SCM is to control and monitor

the head’s position in space. Proprioceptive feedback from the
SCM is essential to being able to maintain one’s balance, and is
also important for interpreting visual information.
Sternocleomastoid Trigger
Points
 The SCM muscle group can contain a up
to seven trigger points, making it’s
trigger point density one of the highest
in the body.
 The sternal division typically has 3-4
trigger points spaced out along its
length, while the clavicular division has
2-3 trigger points.
 Trigger points typically develop in one
SCM muscle group first, but quickly
spread to the SCM on the opposite side
of the neck.
Sternocleomastoid Pain
Each SCM division has a separate and distinct referred pain pattern:

 The sternal division’s referred pain is felt deep in the eye socket
(behind the eye), above the eye, in the cheek region, around the
TMJ, in the upper chest, in the back of the head, and on the top of
the head.

 The clavicular division’s referred pain is felt in the forehead,

deep in the ear, behind the ear, and in the molar teeth on the
same side.

Related symptoms
• Sore Neck
• Tension Headaches
• Migraine
• Dizziness
RX: Sternocleomastoid
• Locating and releasing these
trigger points can be complicated
due to their proximity to many
blood vessels and nerves in the
neck region.

• Because of this, the application of

direct pressure is limited to the
superior trigger point only, with
the rest of the trigger points
released with a specific squeezing-
type of technique.
Upper Fiber Traps
The trapezius is not one, but three
separate muscles:

• The upper trapezius

• The middle trapezius
• The lower trapezius

All three trapezius muscles originate along

the spine and extend laterally to attach to
the shoulder girdle, but each muscle has a
different fiber direction and pull.
Upper Fiber Traps
The whole trapezius muscle creates various movements of the shoulder
blade, neck, and head.

An example, the simple act of flexing the head to the right requires:
• Contraction of the lower trapezius on the right side to fix the right
shoulder blade in place.
• Contraction of the right upper trapezius to pull the neck and head to
the right.
• Relaxation of the left lower trapezius to allow the left shoulder blade
to rise.
• Relaxation of the left upper trapezius to allow the neck and head to
move to the right.

This type of complexity makes it easy for trigger point activity to spread
quickly through the muscle group as a whole.
 UFT Trigger Points
Four primary trigger points in the
trapezius muscle group; two trigger
points in the upper fibers, and one
each in the middle and lower
fibers.

• The anterior trapezius trigger

point

• The upper trapezius trigger point

• The middle trapezius trigger point

• The lower trapezius trigger point

UFT Pain
• “Pain in the neck”

• The mental and emotional stress of modern day life often takes
physical form as trigger points in the lower and upper trapezius
muscles.

• The lower trapezius trigger point is the most sensitive to

psychological and projects pain and tenderness upward into
the neck and shoulder region.
UFT Pain
• The anterior trigger point refers pain to the side of the neck,
jaw, and face, but it is notorious for producing a throbbing
headache in the temple region. This headache pain may also
be described as “behind the eye.”

• Middle trapezius trigger point, which produces a localised

burning-type pain along the spine. It will often recruit the
rhomboid trigger points as they share a similar intra- scapular
pain pattern.
RX: UFT
•The anterior trapezius trigger
point

•The upper trapezius trigger

point

•The middle trapezius trigger

point

•The lower trapezius trigger

point
 Rhomboids
“That Nagging Pain Between the Shoulder
Blades”

• Location: The rhomboid muscle group is found between the

spine and the scapula in the mid- back region. It lies deep to
the Trapezius muscle and is composed of the rhomboid
major and rhomboid minor muscles.
• Structure: The rhomboid minor is smaller than and lies above
(superior to) the rhomboid major. Both muscles originate
along the thoracic spine with their fibers running diagonally
downward and outward to attach along the inside border of
the scapula.
Rhomboids

• Function: In everyday life, the rhomboid muscles function to

position the scapula during various movements of the
shoulder and arm.
 Rhomboids
“That Nagging Pain Between the Shoulder Blades”

• The rhomboid minor originates on the spinous processes of

C7 and T1 and attaches to the medial border of the scapula
near the root of scapular spine.

• The rhomboid major originates from the spinous processes

of T2 to T5 and attaches along the lower half of the scapular
border.
Rhomboid Trigger Points
3 primary trigger points

• The rhomboid minor trigger point

lies just medial to the inside edge of
the scapula, level with the scapular
spine.

• The rhomboid major trigger points lie

one above the other, along the lower
part of the scapular border.

It should be noted that all three of the rhomboid trigger points lie beneath the trapezius muscle and
may be difficult to palpate if there is tension or trigger point activity in the trapezius.
Rhomboid Pain
Referred Pain: The pain concentrates in the region between the
spine and the shoulder blade. It may also extend to the region
above the shoulder blade as well.
The rhomboid and levator scapulae trigger point pain patterns
are very similar except that the rhomboid pattern does not
involve the neck.
Rhomboid Pain
Symptoms/ Clinical Findings
• Pain Between the Shoulder Blades: an aching (but not deep)
pain that is felt along the inside of the shoulder blade.
• Pain is usually felt at rest and not typically affected my
movement.
• A patient will typically present with rounded-shoulder, sunken
chest posture where tight pectoralis muscles pull the shoulder
forward, producing a chronic strain and stretch on the
rhomboids and middle trapezius muscles.
• Rhomboid weakness
• Patients may hear snapping or grinding noises from the
region around the shoulder blade during movements of
the arm.
RX: Rhomboids
• Make sure that you have released any trapezius trigger
points first.

• If you don’t, you will never be able to accurately locate the

rhomboid trigger points by palpation. Even with a relaxed
trapezius muscles, these trigger points will feel rather deep
to your touch (even though they really aren’t that deep)

Positions:

• Side-lying position to allow more forward movement of

their shoulder
• Prone to allow more pressure to be applied
RX:
Rhomboids
RX: Rhomboids
 QL – Quadratus Lumborum
• A small and hidden muscle that plays a prominent role in
normal body mechanics that without its functioning, the
upright posture of the human being is impossible to maintain.
This muscle group has three subsections that each have a distinct
fiber direction:

• The Iliocostal fibers (shown in the following picture as blue)

attach on the Iliac Crest and run vertically upward to attach
to the 12th rib.
• The iliolumbar fibers (shown in the following picture as green)
attach on the Iliac Crest and run diagonally upward and
medially to attach to the transverse processes of the lumbar
vertebrae (L1 > L4)
QL – Quadratus Lumborum
• The lumbocostal fibers (shown in the following picture as red)
attach on the lumbar vertebrae and run diagnonally upward
and laterally to attach to the twelfth (lowest) rib
QL – Quadratus Lumborum
 QL Trigger points
• The primary antagonist to each QL muscle is the
opposing QL muscle on the other side of the body.
• If one muscle develops trigger point activity, the muscle
on the other side will become overloaded and develop
trigger points as well.
• From a clinical perspective, you should always address the
trigger points in both the left and right QL muscles, even if
the pain is limited only to one side.
QL Trigger points
There are four potential trigger
points in the QL muscle:

•The upper QL trigger point is

found just lateral to where the
lumbar paraspinal muscles and
the twelfth rib meet.

•The lower QL trigger point lies

deep in the region where the
paraspinal muscles meet the hip
crest (iliac crest).
QL Trigger points
•The middle or deep QL trigger
points lie closer to the spine than
the superior or lower trigger
points, next to the third and
fourth lumbar vertebrae.
QL Pain
• Usually described as an intense, deep ache but occasionally
can initiate a sharp, knifelike symptom, particularly during
movement.
The distribution of the referred pain from each TP is:

• The upper trigger point refers pain to the flank region of the
low back, along the crest of the hip, and around the front to
the upper groin region.

• The lower trigger point refers pain and tenderness to the hip
joint region, making laying on that side too painful during
sleep.
QL Pain
• The middle trigger points refer pain and tenderness strongly
to the S.I. joint and lower buttock regions. Occasionally,
these trigger points may refer a sharp, “lightening bolt” of
pain to the front of the thigh.
QL Pain
 RX: QL
• The first step in the effective
treatment of the QL trigger
points is being able to
accurately locate and contact
the trigger points.
• Prone position

• Extended side-lying
position
 TFL - Tensor Fasciae Latae
Location:
 A small muscle found on the side of the pelvis and runs
downward in front of the hip joint to blend with the iliotibial
tract just below the hip joint.

Function:
 Its function is primarily to control movement of the leg
during the stance phase of walking.

 It also works to keep the pelvis level when the opposite leg
is raised off the ground during walking (assisting the gluteus
medius and gluteus minimus muscles).
 TFL - Tensor Fasciae Latae
Function:
 It may also help to stabilise the knee joint during weight
bearing activity.
 TFL - Tensor Fasciae Latae
Muscle Structure:
 The upper attachment of the TFL originates
along the outer aspect of the Iliac Crest (of
the pelvis) and Anterior Superior Iliac Spine
(A.S.I.S).

 Two functionally distinct sections, the anterior

and posterior fibers.

 The anterior fibers become tendinous as they

run down the outside of the thigh and attach
to the connective tissue encapsulating the
knee joint.
 TFL - Tensor Fasciae Latae
Muscle Structure:
 The posterior fibers join the iliotibial tract (a
central thickening of the large fascial sheath
covering the outside thigh) and attach to the
lateral tubercle of the tibia leg bone.
TFL Trigger Point
 There is only one trigger point found in the TFL and it
is located in the upper region of the muscle just
below where it attaches to the A.S.I.S.
TFL Pain
 The referred pain pattern
associated with this trigger point
covers the entire hip joint and
extends down the outside
aspect of the thigh, sometimes
nearly to the knee joint.
Tenderness to touch may also
be prominent in the hip joint
and down the thigh
TFL Pain
Symptoms/Clinical Findings
 Pain and/or soreness in the hip
joint (greater trochanter) and
down the outside thigh during
movement of the hip.
 Pain prevents them from walking
quickly.
 Unable to sit in a deep (or low) chair
or flex their hip more than 90°.
TFL Pain
Symptoms/Clinical Findings
 Unable to lie on the affected hip
during sleep and unable to lie on
the unaffected side during sleep
without a pillow between their
knees.
 Adduction of the thigh at the hip is
limited to 15° or less.
 Swinging the leg on the affected
side up and to the side (hip
abduction) may be painful.
RX: TFL
Vastus Lateralis
Location: The quadriceps femoris muscle
group form the thigh musculature found
on the front of the upper leg. The group
is comprised of four muscles:

• The Vastus Lateralis

• The Rectus Femoris

• The Vastus Medialis

• The Vastus Intermedius

 Vastus Lateralis
Function
 The quadricep muscle group as a whole functions to allow a
person to squat, bend backwards, walk up or down stairs, and
move from a standing to a seated position (or vice- versa).
 These muscles are not active while standing with the knees
locked, but become active during the heel-strike and toe-off
phases of walking.
 Vastus Lateralis
Muscle Structure and Actions
 The vastus lateralis is the largest muscle in the group.
 It originates along the posterior-lateral aspect of the femur
bone and runs down the outside of the thigh to attach to the
lateral aspect of the patella bone.
 Contraction of this muscle produces extension of the lower leg at
the knee.
Vastus Lateralis Trigger Points
There are two sets of trigger points in the vastus lateralis muscle:

 The upper vastus lateralis trigger points are located in

mid-thigh region on the outside aspect of the leg.

 They refer pain all along the outside of the thigh and
knee, from the pelvic crest down to the lower leg region
just below the knee.

 The lower vastus lateralis trigger points are found just

above and to the outside of the knee joint. They refer pain
around the outside aspect of the knee joint and below it,
sometimes extending up into the lower lateral thigh region.
Vastus Lateralis Trigger Points
There are two sets of trigger points in the vastus lateralis muscle:

 The pain may also be experienced as going “through the

knee” and into the back of the knee, especially if it occurs
in children.
Vastus Lateralis Trigger Points
RX: Vastus Lateralis
Hamstrings
Muscle Structure & Attachments: The four components of
the hamstring muscle group are detailed below:

The semitendinosus
 Medial aspect of the posterior thigh
 Originates on the ischial tuberosity of the pelvis and
runs down the leg to attach below the medial
condyle on the tibia.
 The belly of this muscle is found in the top portion of
the posterior thigh.
Hamstrings
The semimembranosus
 Also lies on the medial aspect of the posterior thigh
 It attaches to the ischial tuberosity of the pelvis and
runs deep to the other hamstring muscles to attach
to the medial condyle of the tibia just below the
knee joint capsule.
 Hamstrings
The bicep femoris

 It has two heads that lie on the lateral aspect of the posterior
thigh; the long head and the short head.
 The long head of the biceps femoris attaches to the ischial
tuberosity and runs diagonally downward and laterally to
attach to the head of the fibula bone.
 The short head of the biceps femoris attaches along the linea
aspera on the shaft of femur bone and runs diagonally
outward to join the tendon of the long head as it attaches to
the head of the fibula.
Hamstring Trigger Points
The hamstring muscle group
contains two clusters of trigger
points:

 The medial cluster can

contain up to 5 trigger points
that are located about mid-
thigh, along the inside of the
leg.

 The lateral cluster can contain

up to 4 trigger points that are
located about mid- thigh along
the outside aspect of the leg.
Hamstring Pain
 The medial cluster trigger point(s) refer pain strongly
upward to the gluteal fold/upper posterior thigh region
and down the back of the thigh to the medial calf region.

 The lateral cluster trigger points refer pain primarily to the

back of the knee, with some spillover referral to the back of
the thigh.
Hamstring Pain
Symptoms/Clinical Findings of active hamstring

 Posterior thigh or posterior knee pain, worse when walking,

often causes a limp.
 Pain in buttocks, back of the thigh and/or knee while sitting
 Leg pain that disturbs sleep
 Quadriceps femoris trigger point symptoms due to the
prominent antagonistic relationship between these
muscle groups.
RX: Hamstring

+ Active Release Technique

The use of other STR
 Helps warm up an area
 Removes waste products
 Increases oxygenation
 Increases new blood flow
 Further breaks down collagen
 Helps sooth an area after deep pressure has been
applied
 Nice, relaxing end to a treatment
Effleurage
• Technique used to warm up or
warm down the tissues

• Tensile force, works as a

mechanical pump

• Increases fluid flow encourages

venous and lymphatic return

• Increases tissue mobility

Effleurage
• Dilation of capillaries

• Can increase or decrease tone

depending upon speed
 Petrissage
• Examples of petrissage- Kneading, wringing & skin rolling

• A group of techniques that are applied with pressure and

are deep and compress the underlying muscles
• Movements should be slow and repetitive with pressure in
order to loosen the muscles and increase blood flow to the
area
• Promotes relaxation
• Increases fluid flow
• Increases mobility of fibrous tissue
• Decreases tone
Why should you stretch post-massage?

• Excessive tension may still remain post-massage.

• It takes up to two days post-massage to experience full effects.

• Essential to use other techniques to restore good functioning

and reduce tension.

• need to stretch the collagen fibres that have been “knotted” to

allow them to regain their full length.
Post treatment stretches
Passive static stretching

 Involves taking the muscle belly to its outer range

until you can feel a gentle stretch.

 Static stretches are usually held for at least 30 pain free

seconds.

 Research suggests static stretches should be repeated

from 2 to 4 times. As further repetitions do not
promote any further muscle elongation (Bandy, 1997).
Answer of the Question 1
• Central/ Primary
• Satellite/Secondary
• Active
• Latent/potential
Answer of the Question 2
 Dull ache
 Deep
 Sharp
 Pressing pain
 Stabbing
 Burning
 Travelling pain
 Head pain
Answer of the Question 3
• Pain
• Reduced AROM
• High muscle tension or tone
• Muscle tightness
Answer of the Question 4

 Reduced pain
 Increased range of motion
 Decreased muscle stiffness and tension
 Reduction in headaches
 Improved flexibility
 Improved circulation
 Fewer muscle spasms
Answer of the Question 5
• The rhomboid muscle group is found between the spine
and the scapula in the mid- back region. It lies deep to the
Trapezius muscle and is composed of the rhomboid major
and rhomboid minor muscles.

• The rhomboid minor originates on the spinous processes

of C7 and T1 and attaches to the medial border of the
scapula near the root of scapular spine.
• The rhomboid major originates from the spinous
processes of T2 to T5 and attaches along the lower half
of the scapular border
Answer of the Question 6
The semitendinosus
 Medial aspect of the posterior thigh
 Originates on the ischial tuberosity of the pelvis and runs down the leg
to attach below the medial condyle on the tibia.
 The belly of this muscle is found in the top portion of the posterior thigh.

The semimembranosus
 Also lies on the medial aspect of the posterior thigh
 It attaches to the ischial tuberosity of the pelvis and runs deep to the other
hamstring muscles to attach to the medial condyle of the tibia just below the
knee joint capsule.

•The long head of the biceps femoris attaches to the ischial tuberosity and runs
diagonally downward and laterally to attach to the head of the fibula bone.

•The short head of the biceps femoris attaches along the linea aspera on the shaft of
femur bone and runs diagonally outward to join the tendon of the long head as it
attaches to the head of the fibula.
Answer of the Question 7
General Local
Acute conditions requiring medical attention Acute flare-up of inflammatory arthritides

Acute pneumonia Aneurysms deemed life-threatening (may be general

contraindication depending on location)

Advanced kidney, respiratory or liver failure Local contagious condition

Diabetes with complications such as gangrene,

advanced heart or kidney disease or very unstable or Local irritable skin condition
high blood pressure

Hemorrhage Malignancy

Severe atherosclerosis Open wound or sore

Severe and unstable hypertension Recent burn

Shock Undiagnosed lump

Systemic contagious or infectious condition

Answer of the Question 8
 The sternal division’s referred pain is felt deep in the eye socket (behind
the eye), above the eye, in the cheek region, around the TMJ, in the
upper chest, in the back of the head, and on the top of the head.

 The clavicular division’s referred pain is felt in the forehead, deep in

the ear, behind the ear, and in the molar teeth on the same side.

Related symptoms

 Sore Neck
 Tension Headaches
 Migraine
 Dizziness
Thank You