Download Trigger Points

Muscle
TP location
Referral
Misdiagnosis
Special features
Levator Scapulae
(1) Superior Angle
Angle of the neck with
spillover to medial
boarder of scapula
Joint dysfunction of the
cervical spine
Produces classic Stiff
Neck.
TVPs of C1-4
(2) Angle of the neck
to
Medial border of the
scapula from the root
of spine to superior
angle
Scalenes
Anterior neck
Anterior: 1st rib
to
TVPs of C3-C6
Patient unable to shoulder
check.
Finger-like projections Cervical Disc syndrome Pain not usually felt in the
over pec region, upper
scalenes, just in the
limb down to finger and Cervical spine joint
referral zone. thumb. dysfunction
Produce TOS. Medial boarder of
Angina (left side)
scapula, most common
Phantom pain in
to cause pain here.
Costoclavicula
amputated arm
syndrome
Entrapment of nerve roots
Pec minor syndrome
that contributr to long
thoracic nerve
Bursitis
Middle: 1st rib
to
TVPs of C2-C7
Posterior: 2nd rib
to
TVPs of C5-C7
Shoulder tendinitis
Infraspinatus
Deep pain to front of
shoulder, down
anterolateral arm Infraspinous fossa
to
Greater tubercle of
the humerus
Radial aspect of hand Rotator cuff lesions
Can contribute to frozen
Oseoarthitis of the
sholder joint
hand and finger extensors.
Rotator cuff lesions
Shoulder bursitis
Problems here not noticed
unless other issues are
resolved. Rotator cuff tendinitus
or tears
Supraspinatus and
Infraspinatus share the
referral zone. shoulder. Cervical disc syndrome Causes satelites in the
Medial boarder of the
scapular
Teres Minor
Middle of muscle
Pain Local to tendon
attachment
Superior 1/2 of lateral
border of scapula
to
greater tubercle of
humerus
Supraspinatus
Supraspinous fossa
to
Greater tubercle of
the humerus
Cervical disc syndrome
Belly and lateral to
acromion hood
Deep ache in mid
deltoid area
Spillover into arm and
elbow
Can cause altered
sensation in the ring finger,
or cause quadrilateral
space syndrome (axillary
nerve entrapment)
Shoulder bursitis
Infra is usually a deeper
Cervical disc syndrome ache.
Frozen shoulder
Lateral epicondylitis
Subscapularis
Local
Subscapular fossa
to
Lesser tubercle of
humerus
Band of pain on dorsal
wrist
Frozen Shoulder
Signature refferral is band
of pain on dorsal wrist. Rotator Cuff lesions
TrPs here key to recovery
Bursitis
from frozen shoulder
Arthritis
Bicipital tendinitus
Cervical disc syndrome
TOS
Muscle
TP location
Referral
Misdiagnosis
Rhomboids
Medial Border of the
scapula
Local
Fibromyalgia
Deep into posterior
deltoid, over long head
of tricept
GH or AC joint
dysfunction
Major: SP of T2
through T5
to
Medial border of the
scapula from root of
spine to inferior
angle
Special features
Medial Border of the
scapula
Minor: SP of C7
through T1
to
Medial border of the
scapula at the root of
spine
Teres Major
Infer. angle and infer.
1/3 of lat. border of
scapula
to
Medial lip of bicipital
groove of the
humerus
Near scapula
attachment
Near humeral
attachment
Rotator Cuff disease
Latissimus Dorsi
Ache in inferior angle of
scapula and mid
thoracic region
SP of T7-L5, post
sacrum, post illiac
crest (all via
thoracolumbar
fascia)
to
lowest 3-4 ribs and
infer. angle of
scapula
to
medial lib of bicipital
groove of humerus
Serratus Posterior
Superior
Spinous processes
of C7-T3
to
Ribs 2 through 5
Serratus Posterior
Inferior
Deltoid strain
TrPs here are relatively
uncommon
Posterior Shoulder
Down medial aspect of
the arm, forearm,
hand ,ring and little
finger
Cervical disc syndrome
TOS
Entrapment of the
suprascapular nerve
Bicipital tendernitis
Under superior angle of Deep scapular pain
CDS
the scapular
Post. border of deltoid
TOS
and long head of triceps
to olecranon
Elbow joint dysfunction
Feeling of numbness/pain
in the little finger of the
hand (signature sign)
ulnar side of forearm,
hand and little finger
Around the mid point of
rib 11
Local
Kidney disease
Rib joint disfunction
Spinous processes
of T11-L2
to
ribs 9-12
Anterior Deltoid
Lateral 1/3 of clavicle
to
Deltoid tuberosity of
the humerus
Mid-muscle
Local
GH joint arthritis
Bursitis
Rotator cuff ten
Bicipital ten.
C5 nerve compression
TrPs never exist by
themselves and almost
never are the primary
cause of shoulder pain,
usually satellite to
scalenes, pec major, RC
muscles, lats, teres Mj
Muscle
TP location
Referral
Misdiagnosis
Special features
Middle/Lateral
Deltoid
Bipennate - can be
anywhere
Local
GH joint arthritis
Bursitis
Middle deltoid are most
common (compared to
anterior and posterior)
because it is the largest
part and works the hardest
GH joint arthritis
Bursitis
TrPs never exist by
themselves and almost
never are the primary
cause of shoulder pain,
usually satellite to
scalenes, pec major, RC
muscles, lats, triceps
GH joint arthritis
Can be satellite from
infraspinatus or subclavius
Acromion process
to
Deltoid tuberosity of
the humerus
Posterior Deltoid
Rotator cuff ten
Mid muscle
Local
Spine of scapula
to
Deltoid tuberosity of
the humerus
Bicept Brachii
Rotator cuff ten
Either head or miid
muscle
Front of shoulder and
crease of elbow
Supraglenoid
tubercle (long head)
and coracoid process
(short head) of
scapula
to
Radial tuberosity and
the deep fascia
overlying the CET
Brachiallis
Distal half of anterior
surface of humerus
to
the tuberosity and
coronoid process of
ulna
Tricept Brachii
Bursitis
Tendonitis
C5 compression
Under outer edge of
bicepts just above
crease of elbow
Primarily base of thumb Bicipital tendonitis
Anterior shoulder
Just below crease of
elbow
1. Inner edge of tricepts 1.Posterior shoulder,
lateral elbow, when
2. Lateral elbow
severe upper traps and
base of neck
3. Lateral Head
2. Down posterior arm
4. Near elbow
(medially)
3. Posterior upper arm
Infraglenoid tubercle
of scapula (long
head) and the
posterior shaft of the
humerus (lateral and
medial head)
to
Olecranon process of 5. Near elbow
ulna
(centrally)
4. Elbow hypersensitive
to touch
C5 or C6 nerve
compression
TrP can cause entrapped
radial nerve
Many muscles refer pain to
thumb but brachialis and
Carpal tunnel syndrome scalenes are the prime
suspects
Elbow joint arthritis
1. Most common TrP
TOS
2. Can mimic tennis elbow
C7 Nerve compression 3. TrP here can compress
radial nerve
Olecranon bursitis
4. Elbow hypersensitivity
5. Can mimic golfers elbow
5. Medial elbow and
forearm
Brachioradialis
Proximal 2/3 of lateral
supracondylar ridge
of humerus
to
Styloid process of
radius
Mid-muscle
Lateral epicondyle
Lateral epicondylitis
Down lateral forearm
C5 or C6 nerve
compression
Base of thumb
DeQuervain's
tenosynovitis
TrPs in this muscle are
difficult to differentiate from
the supinator and ext. carpi
rad. longus
Muscle
TP location
Referral
Misdiagnosis
Special features
Extensor Carpi
Ulnaris
Mid-muscle (just beow
elbow)
Ulnar side of wrist and
hand
Wrist dysfunction or
arthitis
Feel like a wrist sprain
Lateral epicondyle of
the humerus (via
CET) and posterior
ulna
to
Base of 5th
metacarpal (posterior
surface)
Extensor Carpi
Radialis Longus and
Brevis
Longus: Lat.
supracondylar ridge
of humerus
to
Base of 2nd MCP
(post)
Carpal tunnel syndrome
C7 or C8 nerve
compression
Longus: Lateral side of
elbow crease
3-4 inches down rom
the elbow
Longus: burning pain to
lateral side of forearm
and back of wrist and
hand
Wrist dysfunction or
arthitis
Brevis: Dorsum of wrist
and hand
C7 or C8 nerve
compression
Carpal tunnel syndrome
DeQuervain's
tenosynopvitis
Brevis: Lat.
epicondyle of
humerus (via CET)
to
Base of 3rd MCP
(post)
Extensor Digitorum
Lat. epicondyle of
humerus (CET)
to
Posterior middle and
distal phalanges of
fingers 2-5
Supinator
Proximal 1/3 of muscle, Lateral elbow
very deep
PIP of 3rd and 4th
fingers
Arthitis of the fingers
C7 or C6 nerve
compression
Referred pain into dorsum
of hand and fingers
correspond with
associated muscle fibers,
most common fibers of ring
and middle finger
Carpal tunnel
dysfunction
Mid-muscle
Lat. epicondyle of
humerus and
supinator crest of
ulna
to
Prox. 1/3 of radius
Palmaris Longus
Lat. epicondylitis
Lateral epicondyle
Lat. epicondylitis
Base of thumb
C5 or C6 nerve
compression
TrPs here can entrap radial
nerve
Difficult to differentiate
from brachioradialis and
ext. carpi rad. longus TrPs
DeQuervain's
tenosynovitis
Most common TrPs that
cause lateral epicondyle
pain
Mid-Belly (mid-arm
anterior)
Medial epicondyle of
humerus (via CFT)
to
Palmar aponeurosis
Palm
Base of thumb
TOS
Distal crease of palm
Carpal tunnel syndrome
Medial Epicondylitis
Associated with
Dupuytren's contracture
Ulna side of wrist
Medial Epicondylitis
Entrapment of ulnar nerve
Sometimes lower half of
forearm
Flexor Carpi Ulnaris
Medial epicondyle of
humerus (via CFT)
and prox. 2/3 of ulna
to
Base of 5th MCP,
pisiform, and hook of
hamate (anterior)
Mid-Belly
Spillover into forearm
and palm
TOS
Carpal tunnel syndrome
Wrist joint dysfunction
Ulna nerve compression
Muscle
TP location
Referral
Misdiagnosis
Flexor Carpi Ridialis
Mid-belly
Radial aspect of crease
of wrist
Medial Epicondylitis
Medial epicondyle of
humerus (via CFT)
to
Base of 2nd and 3rd
MCP (anterior)
Near medial elbow
FDS & FDP
Spillover into forearm
and palm
Special features
TOS
Carpal tunnel syndrome
Wrist joint dysfunction
Upper half of anterior
forearm, very deep
Anterior aspect of
fingers and beyond
FDS: Medial epi of
humerous (via CFT),
coronoid process of
ulna and prox 1/2 of
ant. radius
to
Ant. surface of
middle phal. 2-5
TOS
Carpal Tunnel
Pronator Teres
syndrome
Joint disfunction or
arthritis of MCP and IP
joints
Associated with Trigger
finger
No distinction btwn TrPs
within FDS and FDP
Referral can be felt beyond
the fingers
FDP: Prox. 1/2 of ant.
surface of ulna and
interosseus mem.
to
Ant surface of distal
phal. 2-5
Pronator Teres
Medial side of cubital
fossa
Medial epicondyle of
humerus (via CFT),
medial supracondylar
ridge of humerus,
coronoid process of
ulna
to
Middle 1/3 of lateral
radius
Flexor Pollicis
Longus
Lateral side of wrist and
forearm
Base of thumb and
medial forearm
TOS
Carpal Tunnel
May entrap median nerve
Medial epicondylitis
Referral can be felt beyond
the thumb
Wrist joint dysfunction
Several TrPs along
middle to distal radius
Anterior thumb and
beyond
Ant. surface of distal
radius and
interosseus mem.,
the coronoid process
of ulna and medial
epicondyle of
humerus
to
ant. base of the distal
phalanx of the thumb
Adductor Pollicis
Medial epicondylitis
TOS
Carpal Tunnel
Osteoarthritis of the
thumb
Distal aspect of thenar
eminence
Capitate, 2nd and 3rd
MCP Multiple are likely
to
Base of proximal
phalanx of thumb
Lateral aspect and base DeQuevain's
of the thumb
tenosynovitis
Spillover to thumb and
web space
CDS
TOS
Carpal tunnel
Joint dysfunction or
osteoarthritis of 1st
CMC or MCP
Opponens Pollicis
Mid-belly
Flexor retinaculum,
Multiples are likely
tubercle of trapezium
to
Ant. and lat. border
of the 1st MCP
Thumb and radial side
of wrist (both on palmer
side)
DeQuevain's
tenosynovitis
CDS
Carpal tunnel
osteoarthritis of 1st
CMC
Muscle
TP location
Referral
Misdiagnosis
Special features
Dorsal Interosseous
Accessable through
palm
For 1st, along the side
of the finger that it
attaches to, deeply into
the dorsum and through
palm ofhand may
extend along dorsal
side of 5th finger
CDS
TrPs are difficult to resolve
here
Proximally to both
side of ajacent MCPs
of fingers 1 through
5; distally, each one
attaches to one side
of the proximal
phalanx and to
tendon of ext.
digitorum
For 2-4, along side the
finger that attaches to.
TOS
Carpal tunnel
Joint dysfunction or
osteoarthritis of the
fingers
Most pain at DIP joint
TFL
Anterior illiac crest
and ASIS
to
ITB
Rectus Femoris
AIIS to the tibial
tuberosity
Just proximal to GT
Over GT, may go down
(one more anterior, one lateral thigh as far as
more lateral)
knee
Linea aspera of
femur
to
Tibial tuberosity
Vastus Intermedius
Linea aspera of
femur
to
Tibial tuberosity
Vastus Lateralis
Linea aspera of
femur to
Tibial tuberosity
SI joint syndrome Meralgia paresthetica
(1)close to superior
attachment – most
common
(1)Deep in knee (2)Deep ache above
knee and local
(1)Anterior/medial
thigh, just above knee
(1)Knee
(2)mid/ant thigh
Vastus Medialis
Trochanteric bursitis
Knee joint dysfunction
(arthritis, tendinitis,
sprain), Contribute to restless
leg syndrome(RLS)
(2)anterior medial thigh
Knee joint dysfunction
(arthritis, tendinitis,
sprain)
(2)Anterior/medial
thigh(midway)
Anterior thigh, 1/3 of
way down under rectus
femoris
Weakness may cause
knee buckling when
walking
TrPs in VM are very
common in runners
Weakness may cause
knee buckling when
walking
Most intense at upper/
mid-thigh
Not usually into knee
Knee joint
dysfunction(arthritis,
tendinitis, sprain)
Weakness may cause
knee buckling when
walking
Trochanteric bursitis
(1) Anterior/lateral, just
above knee
(2) Lateral, just
posterior to #1
(3) Posterior/lateral,
mid thigh
(4) Lateral, mid thigh
(5) Upper/lateral thigh,
just below the GT
(1) Local to TrP
(2) Local and up lateral
thigh
(3) Lateral thigh, lateral/
posterior knee
(4) Lateral thigh and
knee
(5) Posterior to GT
Knee joint dysfunction
(arthritis, tendinitis,
sprain)
Trochanteric bursitis
Meralgia paresthetica
Common in children and
infants
Latent TrPs are present in
almost everyone because
of quadriceps overload
Knee Locking
Muscle
TP location
Referral
Misdiagnosis
Special features
Adductor Longus Mid-Belly
Deep in and proximal to
groin
Adductor tendinitis
Leading cause of groin
pain
Inguinal hernia
Prostatitis
TrPs is usually felt during a
strong contraction or
sudden twist
Same
Down medial thigh
Body of pubic bone
to
Linea aspera of the
femur
Knee and lower leg
Degenerative joint
disease of the hip
Nerve entrapment of
obturator or
genitofemoral nerves
Adductor
Brevis
Same
Same
Same
(1) Midpoint of muscle
(1) Medial thigh from
groin and almost to the
knee
Adductor tendinitis
Pubic bone
to
linea aspera
Adductor Magnus
Ramus of ischium,
(2) just distal to ischial
and ischial tuberosity tuberosity
to Linea aspera and
adductor tubercle of
the femur
(2) Into internal pelvis
Inguinal hernia
Prostatitis
Visceral or gyneccologic
disease
Nerve entrapment of
obturator or
genitofemoral nerves
Tibialis Anterior
Upper 1/3 of muscle
Lateral condyle of
tibia, proximal 2/3 of
anterior tibia
to
1st cuneiform, base
of 1st metatarsal
Extensor Digitorum
Longus
Lateral condyle of
tibia, proximal 2/3 of
anterior fibula
to
Dorsal surface of
middle and distal
phalanges of toes 2-5
Extensor Hallucis
Longus
Middle 1/3 of anterior
fibula
to
Distal phalanx of big
toe
Great toe
Anteromedial ankle
Anterior compartment
syndrome
Trp here usually satellite
from other calf muscles
Anterior shin splints Pain like gout or turf toe
L5 nerve compression Can cause foot drop slap
(weak ankle dorsiflexion)
1st
metatarsophalangeal
joint dyfunction
Proximal portion of the
muscle
Dorsum of foot
Tarsal joint dysfunction
Toes and anterolateral
ankle
Metatarsophanlangeal
joint dysfunction
Can contribute to hammer/
claw toe
L4 nerve compression
Can be caused by anterior
compartment syndrome
and L4-L5 nerve
compression
Tendinitis
Can cause foot drop slap
(weak ankle dorsiflexion)
Dorsum of foot
Metatarsophanlangeal
joint dysfunction
L4 nerve compression
Over distal aspect of
metatarsal
Base of great toe
Can be caused by anterior
compartment syndrome
and L4-L5 nerve
compression
Can cause foot drop slap
(weak ankle dorsiflexion)
Muscle
TP location
Referral
Misdiagnosis
Special features
Peroneus Longus
Peroneus Longus: Just
distal to head of fibula
Over lateral malleolus;
along lateral aspect of
foot
Lateral compartment
syndrome
Can be caused by
Morton’s foot
Ankle sprain
deep peroneal nerve(drop/
slap foot), or superficial
peroneal nerve
Sacroiliac joint
dysfunction
Unique causes: Morton's
foot
Excessive sitting
(especially on a wallet)
Irritation from injections
Proximal ½ of lateral
fibula
to
Base of 1st
metatarsal and 1st
cuneiform
Peroneus Brevis
Peroneus Brevis: On
either side of, and deep
to, peroneus longus
tendon on distal 1/3 of
lower leg
Lumbar disc syndrome Symptoms: Entrapment of
common peroneal nerve,
Distal 1/2 of lateral
fibula
to
Tuberosity of the 5th
metatarsal
Gluteus Maximus
Post. iliac crest,
posterolateral
sacrum, coccyx
to
Gluteal tuberosity of
femur and ITB
(1) Along sacrum
(2) Slightly above
ischial tuberosity(most
common)
(3) Most medial, near
coccyx
Lumbar facet joint
syndrome
Trochanteric bursitis
Coccygodynia
Disc compression upon
a nerve
Swimmer’s nemesis
Gluteus Medius
All are close to iliac
crest
LB pain
SI joint dysfunction
External surface of
the ilium (from just
inferior to the iliac
crest)
to
Lateral surface of the
greater trochanter
Lumbar facet joint
syndrome
Trochanteric bursitis
Extends much further
then Medius
External ilium
to
Greater
trochanter(deep to
the gluteus medius)
Satellite to QL
Frequently a problem in
pregnancy
Gluteus Minimus
Piriformis
Unique causes: Morton's
foot
Sitting on wallet
Injections
Being overweight
L5 or SI nerve
compression
Causes are the same as
Gluteus Medius
Trochanteric bursitis
(1) Near sacrum
(2) Mid-belly
Sacroiliac joint
dysfunction
Anterior surface of
the sacrum
to
Greater trochanter of
the femur
Piriformis syndrome
(compression of the
sciatic nerve)
Herniated disc
compression upon
spinal nerves L5 or SI
Unique causes: Morton's
foot
Leg length discrepancy
Hyperpronation of the foot
at the subtalar joint
6 Times more prevalent in
women than man
Facet syndrome
Illiopsoas
Anterolaterally
(bodies, discs, and
transverse
processes) on
vertebrae T12-L5
(psoas major) and
the internal surface
of the ilium (iliacus)
to
Lesser trochanter of
the femur
(1) Over lesser
trochanter
(2) over inner border of
ilium posterior to ASIS
(3) into abdomen
lateral to rectus
abdominis and beneath
Local
Lower thoracic
Lumbar, or sacroiliac
joint dysfunction
Appendicitis(psoas
minor)
Unique causes: An
asymmetrically short lower
extremity
Carrying a wallet in a back
pocket
Muscle
TP location
Referral
Misdiagnosis
Special features
Biceps Femoris
Distal half of the
muscle
Dull ache behind knee
Posterolateral thigh
Sciatica
Pain that is deeper and
dull, often will awaken
clients at night
Distal 1/3 of the muscle Region of the gluteal
fold
Sciatica
Pain that is superficial and
sharper
Ischial
Tuberosity(long
head) and linea
aspera(short head)
to
Head of fibula and
the lateral tibial
condyle
Semimembranosis
Proximal calf
Ischial tuberosity
to
Posterior surface of
medial condyle of
tibia
Semitendinosus
Postero-medial thigh
and calf
Lateral condyle of
femur
to
Proximal posterior
tibia
Degenerative joint
disease of the knee
Tendinitis
Mid-belly
Region of the gluteal
fold
Ischial tuberosity
to
Pes anserine tendon
at prox. anteromedial
tibia
Popliteus
Degenerative joint
disease of the knee
Postero-medial thigh
and calf
Sciatica
Pain that is superficial and
sharper
Unique cause: Kicking in
soccer or football (full
flexion of hip and full
extension at knee puts
medial hamstrings @ max
length)
Degenerative joint
disease of the knee
Tendinitis
Just below crease,
between
gastrocnemius heads,
very deep, on tibia
Back of knee superior to Baker’s cyst
location of TrP
Instability of the knee
joint
Unique causes: wearing
high-heeled shoes
Torn PCL
Popliteus tendinitis
Meniscal tear
Torn plantaris muscle
Gastrocnemeus
One in each belly near
proximal attachment
(1) Instep of foot,
posterior calf
Posterior condyles of
femur
One in each about mid- (2-4) Local to the
to
belly
TrP(mostly just distal to
Posterior calcaneus,
knee)
via calcaneal tendon
Posterior compartment
syndrome
Unique causes: Prolonged
shortening (high-heels and
sleeping in fetal position.
Deep vein thrombosis
Unique symptoms:
S1 nerve compression Intermittent claudication
Calf cramps
Growing pains
Plantar fascitis
Soleus
Soleal line of
posterior tibia, head
and proximal half
of
Posterior fibula to the
posterior surface of
calcaneus via
calcaneal tendon
(1) Medial distal
musculotendinous
junction of muscle
(1) Down and into heel
(2) High on lateral side
of calf
(3) Projects to same
side SI joint and
possibly jaw
(3) Slightly more
proximal and more
lateral than(1)
(2) Mid-calf
Posterior compartment
syndrome
Unique causes: Prolonged
shortening (high-heels and
sleeping in fetal position.
Posterior shin splints
Tibial nerve entrapment
Achilles tendonitis
symptoms
Baker’s cyst
Deep vein thrombosis
S1 nerve compression
Intermittent claudication
Plantar fasciitis
Heel spurs
Muscle
TP location
Referral
Misdiagnosis
Tibialis Posterior
Just below proximal
attachment
Over Achilles tendon
Shin splints
Plantar surface of foot
and toes
Tarsal tunnel syndrome
Posterior Proximal
2/3 of posterior tibia
and fibula
to
Plantar surfaces of
navicular, cuneiform,
cuboid, bases of 2nd
to 4th metatarsals
Flexor Digitorum
Longus
Middle1/3 of
posterior tibia
to
Plantar surfaces of
distal phalanges 2-5
Flexor Hallucis
Longus
Middle 2/3 posterior
fibula
to
Plantar surface of
distal phalanx of big
toe
Extensor Digitorum
Brevis
Mid-calf
Buried deep beneath
soleus and
gastrocnemius
Just inferior to proximal
attachment
Plantar surface of
Shin splints
forefoot proximal to toes
2-5
Deep posterior
compartment syndrome
Medial maleolus
Tarsal tunnel syndrome
Tuberosity of
calcaneus
to
the medial/plantar
side of proximal
phalanx of big toe
Unique causes: Morton's
foot
Overuse (walking on soft
sand)
Tenosynovitis of
associated muscle’s
tendons
Middle 2/3 posterior
Plantar surface of the
fibula
great toe and head of
to
the 1st metatarsal
Plantar surface of distal
phalanx of big toe
Shin splints
Deep posterior
compartment syndrome
Tarsal tunnel syndrome
Tenosynovitis of
associated muscle’s
tendons
Lateral to extensor
hallucis brevis TrP
Locally over dorsum of
foot
Medial to extensor
digitorum brevis TrP
Locally over dorsum of
foot
Dorsal calcaneous to
Dorsal surface of
proximal phalanx of
great toe
Abducter Hallicus
Unique causes: Morton's
foot
Deep posterior
Overuse (walking on soft
compartment syndrome sand)
Tenosynovitis of
associated muscle’s
tendons
Dorsal calcaneous
to
Lateral side of the
distal tendons of EDL
of toes 2-4
Extensor Hallucis
Brevis Special features
Along medial side of
heel
Spillover to instep and
back of heel
Unique causes: Morton's
foot
Overuse (walking on soft
sand)
Wearing high Heels
Metatarsal stress
fractures
Unique symptoms: antalgic
gait
Entrapment of a digital
nerve btwn adjacent
metatarsals
Unique causes: Wearing
bad foot wear.
Wearing high heel
Metatarsal stress
fractures
Entrapment of a digital
nerve btwn adjacent
metatarsals
Medial side of the arch
of foot
Unique symptoms:
Numbness on the plantar
surface.
Achilles tendinitis
Tarsal joint dysfunction
EDB and EHB share the
same TrP pain referral
pattern
Unique causes: Wearing
bad foot wear.
Wearing high heel
Unique symptoms: antalgic
gait
Unique causes: Wearing
bad foot wear.
Wearing high heel
Morton's foot (due to
instability)
Muscle
TP location
Referral
Misdiagnosis
Special features
Abductor Digiti
Minimi
Lateral side of arch of
foot
Plantar aspect of 5th
metatarsal head
Plantar fasciitis
Unique symptoms: antalgic
gait
Unique causes: Wearing
bad foot wear.
Wearing high heel
Plantar fasciitis
Causes: Same as ADM
Fallen or weakened arches
Tuberosity of
calcaneus to
Lateral plantar side
of proximal phalanx
of 5th toe
Flexor Digitorum
Brevis
Spillover into adjacent
sole
Tarsal joint dysfunction
Mid-belly(middle of the
sole of foot)
Heads of 2nd to 4th
metatarsals
Dorsal: proximally
attaches to both
sides of adjacent
metatarsals and
distally
to
one side of the
proximal phalanx of
the toe and tendon of
EDL
Metatarsal stress
fracture
Tuberosity of
calcaneus
to
Plantar surface of
middle phalanges
toes 2-4
Interosseous
Metatarsal stress
fracture
Tarsal joint dysfunction
All Interossei - pain and
tenderness along that
side of the toe to which
each muscle attaches
and to plantar surface of
corresponding
metatarsal head
All Interossei - Plantar
fasciitis
Dorsal - Unique symptoms:
antalgic gait
Metatarsal stress
fracture
Unique causes: Wearing
bad foot wear.
Wearing high heel
Plantar/Lumbricals: same
as abductor and flexor
digiti minimi
Entrapment of a digital
nerve btwn adjacent
metatarsals
Tarsal joint dysfunction
Plantar: Metatarsal
3-5
to
Medial side of the
proximal phalanges
of toes 3-5
Lumbricals: Distal
tendon of FDL
to
Distal tendons of
EDL
Suboccipitals
RCP Maj: SP of C2
to
Lateral 1/2 of inferior
nuchal line
Pain that penetrates the Migraines
skull but is difficult to
localize
Greater occipital
neuralgia
Can produce headache
pain (diffuse and difficult to
localize)
Unique causes: Whiplash
Cold draft on neck
RCP Min: Post.
tubercle of C1
to
Medial 1/2 of inferior
nuchal line
OCI: SP of C2
to
TVP of C1
OCS: TVP of C1
to
Lateral occiput
between sup. and inf.
nuchal line
Masseter
Inferior margins of
the zygomatic bone
and the zygomatic
arch of the temporal
bone
to
Anterior surfaces of
the angle, ramus, and
coronoid process of
the mandible
Trigger points in the
upper portion refer to
the upper molars and
maxillary
In lower portion refer to
the lower molars and
temple
All tp cause tooth
sensitivity
TMJ disorder(e.g. OA or Satillite from TrPs in upper
other internal joint
trapezius or SCM
derangement)
Unique Causes: Prolonged
Dental disease
stretching
Headaches
Sinusitis
Occlusal asymmetry(poor
bite)
Protracted head posture
TMJ dysfunction
Direct trauma
Emotional stress
Muscle
TP location
Referral
Lateral Pterygoid
Mucle Belly
Zygomatic bone
Sphenoid bone
to
Neck of the mandible
and the capsule and
articular disc of the
temporomandibular
joint(TMJ)
Medial Pterygoid
Sphenoid and
maxillary bones
to
Internal surface of
the mandible at angle
and inferior aspect of
ramus
Misdiagnosis
Special features
TMJ disorder(e.g. OA or Muscle of mastication most
other internal joint
likely to have Trps
TMJ joint just anterior to derangement)
the ear
Unlike masseter and
Sinusitis
temporalis, the med/lat
pterygoid do not refer to
Tic douloureux the teeth
Ear infections
TMJ joint just anterior to TMJ disorder(e.g. OA or
the ear
other internal joint
derangement)
Spillover just below the
ear
Headaches
Ear infections
Head cold
Sore throat
Unique Symptoms:
Tingling in cheek
Weakness of buccinators(if
buccal nerve is entrapped
by lat. pterygoid
Unlike masseter and
temporalis, the med/lat
pterygoid do not refer to
the teeth.
Unique Causes: Prolonged
stretching
Protracted head posture
TMJ dysfunction
Direct trauma
Emotional stress
TrPs in other muscles of
mastication
Temporalis
Into the superior teeth
Temporal fossa
to
Coronoid process
and the
anterosuperior
aspect of ramus of
the mandible
Above the eye and
temple
Headaches
Dental disease
TMJ disorder(e.g. OA or
other internal joint
derangement)
Unique Causes: Prolonged
stretching
Protracted head posture
TMJ dysfunction
Direct trauma
Emotional stress
TrPs in upper traps or
SCM
Sternocleidomastoid
Manubrium of
sternum and medial
1/3 of clavicle
to
Mastoid process and
lateral 1/2 of superior
nuchal line
Sternal: Occipital ridge
and vertex of the head
Cheek and superorbital
ridge
Sternum
Clavicular: Ear and
Forehead
Swollen lymph nodes
Sinus or migraine
headaches
Osteoarthritis of the
sternoclavicular joint
Trigeminal neuralgia
Tic douloureux
Neurogenic spasmodic
torticollis
ANS symptoms (sternal
head: eye symptoms, such
as ptosis of the upper
eyelid, loss of visual acuity,
and excessive tear
formation; clavicular head:
localized vasoconstriction
and increased sweating)
Proprioceptive symptoms
(sternal head: dizziness,
vertigo, nausea, and
ataxia; clavicular head:
hearing loss)
The referral pain of SCM
TrPs can cross over the
midline
Upper/middle/lower
Trapezius
External occipital
protuberance, medial
1/3 of superior
nuchal line, nuchal
ligament, and SP of
C7 through T12
to
lateral 1/3 of clavicle,
acromion process,
and spine of scapula
Splenius Capitus Nuchal ligament from
level of C3-C6 and SP
of C7-T4
to
Mastoid process and
lateral 1/3 of superior
nuchal line of occiput
Tp in the upper edge
refer to the lateral neck
and temples
Other points in middle
and lower fibers refer
into the posterior neck
and shoulders
Cervical disc syndrome Muscle most commonly
found to have TrPs.
TMJ syndrome
Specifically, the upper
trapezius has the most
Occipital neuralgia
commonly found TrP in the
body; further, the referral
symptoms of this common
TrP have occasionally
spread to the other side of
the body
TrPs in all parts of the
trapezius may produce
spinal joint dysfunction of
the vertebrae to which they
are attached
Vertex of the Head
Cervical joint
dysfunction
Migraine headaches
Spasmodic torticollis
Unique causes: prolonged
forward head posture, or
prolonged posture with
head and neck rotated to
one side (e.g playing the
violin)
sudden excessive stretch
(e.g., whiplash injury)
cold draft on neck
Muscle
TP location
Splenius Cervicis
SP of T3-T6
to
TVPs of C1-C3
Referral
Misdiagnosis
Special features
Upper: Shoots pain
from inside of the head
to the back of the eye
Cervical joint
dysfunction
Causes: same as Splenius
Capitus
Lower: Angle of the
neck
Semispinalis Capitis
Temple area with spill
over to lateral head
Posterior head
TVPs of C7-T6 and
articular processes
of C4-6
to
Medial 1/2 of the
occipital bone
between the superior
and inferior nuchal
lines
Migraine headaches
Spasmodic torticollis
May produce headaches,
eye pain, or even
blurriness of vision in the
ipsilateral eye
Osteoarthritis of cervical Satellite to TrPs in the
spine
upper trapezius or splenius
capitis
Sinus or migraine
headaches
Causes: whiplash or a fall
Just below the occiput
to the root of the spine
of the scapula
Radiculopathy of the
cervical spinal nerves
Osteoarthritic changes of
cervical spine
Wearing a tie or a shirt
with a tight collar
A cold draft on the neck
Erector Spinae Group Iliocotalis Lumborum L1
Spinalis: SP of upper
L-spine and lower
Iliocostalis Thoracis Tspine, lig. Nuchae,
T6 (inf boarder of
SP of C7
scapula) and T11
to
SP of upper Tspine
Logissimus thoracis and Cspine(expt. C1) T10, 11
Erector spinae TrPs in
the thoracic region
usually refer pain both
superiorly and interiorly,
whereas erector spinae
TrPs in the lumbar
region usually refer pain
only inferiorly (usually
into the buttock). Longissimus: Com.
tendon(Tspine), TVP
of T1-T5
to
Ribs 3-12 and TVPs
of Tspine and Cspine
and mastoid process
of temporal bone
Iliocostalis TrPs can
also refer pain to the
anterior thoracic and
abdominal wall, usually
at the same segmental
level, longissimus and
spinalis refer downward
to low back and
buttocks
Iliocostalis: Common
tendon and posterior
surface of ribs 1-12
to TVPs of L1-3 and
post. ribs
6-12(Lspine), post.
ribs 1-6(Tspine),
TVPs of lower
cervicals(Cspine) Transversospinalis
Group Facet syndrome
Angina
pectoris(iliocostalis
thoracic)
Sacroiliac joint
dysfunction
Semispinalis TrPs
generally refer in the
same pattern as
longissimus
Rotatores TrPs refer
pain more medially
(usually directly over the
spine and slightly lateral
to the spine) and in a
more defined manner
than multifidus TrPs. TrPs in the lumbar
region can also refer
pain to anterior
abdominal wall, usually
at the same segmental
level
SI joint and lower
gluteal
Twelfth rib and the
TVPs of L1-L4
to
Posteromedial iliac
crest
Along crest of ilium to
lower abdomen and
groin
Greater trochanter
Referral not found at the
TrP locations
1) TrPs can develop at any
segmental level. 2) TrPs are most likely to
develop in longissimus and
iliocostalis
Patterns of TrPs and TrP
referral zones for the
spinalis have not yet been
identified.
McBurney's point (same as
rectus abdominus)
Quadratus
Lumborum
Pathologic disc
conditions
Longissimus TrP on
lowest rib cause pain
deep along iliac crest
Onto the pelvis,
Multifidi L2, S1
spine and head.
Generally, each
individual
transversospinal is
muscle attaches from
a transverse process
inferiorly
to
Spinous process
superiorly
Osteoarthritis
Pathologic conditions of
the lung or abdominal
viscera (iliocostalis
thoracic)
Iliocostalis TrPs send
pain both up and down
Multifidi and rotatores T4-5, S4
Spinal joint dysfunction
(longissimus-lower TrP
is major cause of LB
pain)
Sciatica
Spinal joint dysfunction
Osteoarthritis
Can cause increased
lumbar lordosis, or
decreased thoracic
kyphosis
Facet syndrome
Angina pectoris
Extreme tension can cause
damage to intervertebral
discs and nerve
compression
Pathologic disc
conditions
Pathologic conditions of
the lung or abdominal
viscera
TrPs can develop at any
segmental level
Back can feel stiff as a
board
Sacroiliac joint
dysfunction
Sciatica
Sacroiliac joint
dysfunction
Causes: joint dysfunction
of the thoracolumbar spine
Lumbar disc syndrome An asymmetrically short
lower extremity
Sciatica
Carrying a wallet in a back
Trochanteric bursitis.
pocket
Emotional stress
TrPs or weakness in the
gluteals.
Muscle
TP location
Pectoralis major
Referral
A TrP on the right side
between the 5th and 6th ribs
has been attributed to
causing cardiac arrhythmia
Costal and Abdominal:
Breast
Unique causes: use of a cane
or crutches
Rib joint dysfunction
Costochondritis
Hiatal hernia
Bicipital tendinitis
Shoulder joint bursitis
Cervical disc syndrome
Medial epicondylitis/
epicondylosis.
Pectoralis Minor
Anterior chest and
shoulder
Ribs 3-5
to
Coracoid process of
the scapula
Cervical disc syndrome
Anterior scalene
Spillover down medial arm syndrome
Medial side of hand Fingers 3-5
Costoclavicular syndrome
Carpal tunnel syndrome
Bicipital tendinitis
Medial epicondylitis/
epicondylosis
Angina pectoris or
myocardial infarction (for
left-sided TrPs)
Subclavius
1st rib at junction with
costal cartilage
to
Middle 1/2 of the
inferior clavicle
Medial muscle side, close
to the manubrium
Along Clavical Cervical disc syndrome
Anterior arm Anterior scalene
syndrome
Lateral forearm Radial side of the hand
Pectoralis minor syndrome
Lateral epicondylitis/
epicondylosis
Serratus Anterior
Local
Ribs 1-9 to
Anterior surface of the
medial border of
scapula
Spillover down ulnar side
of the arm
Special features
Clavical: Anterior shoulder Angina pectoris or
myocardial infarction (for
Sternal: Anterior chest and left-sided
medial aspect of the arm
TrPs)
Medial half of clavicle,
sternum, and costal
cartilages of ribs 1-7
to
Lateral lip of the
bicipital groove of
humerus
Misdiagnosis
Inferior angle of the
scapula
Angina pectoris or heart
attack referral pain (left
side)
Rib joint dysfunction or
fracture
Entrapment of the
intercostal nerves
Sling or a cast
Excessively tight bra strap,
that compresses the muscle
Wearing a heavy back pack
Myocardial infarction
Breast or nipple sensitivity
e.g. wearing a T-shirt
Can cause pec minor
syndrome
Unique causes: use of a cane
or crutches
Sling or a cast
Myocardial infarction
Laboured breathing
Compression of the muscle
(e.g., due to the straps of a
heavy backpack)
Can produce costoclavicular
syndrome (causing
neurologic or vascular
symptoms in
the upper extremity)
Causes: Cast or Sling
Use of a cain
TrPs can occur in any of the
nine digitations of the
serratus anterior. TrPs may
also refer down the ulnar side
of the entire upper extremity
Best treated sideline
Costochondritis
"Stitch in side" when
"pumping the arms" while
running fast
Cervical disc syndrome
Satellite from: Scalene, SCM
Thoracic outlet syndrome
Herpes zoster
TrPs of the intercostal
muscles
Rectus Abdominus
Mid-back
Crest and symphysis of
pubic bone
to
Xiphoid process of the
sternum and costal
cartilages of ribs 5-7
Lower-back
A multitude of visceral
diseases (e.g., peptic
ulcer, hiatal hernia,
appendicitis, intestinal
disease, urinary tract
disease, cholecystitis, and
gynecologic diseases
such as dysmenorrhea)
Sacroiliac and/or lumbar
joint dysfunction.
Pattern of pain that refers to
the back of the trunk often
crosses the midline of the
body, so it is felt on both
ipsilateral and contralateral
sides of the back
May entrap an anterior
branch of a spinal nerve,
resulting in lower abdominal
and pelvic pain
McBurney's point - acute
appendicitis (misdiagnosis)
Eternal Obliques
Abdominal
aponeurosis, pubic
bone, inguinal
ligament, and anterior
iliac crest
to
Lower eight ribs
Multiple referals that run
across the abdominals
Inguinal Ligament and
genitals
A multitude of visceral
diseases (e.g., peptic
ulcer, hiatal hernia,
appendicitis, intestinal
disease, urinary tract
disease, cholecystitis, and
gynecologic diseases
such as dysmenorrhea)
1) The ext and int ab obliques
are next to each other,
superficial
and deep, and their referral
pain patterns have not been
discerned from each other.
(The only exception to this is
the presence of TrPs in the
upper region of the ext ab
oblique where it does not
overlie the int ab oblique). 2) The ab obliques' pattern of
referral pain often crosses the
midline of the body and is felt
on both the ipsilateral and
contralateral sides of the
body.