MYOFASCIAL

TRIGGER POINTS
Classified as simple/uncomplicated
Foci of hyperirritable tissue
Causes Referred autonomic phenomenon (distal), sensory pain & tenderness, motor spasm,
autonomic vasodilation & hypersecretion) weakens the muscle/ prevents full lengthening
Myofascial, cutaneous tissue, ligaments, periosteum, fascia
ACTIVE: Symptomatic at rest or during motion of the muscle (activation by many factors)
LATENT: Pain only when palpated
DIAGNOSIS

■ History Sudden onset = acute overload

■ Gradual onset = chronic overload
■ Decreased length and strength of muscle
■ Taut palpable band/nodule/knot ( flat or pincer palpation)
■ Characteristic referred pain pattern
■ Exquisite, focal tenderness (Jump Sign) = essential but non-specific
■ Local Twitch Response
■ Reproduction of complaint = specific and strongly diagnostic
MANAGEMENT

Inactivate Trigger Point

Spray and stretch
Ultrasound and stretch
Ischemic compression (Nimmo)
PIR. What does PIR stand for? When is it used?
Drink plenty of water
Maintain good posture
Avoid Chilling
Remove Subluxations (or aberrant restrictions)
GLUTEUS MEDIUS

O: Outer ilium 1. Near PSIS: refers pain to gluteal cleft & fold and SI
joint
(between anterior & 2. Mid Iliac crest: refers pain to entire buttock &
posterior gluteal posterior proximal thigh
3. Lateral iliac crest: refer pain over sacrum, coccyx,
lines) gluteal cleft
I: Greater Trochanter
(superior & lateral
surfaces)
A: Abduction of the
hip, stabilizes pelvis
& prevents free limb
from sagging during
gait
Ant fibres: Flexion &
medial rotation of
hip
Post fibres:
Extension & lateral
rotation of hip
N: Superior gluteal
nerve (L4, L5, S1)
B: Superior gluteal
artery
GLUTEUS MAXIMUS

1. Adjacent to sacrum: refers pain to gluteal cleft, gluteal

fold, SI joint
2. Superior to ischial tuberosity: refers pain to entire
buttock
3. Medial inferior fibres: refers pain to coccyx & gluteal cleft
O: Posterior iliac crest,
sacrum, coccyx &
sacrotuberous ligament
I: Iliotibial band (ITB) &
gluteal tuberosity of femur
A: Extension & External
Rotation of Hip & Posterior
Pelvic tilt
Upper 1/3 = abduction of
hip
Lower 2/3 = adduction of
hip
N: Inferior Gluteal nerve (L5,
S1, S2)
B: Inferior & superior gluteal
arteries
GLUTEUS MINIMUS

1. Anterior Muscle: refers pain down lateral leg, thigh &

buttock
2. Posterior Muscle: refers pain down the posterior leg,
thigh & medial buttock
Symptoms: Hip pain with a limp, difficult to find a
position of relief
O: Outer ilium (between Activation: SI dysfunction, walking too fast or too far,
sitting on wallet
anterior & inferior
gluteal lines)
I: Greater trochanter
(anterior surface)
A: Abduction of hip,
stabilizes pelvis &
prevents free limb from
dropping during gait
Anterior Fibres: Internal
rotation & flexion of hip
Posterior Fibres:
External rotation &
extension
N: Superior gluteal
nerve (L4, L5, S1)
B: Superior gluteal
artery
TENSOR FASCIA LATAE

Pain is usually referred to the hip joint, down the lateral thigh to
the knee
1.Superior Muscle Belly
O: ASIS & anterior 2. Anterior Muscle Belly
aspect of iliac crest Symptoms: hip pain (greater trochanter)< cannot walk quickly
I: Iliotibial band (below Activation: Habitual walking on a slope, prolonged sitting with hips
hyperflexed
greater trochanter)
A: Flexion, abduction &
internal rotation of hip
joint, anterior pelvic tilt
& tenses ITB to support
femur on tibia during
standing
N: Superior gluteal
nerve (L4, L5, S1)
B: Superior gluteal &
deep femoral arteries
S: Gluteus medius &
minimus and gluteus
maximus (upper fibres)
PIRIFORMIS
1. Medial Muscle: refers pain down posterior thigh &
medial buttock
2. Lateral Muscle: refers pain down the posterior
thigh & lateral buttock
Symptoms: LBP, Groin, perineum, buttock,
O: Anterior Sacrum dyspareunia, impotence
Activation: Forceful rotation while on one leg, flexing
(occasionally the hips with the knees spread apart
sacrotuberous * Note sciatic nerve (anatomical variations)
ligament)
I: Greater trochanter
(superiomedial
surface)
A: Lateral rotation of
hip, abduction of hip
when thigh is flexed
N: Nerve to piriformis
(L5, S1, S2)
B: Superior gluteal &
inferior gluteal arteries
QUADRATUS LUMBORUM
1. Deep in the angle where the crest & lower lateral rib
cage
2. Inner crest of ilium where iliocostalis lumborum fibres
attach
3. Angle where paraspinal muscles & 12th rib meet
MFTP pain referral is felt in the hips, buttocks, around SI
joint or at the base of the spine
Symptoms: LBP, Deep ache at rest, severe when
standing
O: Posterior iliac crest Activation: Awkward movement (lift), leg length inequality
& iliolumbar
th
ligament
I: 12 rib (inferior
boarder) & TPs L1-L4
A: Unilateral: elevation
of pelvis, lateral flexion
of trunk & depression
of 12th rib
Bilateral: Extension of
lumbosacral spine
(increases lumbar
lordosis)
N: Lumbar plexus (T12-
L3)
B: Subcostal & lumbar
arteries
PSOAS
1. Upper Muscle: refers pain to posterior low back
& upper medial buttock
2. Lower Muscle: refers pain down anterior thigh
& inguinal region
Symptoms: LBP, Decreased with hip flexion
O: MAJOR: TPs of L1-L5 Activation: Sitting with knees higher than hips,
joint dysfunction in the T/L region
vertebral bodies of T12-
L5 & intervening IVD
MINOR: T12-L1
vertebrae & their
related IVD
I: MAJOR Lesser
trochanter of femur
MINOR: Iliopectineal
arch
A: Flexion & external
rotation of hip, Flexion &
lateral flexion of spinal
joints, anterior pelvic tilt
(hip joint)
N: Lumbar plexus
ventral rami MAJOR: L1,
L2, L3 & MINOR: L1
B: Iliolumbar artery
(branch of internal iliac)
ILIACUS

May be located in the upper muscle & lower muscle

which both refer pain to the anterior thigh & inguinal
region
Symptoms: LBP, Decreased with hip flexion
Activation: Sitting with knees higher than hips, joint
O: Inner surface of iliac dysfunction in the T/L region
fossa & sacral ala
I: Lesser trochanter of
femur
A: Flexion & external
rotation of hip & anterior
pelvic tilt
N: Femoral nerve (L2,
L3)
B: Internal Iliac artery
GASTROCNEIUMS
Upper Medial head (most common): generally,
refers pain over the medial calf & medial
longitudinal arch of the foot
Medial & Lateral head: generally, refers pain
over the local area superiorly & inferiorly on
the ipsilateral side

O: Medial Head: above medial

condyle of femur (posterior surface)
Lateral Head: above lateral condyle
of femur (posterior surface)
I: Calcaneus (via Achilles Tendon)
A: Plantar Flexion of foot, (knee
flexion & inversion: weak)
N: Tibial Nerve (S1, S2)
B: Sural branches of popliteal artery
SERRATUS ANTERIOR

O: Ribs 1-9 (lateral Usually over the lateral inferior portion of the
surface) scapula, may experience pain in exhaling
(referral pattern may be misinterpreted as
I: Anterior medial border symptoms of lung disease and heart attacks)
of scapula
A: Protraction (abduction)
& upward rotation of
scapula & stabilizes for
upper extremity
movements
N: Long thoracic nerve
(C5, C6, C7)
B: Lateral thoracic artery,
thoracodorsal artery,
dorsal scapular artery
PECTORALIS MAJOR

Pain may extend up over subclavicular areas & may

cover the entire ipsilateral pectoral & anterior deltoid
region and radiate down the ulnar side, elbow, forearm &
hypothenar side of hand (last 3 digits)
- Note that pain can mimic a heart attack

O: Clavicular Fibres: Medial

½ of clavicle
Sternal Fibres: Anterior
Sternum
Costal Fibres: Costal
cartilage ribs 1-6
I: Lateral lip of bicipital
groove of humerus (crest of
the greater tubercle)
A: Adduction & medial
rotation of shoulder,
horizontal adduction of
shoulder & flexion of
shoulder (clavicular portion)
N: Medial & lateral pectoral
nerve (C8,T1)
B: Thoracoacromial trunk
UPPER TRAPEZIUS
Primary locations are just above the superior border of
the scapula & just inferior to the medial angle of the
scapula
Refers pain over posterolateral neck & mastoid process
O: Upper: EOP, nuchal line & May cause tension neck ache
ligament
Middle: SPs of C7-T5 Intense pain may reach temples, back of eye and angle
of the jaw
Lower: SPs of T5-T12
Pain can extend to occiput and rarely lower molar teeth
I: Lateral 1/3 of clavicle, can be accompanied by dizziness
acromion, spine of scapula
A: Elevation & retraction
(adduction of scapula),
upward rotation of scapula,
stabilization of scapula for
arm movements
Unilateral: Lateral Flexion of
head
Bilateral: Extension of head
N: Spinal accessory (CN XI),
ventral rami of C2-C4
B: Transverse cervical &
dorsal scapular arteries
SUPRASPINATUS Primary referral
- felt as a deep ache in the mid-deltoid region of the
shoulder; pain often extend down the lateral arm &
upper forearm; pain can concentrate at lateral
epicondyle; rarely pain extends to the wrist

Activation of MDTPs may occur is heavy objects are

carried with arm handing down or when lifted above
shoulder height

Associated MFTPs are commonly found in

O: Supraspinous infraspinatus & upper trapezius, anterior/ middle
fossa of scapular deltoid & latissimus dorsi
I: Greater Tubercle of
humerus (superior
facet)
A: Abduction of
shoulder, stabilizes
GH joint
N: Suprascapular
nerve (C5, C6)
B: Suprascapular
artery
SUBSCAPULARIS
Pain referral is generally over the
posterior axillary fold & medial arm
Sometimes pain referral extends down
to wrist & over mid deltoid

O: Subscapular fossa of
scapula
I: Lesser Tubercle of humerus
A: Medial rotation of shoulder,
stabilized GH joint
N: Upper & lower subscapular
nerves (C5, C6)
B: Circumflex scapular artery,
dorsal scapular artery
INFRASPINATUS
MFTPs occur mainly in muscle belly
Primary referral is to the anterior deltoid region in
shoulder joint
O: Infraspinous
fossa, inferior Pain may extend down front & lateral aspect of arm &
forearm and sometimes include the radial half of hand
portion of spine of
scapula Less commonly, pain may refer to suboccipital &
posterior cervical areas
I: greater tubercle of Rarely may refer pain over ipsilateral rhomboid muscle
humerus (middle MFTP activation: usually results from overload while
facet) reaching backward and up

A: lateral rotation of
shoulder, stabilize
GH joint
N: Suprascapular
nerve (C5, C6)
B: Suprascapular
artery, scapular
circumflex artery
S: teres minor,
deltoid (posterior
fibers)
LEVATOR SCAPULARE
Primary location for trigger points is at the angle of the
neck (where the muscle emerges from deep to the
trapezius muscle)
Secondary location for trigger points is just superior to
the scapular attachment of the muscle
Both primary and secondary location trigger points refer
pain to the angle of the neck, with a spill over zone along
the medial border of the scapula and also out to the
posterior shoulder
Symptoms: Stiff neck, unable to turn head to same side
Activation: chilling, stress and spectator neck

O: TVPs of C1-C4
I: Medial border of scapula
(superior part)
A: Elevation of the scapular,
extension & lateral flexion of
neck
N: Dorsal scapular nerve (C3,
C4, C5)
B: Dorsal scapular artery
STERNOCLEIDOMASTOID
Trigger points can be located throughout the entire
muscle belly
O: Sternal head: Primary referral zones are over the mastoid process &
manubrium of sternum supraorbital regions of the face
Clavicular head: medial
1/3 of clavicle Referred pain from these trigger points can be
misdiagnosed as tension headache, cerviocephalagia
and myofasial pain-dysfunction syndrome
I: mastoid process of Referral pain from the upper part of the SCM can cause
temporal bone disequilibrium problems

A: rotation of head to Symptoms: Tension, HA, Frontal HA

contralateral side, lateral Activation: sleeping with 2 pillows, Turing head to read
flexion to ipsilateral side, under night light
bilateral neck flexion &
capital extension
N: Motor: spinal
accessory (CN XI)
Sensory: ventral rami of
C2, C3
B: Occipital & superior
thyroid arteries
S: longus capitis &
longus cervicis
SPLEIUS CERVICUS & CAPITIS
MFTPS are generally located in the muscle belly & refer pain over the posterior
neck, above the ear at the top of the head & rare occasions even the
supraorbital region
Capitis: Pain on top of the head
Activation: Trifocals
Cervicis: Pain in neck, cranium and eye
Symptoms of still neck
Activateion: Seated with strong thoracic kyphosis or sleeping with head back

Capitis
O: SPs of C3-T4 & Nuchal
ligament (lower portion)
I: Mastoid process of
temporal bone, occipital
bone (superior nuchal line)
Cervicis
O: SPs T3-T6
I: TPs of C1-C3 (posterior
tubercles)
A:
Unilateral: ipsilateral
rotation & lateral flexion of
head & neck
Bilateral: Extension of head
(capitis) & neck
N: Cervical spinal nerves
(dorsal rami)
B: Occipital artery
S: upper trapezius,
semispinalis, longus capitis
SUBOCCIPITALS
Rectus capitis posterior MFTPs refer head pain that may be difficult to
major localize; pain is often described as being from the
O: Spine of axis (C2) occiput to the eye and forehead are a

I: Lateral portion of
nuchal line
A: Extension, ipsilateral
MFTPs typically occur when a person is
rotation & lateral flexion maintaining flexion or extension of the
of the head associated joints for a period of time
Rectus capitis posterior MFTPs are often accompanied by MFTPs in the
minor trapezius, SCM and the splenius muscles
O: Posterior tubercle of
atlas (C1)
I: Medial portion of
inferior nuchal line
A: Extension & ipsilateral
lateral flexion of head
Obliquus capitis superior
O: TVP of atlas (C1)
I: Below inferior nuchal
line (occipital bone)
A: Extension, ipsilateral
rotation & lateral flexion
of head
Obliquus capitis inferior
O: Spine of axis (C2)
I: TVP of atlas (C1)
A: Extension & ipsilateral
rotation of head
N: Suboccipital nerve
(dorsal rami of C1)
TEMPORALIS

MTFP pain referral is typically above & below

and may refer to upper teeth
Symptoms: head & tooth pain ‘teeth don’t
meet right’
Activation: Bruxism, gum chewing

O: Temporal fossa (temporal

sphenoid & frontal bone lateral
aspects & fascia)
I: Coronoid process & ramus of
mandible
A: Elevation of mandible,
retraction of mandible (posterior
fibers)
N: Trigeminal nerve (CN 5-
Mandibular branch)
B: Maxillary & superficial
temporal arteries
DELTOID

O: Lateral 1/3 of clavicle, Shoulder referral pattern

acromion & spine of scapula
I: Deltoid tuberosity of
humerus
A:
Middle fibers: abduction of
GH joint
Anterior fibers: Flexion,
horizontal adduction &
medial rotation of GH joint
Posterior fibers: Extension,
horizonal abduction& lateral
rotation of GH joint
N: Axillary nerve (C5, C6)
B: Posterior & anterior
humeral circumflex artery
deltoid branch of
thoracoacromial artery
EXTENSOR CARPI RADIALIS - MFTPs may develop in the
proximal & middle muscle belly
Main referral pattern is initially
pain over the lateral epicondyle
followed by pain radiating down
toward the forearm, wrist and
posterior hand

Longus
O: Lower lateral supracondylar ridge (below
brachioradialis)
I: base of 2nd metacarpal
A: Extension of wrist, radial flexion,
abduction of wrist
(weak flexion & supination)
N: Radial nerve (C5, C6)
B: Radial recurrent & brachial arteries

Brevis
O: Lateral epicondyle (common extensor
tendon)
I: Base of 3rd metacarpal
A: Extension and abduction of wrist (weak
flexion of elbow joint)
N: Radial nerve (C7, C8)
B: Radial recurrent artery
References

Vizniak, N.A, (2017). Quick reference

evidence informed muscle manual. Canada:
Professional Health Systems Inc.

SD4Medical. (2019). Essential Anatomy

[App dowload]. Retrieved from
https://3d4medical.com/apps/essential-
anatomy-5