Download For Immediate Relief of MUSCULAR PAIN

Advanced Manual Techniques Using
TRIGGER-& ACCUPRESSURE POINTS
For Immediate Relief of
MUSCULAR PAIN, TENSION, & DYSFUNCTION
VOLUME I
UPPER EXTREMITIES
BY
TORBJORN M. HANSON, A.c., MANUAL THERAPIST
© T. HANSON 2012
TORBJORN HANSON, A.c.
Kinesiologist & Muscle Therapist
Torbjorn has 28 years of clinical experience in manual therapy for pain or
dysfunction in muscles, tendons, ligaments and joints. He holds a degree
from Sweden in Acupuncture and Physio Therapy, and has specialized in
Trigger Point Therapy, Acupressure, Kinesiology and Sports Medicine. For
5 years he wrote a column and answered reader questions on sports injuries
in B&K Sports Magazine, Scandinavia’s largest fitness publication.
In 1994 Torbjorn founded Sports Performance Therapy Center, with a vision
to bring together diversified therapies that would get patients Better, Faster.
This state of the art physical therapy clinic is located inside Club Sport of
Pleasanton, 184,000 square foot athletic club.
He is also the founder of POSTU-Rx, a computer software program
developed to prescribe custom made exercises, to stretch short muscles, and
to strengthen elongated muscles. This program brings a new concept to
sports medicine.
His extensive work with professional and recreational athletes has led to the
development of HandsOn Muscle Therapy. A cutting edge approach to
Injury Rehabilitation and Prevention as well as Performance Enhancement.
Torjorn has been teaching his techniques to therapists and physicians
throughout Europe. His hands-on work is followed by a long record of
success and gives instant relief and functional improvement in muscles/joint
pain syndrome and sports injuries. His unique use of manual muscle testing
provides feedback that assures specific therapy for each individual and every
injury.
HansOn Muscle Therapy
H.M.T. is an advanced manual technique using trigger and acupressure points for
immediate relief of muscular pain, tension and dysfunction.
H.M.T. is a diversified system that integrates Feedback from postural evaluation, range
of motion assessment and specific muscle testing to pinpoint areas of myofascial tension.
Muscular Imbalance
Sprains, strains or micro tearing due to overuse or trauma of certain muscles leads to an
accumulation of tension, i.e. muscle shortening and adhesions.
Anytime there is muscle shortening, and subsequent muscle lengthening of the
antagonistic muscles, there is a MUSCULAR IMBALANCE. In other words, the
body is out of ALIGNMENT.
The core theory in H.M.T. is that muscular imbalance is the cause of injuries and decreased
performance.
Muscle shortening causes:
Decreased range of motion
Postural imbalances
Change joint positions with decreased joint space
Decreased vascular circulation
Inhibition of lymphatic drainage
Decreased strength
Friction, pressure, compression and excessive pulling over time leads to dysfunction,
inflammation and pain. This pain is caused by soft tissue damage or nerve entrapment and
ultimately leads to neuropathy, joint pathology and joint degeneration.
Reading Body Feedback
H.M.T. uses postural and range of motion assessments together with manual testing of individual
muscles, the recognition of referred pain patterns, and acupressure meridian distribution to
determine primary muscles with the most accumulated tension.
1
Circuit Breakers
Accumulation of tension in muscles, fascia and tendons manifest as hypersensitive myofascial
reflex points know as trigger points or acupressure points. Those reflex points act as circuit
breakers and when overloaded with excessive tension can give rise to local or referred pain.
Trigger or acupressure points are activated directly by acute overload, overwork, fatigue or direct
trauma to the muscle they are located in. Those reflex points can also be activated indirectly by
other reflex points, visceral disease, joint dysfunction, or emotional distress. Once a reflex point
is activated, repeated muscular stress of a lesser degree can activate pain in the reference zone,
especially when the muscle becomes fatigued.
Research shows that a change in electrical resistance (3) and temperature (4) can be measured at
the dermal location of a reflex point. This can be confirmed with ohm meters and thermograms.
“Getting to the Point”
There are approximately 700 acupressure points on the human body and all skeletal muscles can
develop multiple trigger points. The acupressure points have definite anatomical locations while
the trigger point locations are not fixed.
The proper point to select for therapy is not always located at the site of pain, but rather at the
site of maximal accumulated tension. Due to the number of points possibly related too an injury,
the therapeutic skill lies in the ability to select the right point(s) for each specific injury.
H.M.T. teaches the relationship between different reflex points, referred pain patterns and
acupuncture meridian distribution.
H.M.T. utilizes patient muscle feedback by the unique use of indicator muscle testing in how to
select the primary point(s) for each individual condition. This muscle feedback takes away
the “guesswork” or the “hit or miss” approach in the selection of appropriate reflex points for a
specific condition.
Re-setting The Circuit/Releasing the Tension
Once a primary reflex point has been localized, it should be released of its excessive tension with
deep friction massage. Deep intermittent digital pressure to a reflex point in a specific direction
causes a form of “depolarization”. Digital pressure on a primary reflex point will elicit local
and/or referred pain. Complete release of tension with digital pressure to a reflex point will cause
all elicit pain to completely disappear.
2
Proper release of tension in a reflex point will immediately abolish readings of changed electrical
resistance. Inactivation of the reflex point allows associated muscle(s) to return to proper tone
and hence restore muscular balance.
Releasing tension to acupressure or trigger points in shortened muscles is very effective in
reducing joint pressure and restoring range of motion. Lasting results will be achieved in
eliminating local or referred pain caused by muscle shortening. This also improves vascularity
and lymphatic drainage which stimulates the body’s natural self-curative abilities.
Due to somatovisceral effects, a release of a hypersensitive myofascial reflex point can improve
tension related visceral ailments and provide emotional release.
Some theories suggest that digital pressure applied to acupressure points may also stimulate the
nervous system to release neuro-hormones (such as endorphins). Research has documented that
this is the case with acupressure (5). This would explain the analgesic effect often experienced
with the release of an acupressure point. The analgesic effect is generally short lasting in cases of
joint or nerve pathology. In other cases however, endorphin release may break the pain cycle and
promote lasting or permanent relief.
References:
(1) Travell J. Bigelow NH: Referred somatic pain does not follow a simple “segmental”
pattern. Fed Proc 5:106, 1046.
(2) Travell J. & Simons D: Myofascial pain and dysfunction. The trigger point manual,
upper extremities. Vol. 1, pg. 15, 1983.
(3) Sola AE and Williams RL: Myofascial pain syndromes. Neurol 6:91-95, 1956.
(4) Fisher AA: Thermography and pain. Arch Phys Med Rehabil 62:542, 1981.
(5) Mayer FJ, Price DD, Barber J, et al: Acupuncture analgesia: Evidence for activation
of pain inhibitory system as a mechanism of action. In advances in pain research and
therapy, edited by J.J. Bonica, D. Albe-fessard, Vol 1 Raven press, New York 1976
(pp. 751-754).
3
Objective #1
A) Find and relieve muscular tension
B) Immediate pain relief
C) Restore normal range of motion, posture and strength.
Muscular tension will cause muscular imbalance with uneven wear and tear
to muscles, tendons and ligaments thus causing tissue damage with pain and
inflammation.
Muscular tension will cause a blockage of circulation with a relative oxygen
deprivation as well as inhibited drainage of lymphatic waste products thus
becoming the cause of muscle contraction, spasm, inflammation, pain and
swelling.
Excessive muscle tension can trap and pinch nerves thereby causing
radiating pain patterns and neuropathy.
Muscular tension results in muscular imbalance with altered posture. This
misalignment will alter joint position and space, thus causing joint pathology
and eventual joint degeneration.
Muscular tension results in muscular imbalance with inhibited range of
motion, decreased function, strength and endurance.
4
Objective #2
A) Find the underlying cause of muscular tension
B) Educate to prevent recurrence of symptoms
Physical cause:
Direct trauma
- Impact
- Sudden uncontrolled body movement
= Immediate tissue damage and tension.
Microtrauma
- Repetitive movement patterns
- Improper movement patterns
- Poor posture
- Poor sleeping position
- Improper pedal foundation
= Accumulative structural stress causing tension and eventual tissue damage.
Mental / Emotional cause:
- ongoing mental / emotional stress
- past unresolved mental / emotional stress
= Accumulative emotional stress causing chronic muscular tension and
eventual tissue damage.
Nutritional / Chemical cause:
- Nutritional deficiencies
- Dehydration
- Toxic conditions
= Lymphatic congestion and muscular tension
Environmental cause:
- Allergies
= Lymphatic congestion with muscular tension.
5
Hanson Muscle Therapy
HMT
Synopsis
Posture and Range of motion evaluation is used together
with manual testing of individual muscles and recognition
of referred pain patterns to localize muscles with
accumulated tension.
Indicator muscle testing is used as feedback to pinpoint
the exact location of active trigger points and acupoints in
muscles with accumulated tension.
Digital intermittent friction massage is used to relieve
tension and inactivate those points.
HansOn Muscle Therapy will:
A) Relieve pain and tension immediately.
B) Restore muscular balance and joint integrity.
C) Improve vascularity and lymphatic drainage to
injured tissue which will initiate healing.
6
How to LOCALIZE MUSCLES with
ACCUMULATED TENSION
Evaluate posture of pain area
Use form A:1-3 for Anterior, Posterior and Lateral view Posture Evaluation.
Reference; “Postu-Rx Manual for Muscle Imbalance” or DVD to establish
standard for normal posture. Each postural imbalance indicates which muscles are
tense / shortened or elongated.
Evaluate range of motion of the joints proximal to the pain
area.
Use form B:1 for the upper extremities, form B:2 for lower extremities and spine to
establish standard for normal range of motion.
Reference; “Postu-Rx Manual for Muscular Imbalance” or DVD to establish
standards for normal range of motion. Each range of motion imbalance indicates
which muscles are tens / shortened or elongated.
Perform manual muscle testing of muscles in pain area
Use form C:1, for testing upper extremity muscles #1-35 or form C:2 for lower
extremity and spine muscles #36-72. Each muscle will test either normal,
hypotonic/weak/elongated, or hypertonic/tense/shortened.
Reference; HMT Manual Muscle Testing manual I (upper extremity, muscles # 135), and II (lower extremity and spine, muscles #36-72).
“Muscle Testing and Function” by Kendall or “Applied Kinesiology, Synopsis” by
Walther, can also be used.
Ask the Patient where the pain is felt and fill in the
appropriate pain zones
Use form D:1, For the patient to indicate pain patterns on anterior, posterior or
lateral illustration.
7
How to prioritize which muscle to treat first
Postural Evaluation, Range of Motion Assessment, Manual Muscle Testing, Referred Pain
Patterns and Acu-Meridians is what determines which muscles have an accumulation of
tension and harbor active trigger points or AcuPoints. Use the Priority sheet (Form E) to
determine which muscle(s) are indicated the most.
Example I:
A patient presents with a right shoulder promlem.
Postural Exam:
Anterior view show a medially rotated right arm. See exam form A-1 on page #11
This indicares that the muscles that medially rotate the arms are relatively shorter (more
contracted) than the muscies that laterally rotate the arms. This also indicates that the
muscles that laterally rotate the arms are relatively elongated compared to the muscles
that medially rotate the arms.
Shortened muscles
Medial rotators of arm
#8 Pectoralis Major Clavicular
#9 Pectoralis Major Sternal
#10 Latissimus Dorsi
#12 Teres Major
#14 Subscapularis
#18 Deltoid Anterior
Elongated muscles
Lateral rotators of arm
#16 Infraspinatus
#17 Teres Minor
#20 Deltoid Posterior
Posterior view shows and elevated right scapula. See exam form A-2 on page #12
This indicates that the muscles that elevate the scapula are shortened and the muscles that
depress the scapula are elongated
Shortened muscles
Elongated muscles
#1 Trapezius Upper
#3 Trapezius Lower
#5 Levator Scapulae
(#10 Latissimus Dorsi)
#6 Rhomboids
#7 Pectoralis Minor
8
Lateral view shows a right anterior humeral head. See exam form A-3 on page #13
This indicates that the muscles that pull the humeral head anterior are shortened, and the muscles
that pull the humeral head posterior are elongated.
Shortened Muscles
Elongated Muscles
Pull humeral head anterior
Humeral head posterior
#1 Trapezius Upper
#2 Trapezius Middle
#4 Serratus Anterior
#3 Trapezius Lower
#7 Pectoralis Minor
#20 Deltoid Posterior
#8 Pectoralis Major Clavicular
#9 Pectoralis Major Sternal
#18 Deltoid Anterior
#27 Coracobrachialis
Mark form E:1 with the muscles that are shortened and elongated in the Postural Evaluation.
See example page 23.
9
10
JOE DEMO
D1
Have patient use a colored pen. “Stripe” zones with moderate pain.
“Checker” zones with severe pain.
PAIN MAPPING
PATIENT’S NAME: __________________________________________________PATIENT ID NO: 123-45-6789
____________________
A1
HansOn Muscle Therapy
POSTURAL EVALUATION
JOE DEMO
123-45-6789
PATIENT’S NAME: __________________________________________________ PATIENT ID NO: ____________________
DIAGNOSIS: _________________________________________________________________________
AGE: _________
Anterior to Posterior view (AP)
LEFT
RIGHT
DATE
DATE
EXAM BY
A
A
A
A
A
A
A
A
A
A
A
EXAM BY
1. FEET
NO. 1:1
NO. 1:2
Normal = A
Supinated = B
Pronated = C
NO. 1:3
2. LEG LENGTH
NO. 1:4
3. KNEES
NO. 1:6
4. FEMUR
NO. 1:3
Normal = A
Right Shorter = C
Left Shorter = B
NO. 1:5
Normal = A
Bowlegged = B
Knock-kneed = C
NO. 1:7
Normal = A
Medial Rotation = C
Lateral Rotation = B
5. HIPS
NO. 1:8
NO. 1:8
Normal = A
Right Higher = C
Left Higher = B
6. SHOULDERS
NO. 1:9
NO. 1:9
Normal = A
Left Higher = B
Right Higher = C
NO. 1:10
7A. TORSO ROTATION
NO. 1:10
7B. HIP ROTATION
NO. 1:11
8A. HEAD TILT
NO. 1:10
Normal = A
Right Anterior rot. = B Left Anterior rot. = C
NO. 1:10
Normal = A
Right Anterior rot. = B
Left Anterior rot. = C
NO. 1:11
Normal = A
Right Tilt = B
NO. 1:12
Left Tilt = C
8B. HEAD ROTATION
NO. 1:12
Normal = A
Turned Right = B
Turned Left = C
9. ARMS
NO. 1:14
Normal = A
Lateral Rotation = B
Medial Rotation = C
NO. 1:13
A
A
A
A
A
A
A
A
A
A
C
NOTES: ____________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Copyright© 1996-2011 Sports Performance Rehabiolitation & Fitness Systems, Tobjorn Hanson, Bertil Sultan
11
A2
HansOn Muscle Therapy
POSTURAL EVALUATION
JOE DEMO
123-45-6789
PATIENT’S NAME: __________________________________________________ PATIENT ID NO: ____________________
DIAGNOSIS: _________________________________________________________________________ AGE: _________
Posterior to Anterior view (PA)
LEFT
RIGHT
DATE
DATE
EXAM BY
A
A
A
A
A
A
A
A
A
A
A
A
A
A
NO. 2:1
EXAM BY
1. ACHILLES TENDON
NO. 2:2
Normal = A
Supinated = B
Pronated = C
2. KNEES
NO. 1:5
Normal = A
Knock-kneed = C
Bow Legged = B
NO. 1:4
3. HIPS
NO. 1:8
Normal = A
Left Higher = B
Right Higher = C
NO. 1:8
4. RIB CAGE
NO. 2:3
NO. 2:3
Normal = A
Right Side Lower = C
Left Side Lower = B
NO. 2:4 5A. ENTIRE SPINE CURVATURE NO. 2:4
Normal = A
Curve Apex Left = C
Curve Apex Right = B
NO. 2:5
5B. THORACIC SCOLIOSIS NO. 2:5
Normal = A
Curve Apex Right = B
Curve Apex Left = C
NO. 2:6
5C. LUMBER SCOLIOSIS
NO. 1:9
6. SHOULDERS
NO. 2:6
Normal = A
Curve Apex Right = B
Curve Apex Left = C
A
A
A
A
A
A
A
NO. 1:9
Normal = A
Left Higher = B
Right Higher = C
A
NO. 2:7 7A. SCAPULA ROTATION NO. 2:11
Normal = A
Superior = B
Inferior = C
A
NO. 2:8 7B. SCAPULA HOR. LEVEL NO. 2:12
Normal = A
Abducted = B
Adducted = C
NO. 2:9 7C. SCAPULA VERT. LEVEL NO. 2:13
Normal = A
Elevated = B
Depressed = C
NO. 2:10 7D. SCAPULA THORACIC NO. 2:14
STABILIZATION
Right Tilt = B
Left Tilt = C
8A. HEAD TILT
NO. 1:11
Right Tilt = B
NO. 1:12
NO. 1:11
Normal = A
Left Tilt = C
8B. HEAD ROTATION
NO. 1:12
Normal = A
Turned Right = B
Turned Left = C
A
B
A
A
A
NOTES: ____________________________________________________________________________________
Copyright© 1996-2011 Sports Performance Rehabiolitation & Fitness Systems, Tobjorn Hanson, Bertil Sultan
12
A3
HansOn Muscle Therapy
POSTURAL EVALUATION
JOE DEMO
123-45-6789
PATIENT’S NAME: __________________________________________________ PATIENT ID NO: ____________________
DIAGNOSIS: _________________________________________________________________________
AGE: _________
Lateral View
LEFT
RIGHT
DATE
DATE
EXAM BY
A
A
1. KNEES
NO. 3:2
Normal = A
Flexed = C
Hyperextended = B
2.
PELVIS
&
LUMBER
SPINE
NO. 3:3
NO. 3:3
NO. 3:1
Normal = A
Posterior tilt / lack of lumber curve = B
Anterior tilt / excess lordosis = C
NO. 3:4
A
EXAM BY
3. THORAX & HEAD POSITION
4. ABDOMEN
A
A
A
A
A
5. HEAD TILT
NO. 3:6
A
Normal = A
Posterior tilt / excess lordosis = B
Anterior tilt / straight neck = C
NO. 3:7
Posterior = B
NO. 3:9
Excessive = B
6. HUMERAL HEAD
Normal = A
7A. ELBOW FLEXION
Normal = A
A
NO. 3:5
Normal / flat = A
Protruding = B
NO. 3:6
A
NO. 3:4
Normal = A
Excess kyphosis / head forward = B
Lack of thoracic curve / head posterior = C
NO. 3:5
A
NO. 3:8
Anterior = C
NO. 3:10
Deficient = C
C
A
NOTES: ____________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Copyright© 1996-2011 Sports Performance Rehabiolitation & Fitness Systems, Tobjorn Hanson, Bertil Sultan
13
Range of Motion (ROM) Exam
Upper extremity ROM show limited and painful abduction on the right.
See exam form B-1 on page #16
This indicates The muscles responsible for the antagonistic (opposite) range of motion, the
adductors, are shortened and therefore limiting abduction. The muscles responsible for the
abduction are relatively elongated.
Shortened muscles
Shoulder adductors
#8 Pectoralis Major Clavicular
#9 Pectoralis Major Sternal
#10 Latissimus Dorsi
#12 Teres Major
#24 Triceps Long Head
#27 Coracobrachialis
Elongated muscles
Shoulder abductors
#11 Supraspinatus
#18 Deltoid Anterior
#19 Deltoid Middle
#20 Deltoid Posterior
Upper Extremity ROM shows limited and painful lateral rotation (with 90 degrees
of abduction) on the right. See exam form B-1 on page #16
This inidcates that the medial rotators of the arm are shortened and the lateral rotators are
elongated which would limit lateral rotation.
Shortened muscles
Elongated muscles
Medial rotators
Lateral rotators
#8 Pectoralis Major Clavicular
#16 Infraspinatus
#9 Pectoralis Major Sternal
#17 Teres Minor
#10 Latissimus Dorsi
#20 Deltoid Posterior
#12 Teres Major
#14 Subscapularis
#18 Deltoid Anterior
14
Cervical ROM shows that lateral flexion to the left is limited. See exam form B-3 on page #17
This indicates that the muscles responsible for lateral flexion to the left are elongated.
Muscles responsible for the antagonistic (opposite) movement, lateral flexion to the right
are shortened.
Shortened muscles
Elongated muscles
Right lateral Flexors
Left lateral flexors
#1 Trapezius Upper
#1 Trapezius Upper
#36 Sternocleidomastoid
#36 Sternocleidomastoid
#37 Scalenes
#37 Scalenes
#39 Neck Extensors
#39 Neck Extensors
Mark form E:1 with the muscles that are tested shortened and elongated in the Range Of
Motion Assessment. See example page 23.
15
B1
HansOn Muscle Therapy
RANGE OF MOTION EVALUATION
JOE DEMO
123-45-6789
PATIENT'S NAME: __________________________________________________ PATIENT ID NO: ____________________
DIAGNOSIS : _________________________________________________________________________
Upper Extremity
DATE
A
A
EXAM BY
A
A
A
A
A
A
ANAT. POSITION No. EXAM BY
Hyper Extension
60º
4:13
4:2
Flexion
180º
4:14
Range
240º
4:3
Abduction
180º
4:15
4:4
Adduction
75º
4:16
Range
255º
4:5
Lat. Rotation
90º
Shoulder 4:6
Med. Rotation
70º
Range
Horiz. Abduction
Horiz. Adduction
Range
160º
Left
A
A
A
A
No.
4:1
A
A
A
A
DATE
AVG. RANGE
MOTION
4:7
4:8
Left
4:20
Half Nelson Test
Pectoralis major Test
Pectoralis minor Test
- or +
4:23
4:12 Latissimus dorsi/Teres major Test - or +
Extension
0º
4:25
4:24
4:26
4:29
4:33
4:34
Left
4:35
4:36
4:27
Right
Flexion
Range
150º
Supination
Pronation
Range
Extension
Flexion
80 - 90º
4:31
80 - 90º
4:32 Forearm
4:28
150º
160 -180º
70º
4:37
80º
4:38
30º
4:39
Radial Deviation
Range
20º
4:40
50º
Elbow
Right
Right
Range
Ulnar Deviation
150º
C
A
A
A
180º
4:22
Forearm 4:30
Wrist
130º
- or +
4:11
Elbow
4:19
4:21
4:10
Left
Right
4:18 Shoulder
50º
A
A
C
A
4:17
- or +
4:9
AGE: _________
Wrist
A
A
A
A
A
A
A
A
The zero position is the plane of reference. When a part fails to reach the zero position, the degrees designated the joint motion obtained, are subtracted in
computing the range of motion. For reporting range of motion POSTU-Rx software program use Normal=A, Higher=B and Lower=C.
NOTES: _______________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Copyright© 1996-2011 Sports Performance Rehabilitation & Fitness Systems, Tobjorn Hanson, Bertil Sultan
16
B3
HansOn Muscle Therapy
RANGE OF MOTION EVALUATION
JOE DEMO
PATIENT'S NAME: __________________________________________________
123-45-6789
PATIENT ID NO: ____________________
DIAGNOSIS : _________________________________________________________________________
AGE: _________
SPINE
No.
AVG.
RANGE
6:1
45º
6:2
45º
MOTION
Flexion
Extension
Range
Lateral bending left
Lateral bending right
Range
Rotation/Turning left
Rotation/Turning right
Range
Flexion
Extension
Range
Lateral bending left
Lateral bending right
EXAM BY
A
A
90º
6:3
45º
6:4
45º
Cervical
Spine
90º
6:5
6:6
70º
6:7
80º
6:8
20-30º
A
A
100-110º
6:9
35º
6:10
35º
70º
6:11
45º
6:12
45º
C
A
A
A
70º
140º
Range
Anterior rotation left
Anterior rotation right
Range
DATE
Thoracic &
Lumber
Spine
90º
A
A
A
A
The zero position is the plane of reference. When a part fails to reach the zero position, the degrees designated the joint motion obtained, are subtracted in
computing the range of motion. For reporting range of motion POSTU-Rx software program use Normal=A, Higher=B and Lower=C.
NOTES: _______________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Copyright© 1996-2011 Sports Performance Rehabilitation & Fitness Systems, Tobjorn Hanson, Bertil Sultan
17
Manual Muscle Testing
Manual muscle testing revealed weakness/hypotonicity in #2 Trapezius Middle. #3
Trapezius Lower, #16 Latissimus Dorsi, and #20 Deltoid Posterior on the right side.
See exam form C-1 on page #19
Weakness/hypotonicity means that the person is unable to sustain a contraction of the
muscle being tested, it also means that the muscle is elongated.
Manual muscle testing revealed hypertonicity in #7 Pectoralis Minor, #9 Pectoralis
Major Sternal, and #14 Subscapularis on the right side.
Hypertonicity is indicated when a patient is able to sustain a contraction of the muscle
being tested, but unable to sustain the same contraction following a passive stretch.
Hypertonicity means that the muscle is shortened.
Shortened muscles
Elongated muscles
Testing weak after stretch
Testing weak
#7 Pectoralis Minor
#2 Trapezius Middle
#9 Pectoralis Major Sternal
#3 Trapezius Lower
#14 Subscapularis
#16 Infraspinatus
#20 Deltoid Posterior
Mark form E:1 with the muscles that tested shortened/Hyper Tonic or Elongated /
Hypotonic on Manual Muscle Testing. See example page 23.
18
C1
HansOn Muscle Therapy
UPPER EXTREMITY MUSCLE CHART
JOE DEMO
123-45-6789
PATIENT’s NAME _________________________________________ PATIENT ID NO __________________________
LEFT
RIGHT
EXAMINER DATE
#1
C2, 3, 4 - Trapezius, upper - S.I, U.B., G.B.
#2
C2, 3, 4 - Trapezius, middle - S.I., U.B., T.W.
#3
C2, 3, 4- Trapezius, lower - U.B.
#4
C5, 6, 7, 8 - Serratus anterior - Lu, Sp, P., G.B.
#5
C3, 4, 5 - Levator scapulae - S.I.
#6
C4, 5 - Rhomboids - U.B.
#7
C6, 7, 8, T1 - Pectoralis minor - Lu, St., Sp., P.
#8 C6,7,8,T2 - Pectoralis major (Clavicular division) - Lu.,St.,Sp.,K.
#9
C6,7,8,T2 - Pectoralis major (Sternal division) - St.,Sp.,K.,P.
#10
C6, 7, 8 - Latissimus dorsi - U.B., G.B.
#11
C4, 5, 6 - Supraspinatus - L.I., S.I., T.W.
#12
C5, 6, 7 - Teres major - S.I.
#13
Shoulder medial rotators
#14
C5, 6, 7 - Subscapularis - H.
#15
Shoulder lateral rotators
#16
C4, 5, 6 - Infraspinatus - S.I.
#17
C5, 6 - Teres minor - T.W.
#18
C5, 6 - Deltoid anterior - L.I.
#19
C5, 6 - Deltoid middle - L.I., T.W.
#20
C5, 6 - Deltoid posterior - S.I., T.W.
#21
C5, 6 - Biceps long head - Lu., P.
#22
C5, 6 - Biceps short head - Lu., P.
#23
C5, 6 - Brachialis - Lu., H., P.
#24
C7, 8 - Triceps long head - S.I., T.W.
#25
C7, 8 - Triceps medial head - L.I., S.I., T.W.
#26
C7, 8 - Triceps lateral head - T.W.
#27
C6, 7 - Coraco brachialis
#28
C5, 6 - Brachioradialis - Lu., L.I.
#29
C5, 6, 7 - Supinators - Lu., L.I.
#30
C6, 7 - Pronator teres - P.
#31
C7, 8, T1 - Pronator quadratus - Lu., H., P.
#32
C6, 7, 8 - Flexor carpi radialis - P.
#33
C7, 8, T1 - Flexor carpi ulnaris - H.
#34
C5, 6, 7, 8 - Extensor carpi radialis - T.W.
#35
C6, 7, 8 - Extensor carpi ulnaris - S.I., T.W.
#1
#2
#3
#4
#5
#6
#7
#8
#9
#10
#11
#12
#13
#14
#15
#16
#17
#18
#19
#20
#21
#22
#23
#24
#25
#26
#27
#28
#29
#30
#31
#32
#33
#34
#35
ABBREVIATION KEY: ↓= Hypotonic when manually tested, GRADING SCALE; ↓0 = Gone, no contraction felt, ↓1= Trace; muscle can be felt to tighten, but
cannot produce movement, ↓2 = Poor; produces movement with gravity eliminated, but cannot function against gravity, ↓3 = Fair; can raise part against gravity.
↓4 = Good; can raise part against outside resistance as well as against gravity, 5 = Normal; can overcome a greater amount of resistance than a “good” muscle,
↑ = Hypertonic when manually tested, F = Flexibility/Stretching Exercise, S = Strengthening Exercise, TP = Trigger Points, TP = Trigger Points with referred
pain, s.c.s. = Strain Counter Strain, i.m. = Ice Massage.
Copyright© 2011 Sports Performance Rehabilitation & Fitness Systems, Tobjorn Hanson, Bertil Sultan
19
Primary Pain Zone
This manual uses Travell & Simons “Myofascial pain syndromes” Vol. I and II as a reference
for trigger points and their Local and Referred Pain Patterns (RPP).
Since there are so many trigger points and muscles to take into account plus the fact that so many
of those pain patterns overlap each other, there is a need for a helping tool.
HMT uses 7 Pain Zones. The patient mark where they experience their pain on form D:1 (see
example page 10). On this form there is an outline drawing of a man seen in Front, Bank, Right
and Left view. The drawings has been divided into 7 zones (see page 21). A key for each zone
will indicate all muscles who has trigger points that refer pain into that zone. The zone or zones
the patient has marked on form D:1 will give an indication on muscles that should be checked and
cleared of trigger points. The patient fill in where their greatest pain is felt. They are instructed
to mark strips for moderate pain and checkered for severe pain in the appropriate zones.
In the example the patient has marked the posterior pain zone “II”, the posterior portion of shoulder.
This pain could be caused by local trigger points or acu-points in the muscles located in this
zone or by remote trigger points referring pain into this zone.
Trigger points in muscles #5 Levator scapulae, #11 Superspinatus, #12 Teres Major, #14 Subscapularis,
#17 Teres Minor, #20 Deltoid Posterior, #24 Triceps Long Head, and #37 Scalenes can all cause
pain into the posterior shoulder of zone “II” (See pages 30-41)
20
21
I
II
III
IV
7 PAIN ZONES
V
VI
VII
Prioritizing Muscles to Treat
Primary or active trigger points and acu-points are more frequently found in the
shortened/hypertonic muscles.
After examining posture, assessing range of motion and manually testing the muscles of
the shoulder and taken the patients marked pain zones with muscles that refer pain into
the same area as the patients complaint is taken under consideration. Eight muscles were
indicated as shortened (hypertonic) with higher frequency than others.
#9 Pectoralis Major Sternal was indicated 5 times.
#12 Teres Major was indicated 4 times.
#14 Subscapularis was indicated 4 times.
#8 Pectoralis Major Clavicular was indicated 4 times.
#10 Latissimus Dorsi was indicated 4 times.
#1 Trapezius Upper was indicated 3 times.
#7 Pectoralis Minor was indicated 3 times.
#9
#12
#14
#8
#10
#1
#7
IIII
IIII
IIII
IIII
IIII
lll
lll
See pages 23 and 24 showing Priority Form E:1 and E:2.
This example shows how integration of postural evaluation, range of motion assessment,
manual muscle testing, recognition of referred pain patterns and acu puncture meridians
will help us prioritize which muscles to check and clear from trigger and acu-points.
Primary active trigger points or acu-points will be found in one of those muscles.
In HMT all muscles that have been indicated as shortened or hypertonic can be treated.
Treatment consist of releasing trigger and acu-points in shortened muscles as well as
giving the patient the home stretching (Flexibility) exercise to prevent the muscles from
shortening again and hence help the treatment last.
22
UPPER EXTREMITY
#9 –
PECTORALIS MAJOR
STERNAL
▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬
▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬
Origin: Anterior surface of the sternum, cartilage of the first six or seven ribs,
aponeurosis of the External Oblique.
Insertion: Crest of the greater tubercle of the humerus. The fibers twist on themselves
and are more posterior and cranial in comparison to the clavicular fibers.
Action:
Adducts and medially rotates humerus. Horizontally adducts humerus towards the
contralateral anterior superior iliac spine.
Reversed origin-insertion and change of action:
The Pectoralis Major Sternal may assist in elevating the thorax as in forced inspiration. In
crutch walking or in parallel bar work, it will assist in supporting the weight of the body.
Myotatic unit / Synergists & Antagonists:
Adduction of humerus:
Synergists: #8 Pectoralis Major Clavicular, #10 Latissimus Dorsi, #12 Teres Major, #24
Triceps Long Head, #27 Coracobrachialis.
Antagonists: #11 Superspinatus, #18 Anterior Deltoid, #19 Middle Deltoid, #20 Posterior
Deltoid.
Medial rotation of humerus:
Synergists: #8 Pectoralis Major Clavicular, #10 Latissimus Dorsi, #12 Teres Major, #14
Subscapularis, #18 Anterior Deltoid.
Antagonists: #16 Infraspinatus, #17 Teres Minor, #20 Posterior Deltoid.
Horizontal adduction of the humerus:
Synergists: #8 Pectoralis Major Clavicular.
Antagonists: #2 Middle Trapezius, #3 Lower Trapezius.
Nerve Suppy: Lateral and medial pectoral, C6, C7, C8, T1
9:1
I
I
I
II
II
TP III
22
TP IV
9:2
#9 Pectoralis Major Sternal
I
III
II
9:3
Entrapments:
Entrapment of a lymph duct by passage between tense, shortened fibers of an involved
Pectoralis Major Sternal may cause edema of the breast. These signs of entrapped
lymphatic drainage and breast tenderness are relieved by extinction of the related TP’s.
Pectoralis Major Sternal Trigger Points:
TP’s are localized through the Pectoralis Minor against the chest wall. Trigger points in
the Pectoralis Minor may be distinguished from Pectoralis Major by the fiber direction of
palpable bands (TP’s).
TP I :
Location: Three trigger points are found in the lateral portion of the muscles sternal
division. Between the 2nd and 4th ribs approximately 4.5-5.5 cun lateral to the center of
the sternum.
Referred Pain Pattern: Anterior chest, down the inner aspect of the arm, accented pain
in the area of the medial epicondyle. In severe cases the pain will travel to the volar
aspect of the forearm and the ulnar side of the hand, the last 2 of 2½ digits usually
innervated by the sensory fibers of the ulnar nerve.
TP II:
Location: Two trigger points are found in the medial sternal section, 0.5-1.5 cun lateral
to the center of the sternum, between the 3rd and 4th rib.
Referred Pain Pattern: Locally in the medial portion of the muscle, and over the
sternum without crossing the midline.
TP III:
Location: Two trigger points are found in the costal/abdominal section of the muscle at
the lateral free margin of the muscle approximately 5-6 cun lateral to the center of the
sternum in the region of the 4th intercostals space.
Referred Pain Pattern: Pain in the lower anterior chest, breast tenderness with
hypersensitivity of the nipple, intolerance to clothing and often breast pain.
TP IV:
Location: One trigger point is located medially in the costal/abdominal section of the
muscle. The same location or nearby the K. 22 acupuncture point, in the 5th intercostals
space, 2 cun lateral to the center of the sternum.
Referred Pain Pattern: Local spot tenderness associated with ectopic cardiac rhythms,
but not with any pain complaint.
When active trigger points occur in the left pectoralis major, the referred pain can easily
be confused with coronary insufficiency. All patients with those symptoms should be
checked by their physician to clear any cardiac disease or dysfunction.
It is possible for coronary artery insufficiency or other intrathoracic organ
diseases/dysfunctions to create viscerosomatic satellite trigger points in the skeletal
muscles of the anterior chest wall. Caution must be taken so that release of trigger points
in this area are not masking any organ pathology, always refer to the patients physician
when in doubt.
9:4
On the other hand it is possible for active trigger points to mimic pai patterns of cardiac
or gallbladder pathology without any organ dysfunction to be found. Release of those
trigger points will permanently relieve symptoms.
Associated Trigger Points:
#2 Middle Trapezius, #4 Serratus Anterior, #6 Rhomboids, #7 Pectoralis Minor, #8
Pectoralis Major Clavicular, #10 Latissimus Dorsi, #14 Subscapularis, #17 Teres Minor,
#18 Anterior deltoid, #20 Posterior deltoid, #27 Coracobrachialis, #36
Sternocleidomastoid, #37 Scalenes.
Satellite Trigger Points:
#7 Pectoralis Minor, #8 Pectoralis Clavicular, #10 Latissimus Dorsi, #14 Subscapularis,
#30 Pronator Teres, #32 Flexor Carpi Radialis, #33 Flexor Carpi Ulnaris. These muscles
lie within the zones of referred pain from TP’s in the Pectoralis Major Sternal.
Pain experienced in the Pectoralis major clavicular can be of a referred nature from
trigger points in the following muscles:
#4 Serratus Anterior, #7 Pectoralis Minor #37 Scalenes.
Acupuncture Meridians:
Stomach (St.), Spleen (Sp.), Kidney (K.), Pericardium (P.)
Pectoralis Major sternal Local Acupuncture points:
St. 15:
Location: In the 2nd intercostal space on the mammillary line.
Indications: Cough, asthma, fullness in the chest, mastitis.
St. 16:
Location: In the 3rd intercostals space on the mammillary line.
Indications: Cough, asthma, fullness of the chest, mastitis.
St. 17:
Location: In the center of the nipple, in the 4th intercostals space.
Indications: Therapy is contraindicated.
St. 18:
Location: In the 5th intercostals space on the mammillary line.
Indications: Cough, Asthma, mastitis, lactation deficiency, pain in the chest.
Sp. 18/TP:
Location: 2 cun lateral to the nipple, in the 4th intercostals space.
Indications: Sensation of fullness and pain in the chest, cough, mastitis, lactation
deficiency.
9:5
Sp. 19:
Location: In the 3rd intercostal space, 6 cun lateral to the center of the sternum.
Indications: Sensation of fullness and pain in the chest and hypochondriac region.
K. 22/TP
Location: In the 5th intercostals space, 2 cun lateral to the center of the sternum.
Indications: Cough, Asthma, local point tenderness associated with ectopic cardiac
rhythms.
K. 23
Location: In the 5th intercostals space, 2 cun lateral to the center of the sternum.
Indications: Cough, Asthma, sensation of fullness in the chest and hypochondriac region,
mastitis.
K. 24
Location: In the 4th intercostals space, 2 cun lateral to the center of the sternum.
Indications: Cough, Asthma, sensation of fullness in the chest and hypochondriac region,
mastitis.
K. 25
Location: In the 3rd intercostals space, 2 cun lateral to the center of the sternum.
Indications: Cough, Asthma, chest pain.
K. 26
Location: In the 1st intercostals space, 2 cun lateral to the center of the sternum.
Indications: Cough, Asthma, sensation of fullness in the chest and hypochondriac region.
P. 1/TP
Location: 1 cun lateral to the nipple in the 4th intercostals space.
Indications: Suffocating sensation in the chest, pain in the hypochondriac region,
swelling and pain of the axillary region.
9:6
UPPER EXTREMITY
#12 -
TERES MAJOR
▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬
▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬
Origin: Dorsal surface of the inferior angle and lower third of the lateral border of the
scapula.
Insertion: Crest of the lesser tubercle of humerus.
Action:
Medially rotates, adducts, and extends the shoulder joint.
Reversed Origin-Insertion and Change of Action: When arm is fixed, Superior
rotation of the glenoid cavity.
Myotatic unit / Synergists & Antagonists:
Medial rotation of the Humerus:
Synergists: #8 Pectoralis major clavicular, #9 Pectoralis major sternal, #10 Latissimus
dorsi, #14 Subscapularis, #18 Anterior deltoid.
Antagonists: #16 Infraspinatus, #17 Teres minor, #20 Posterior deltoid.
Adduction of the Humerus:
Synergists: #8 Pectoralis major clavicular, #9 Pectoralis major sternal, #10 Latissimus
dorsi, #24 Triceps long head, #27 Coracobrachialis.
Antagonists: #11 Superspinatus, #18 Anterior deltoid, #19 Middle deltoid, #20 Posterior
deltoid.
Extension of the Humerus:
Synergists: #10 Latissimus dorsi, #20 Posterior deltoid, #24 Triceps long head.
Antagonists: #8 Pectoralis major clavicular, #18 Anterior deltoid, #21 Biceps long head,
#22 Biceps short head, #27 Coracobrachialis.
Glenoid Cavity rotated superiorly:
Synergists: #1 Upper Trapezius, #3 Lower trapezius, #4 Serratus anterior.
Antagonists: #5 Levator scapula, #6 Rhomboids, #10 Latissimus dorsi.
Nerve Supply: Lower subscapular, C5, C6, C7.
Teres Major Trigger Points:
TP I :
Location: In the posterior axillary fold, 1.5 cun into the axilla, where the Latissimus
dorsi wraps around the Teres major.
12:1
PT . I
II
12:2
#12 Teres Major
II
I
12:3
TP II:
Location: Close to the origin of the muscle on the inferior angle of the scapula.
Referred Pain Pattern: Posteriorly into the shoulder joint, occasionally to the dorsal
forearm.
Associated Trigger Points:
#10 Latissimus dorsi, #14 Subscapularis, #16 Infraspinatus, #17 Teres minor, #18
Anterior deltoid, #24 Triceps long head.
Satellite Trigger Points:
#11 Supraspinatus, #16 Infraspinatus, #17 Teres minor, #18 Anterior deltoid, #34
Extensor carpi radialis, #35 Extensor carpi ulnaris.
Pain experienced in the Teres Major can be of a referred nature from trigger points
in the following muscles:
#4 Serratus anterior, #5 Levator scapula, #10 Latissimus dorsi, #11 Supraspinatus, #14
Subscapularis, #16 Infraspinatus, #17 Teres minor, #20 Posterior deltoid, #24 Triceps
long head, #37 Scalenes.
Acupuncture Meridians:
Small Intestine (S.I.)
Teres Major Local Acupuncture points:
S.I. 9:
Location: Posterior and inferior to the shoulder joint. When the arm is adducted, the
point is 1 cun above the posterior end of the axillary fold.
Indications: Pain in the scapular region, pain and motor impairment of the hand and arm.
12:4
UPPER EXTREMITY
#14 -
SUBSCAPULARIS
▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬
▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬▬
Origin: Subscapular fossa of the scapula.
Insertion: Lesser tubercle of the humerus and shoulder joint capsule.
Action:
Medially rotates the shoulder joint, and stabilizes the head of the humerus in the glenoid
cavity, preventing it from subluxating anteriorly during movements of this joint.
Myotatic unit / Synergists & Antagonists:
Medial rotation of the Humerus:
Synergists: #8 Pectoralis major clavicular, #9 Pectoralis major sternal, #10 Latissimus
dorsi, #12 Teres major, #18 Anterior deltoid.
Antagonists: #16 Infraspinatus, #17 Teres minor, #20 Posterior deltoid.
Nerve Supply: Upper and lower subscapular, C5, C6, C7.
Subscapular Trigger Points:
TP I:
Location: Deep in the posterior axillary fold on the anterior portion of the scapula, close
to its lateral border and the muscle insertion. It lies 3 fingers into the axilla.
TP II:
Location: Deep in the axilla, on the anterior portion of the scapula, approximately at the
mid-scapular level.
TP III:
Location: On the anterior portion of the scapula, real deep, medial to TP I.
To palpate those TP’s, the arm must be abducted as much as possible (in involved cases
the patient may only be able to abduct the arm to 30 degrees). The scapula must be
abducted by the therapist causing traction by pulling the arm or scapula laterally.
Referred Pain Pattern:
Severe pain both at rest and on motion. The essential zone lies over the posterior aspect
of the shoulder, spillover reference zones cover the scapula and extends down the
posterior aspect of the arm to the elbow, frequently the pain refers like a strap around the
wrist.
14:1
Insert Subscapularis Picture
TP. I
III
II
14:2
#14 Subscapularis
I
III
II
14:3
Associated Trigger Points:
#8 Pectoralis major clavicular, #9 Pectoralis major sternal, #10 Latissimus dorsi, #12
Teres major, #16 Infraspinatus, #18 Anterior deltoid, #20 Posterior deltoid, #24 Triceps
long head.
Satellite Trigger Points:
#10 Latissimus dorsi, #12 Teres major, #16 Infraspinatus, #17 Teres minor, #19 Middle
deltoid, #20 Posterior deltoid, #24 Triceps long head, #25 Triceps medial head, #26
Triceps lateral head, #31 Pronator quadratus. Those muscles lie within the zones of
referred pain from TP’s in the subscapularis.
Pain experienced in the Subscapularis can be of a referred nature from trigger
points in the following muscles:
#4 Serratus anterior, # 7 Pectoralis minor, #9 Pectoralis major sternal, #10 Latissimus
dorsi, #16 Infraspinatus.
Acupuncture Meridians:
Heart (H.)
Subscapularis Local Acupuncture points:
H. 1:
Location: In the center of the axilla, on the medial side of the axillary artery.
Indications: Pain in the costal and cardiac regions, scapula, cold and pain in the elbow
and arm.
14:4