Myofascial Pain of the Elbow Wrist and Hand
4/15/2015
Myofascial Pain of the Elbow Wrist and Hand Paul Bonzani MHS, OTR/L , CHT
What is Myofascial Pain? Muscle Pain Caused by Trigger Points Associated with:
Fibromyalgia Associated with Tender Points Related to articular dysfunction.
Spasm Muscle stiffness Muscle pain related to: Active TrP
Widespread pain duration lasting more than 3 months. 11 of 18 tender point sites are painful to 4 Kg of pressure.
Latent TrP Taut bands. Twitch responses
Myofascial TrP Definition A hyperirritable spot in skeletal muscle associated with a palpable nodule in a taut band. The spot is painful and has characteristic pain referral patterns, motor dysfunction y and possible p autonomic changes. g There are central and attachment points and they can be active or latent. They can be a primary point or a satellite point associated with a primary point.
1
4/15/2015
Development of Trigger Points (TrP) Stimulation of muscle nociceptors. Release of Bradykinin, Prostaglandin and Serotonin Stimulation of group III and IV muscle fibers Lowers the firing threshold of group IV afferents (C-fibers) Leads to hypersensitivity of the muscle tissue causing pain associated with TrP.
Acute overload, Overwork fatigue
X
Nociceptive sensory input
TrP
X
Pain referral zone
Peripheral Sensitization Decreased threshold and increased responses to repeated stimuli. Sensitization of p peripheral p nerve endings g byy inflammatory mediators. Changes in voltage-gated sodium channels. Lowers activation of threshold of the neuron
2
4/15/2015
Factors Causing Sensitization Postural
Repetitive Activity
Sensitization of TrP Lesion Sensitization Vasoneuroactive Substance release
Edema
Ischemia
Release of SP
Venous Congestion
Central Sensitization Repetitive C-Fiber discharge leads to progressive increase of second order neuron discharge. This is called “Wind Up”. Temporal summation of these discharges occur in the dorsal horn. Brief C fiber input results in rapid changes in membrane excitability in WDR cells. Post stimulus changes may last for hours.
3
4/15/2015
Central Sensitization
Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013. Author OpenStax College
Dorsal Horn Sensitization
Drdla and Sandkühler Molecular Pain 2008 4:18 doi:10.1186/1744-8069-4-18 (http://www.molecularpain.com/content/4/1/18)
Central Sensitization
Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013. Author OpenStax College
4
4/15/2015
Peripheral Sensitization/Central Sensitization https://www.youtube.com/watch?v=4LEy8B1D3QE h // b / h? 4LE 8B1D3QE
Muscle Fiber Arrangements
Motor End Plate
By OpenStax College [CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons
5
4/15/2015
Referred Pain Convergence theory: Convergence of nociceptive fibers (of the same dermatome) onto a single ascending tract.
16
Symptoms of Myofascial TrP’s Active TrP Clinical pain complaint. Aching Referred Activation is associated muscle overload.
Latent TrP Symptoms are similar to an active TrP however the degree of symptoms is generally less. Primary symptoms are decreased motor activity or stiffness. TrP become latent in later years
Occurs in middle years.
Physical Examination and Findings Taut Band. Tender Nodule. Local L l Twitch T i h Response. R Limited ROM. Painful Contraction. Weakness
6
4/15/2015
Trigger Point Examination Principles of exam: Stretch the taut band Palpate along the band to the area of maximum tenderness Flat palpation Pincer palpation Local twitch response
Principles of Treatment Trigger point pressure release. Stroking massage B hi technique h i Breathing Muscle Stretching Contract-relax Cold application
Triceps: Long Head TrP
By Anatomography (en:Anatomography (setting page of this image)) [CC BY-SA 2.1 jp (http://creativecommons.org/licenses/by-sa/2.1/jp/deed.en)], via Wikimedia Commons
7
4/15/2015
Triceps: Lateral Head TrP
Triceps Brachii: Medial Head TrP
By Anatomography (en:Anatomography (setting page of this image)) [CC BY-SA 2.1 jp (http://creativecommons.org/licenses/by-sa/2.1/jp/deed.en)], via Wikimedia Commons
Anconeus TrP
8
4/15/2015
Triceps TrP’s Symptoms Vague posterior shoulder and upper arm pain. Pain with forceful elbow extension. Associated A i d with: ih Medial epicondylitis-medial head Lateral epicondylitis-long head
Triceps LH Examination
Triceps L/M Head
9
4/15/2015
Triceps Intervention
Biceps Brachii TrP
By Niwadare (Own work) [CC BY-SA 4.0 (http://creativecommons.org/licenses/bysa/4.0)], via Wikimedia Commons
Biceps TrP Symptoms Superficial anterior shoulder pain. Distinguish from deltoid insertion pain.
Pain occurs with shoulder elevation and abduction. abduction Pain when carrying heavy objects with a supinated forearm. Associated with sprain/partial distal biceps tendon injury.
10
4/15/2015
Biceps Examination
Biceps Mobilization Program
Pronator Teres
11
4/15/2015
Pronator Teres TrP Symptoms Pain with supination and cupping of the hand. Pain can increase with wrist flexion.
Stiffness of digital extension with the forearm in supination. Associated with medial epicondylitis/median nerve compression.
Pronator Examination
Pronator Mobilization Program
12
4/15/2015
Flexor Carpi Radialis/Ulnaris
By Anatomyczar (Own work) [CC BY-SA 4.0 (http://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia Commons
Flexor Carpi Radialis/Ulnaris Symptoms Pain at the radial volar forearm and cramping at the common flexor origin. Palpation of the FCR/FCU tendon is negative for pain Associated with FCR ganglion. Must assess for ganglion prior to treating the TrP. Must clear Guyon’s canal compression.
FCR/FCU Examination
13
4/15/2015
FCR/FCU Mobilization
Brachioradialis/ECRL Referral Zones
ECRB/ECU Referral Zones
14
4/15/2015
Brachioradialis/ECRL/ECR B/ECU Symptoms Weakness of grip with large handle items. Activated with forceful motion of the wrist Pain P i to the h lateral l l epicondyle. i d l All but the ECU are associated with lateral epicondylitis and can be satellite points to each other .
Brachioradialis Examination/Mobilization Program
ECRL/Supinator Examination
15
4/15/2015
ECRL/ECRB Release and Mobilization
Extensor Digitorum
Extensor Digitorum/Examination Release
16
4/15/2015
Common Hand TrPs
By LeftHand.jpg: Ludor derivative work: AS990 (LeftHand.jpg) [GFDL (www.gnu.org/copyleft/fdl.html) or CC-BYSA-3.0 (http://creativecommons.org/licenses/by-
See page for author [CC BY 4.0 (http://creativecommons.org/licen ses/by/4.0)], via Wikimedia Commons
Adductor and 1st DI Exam and Release
The End
17
Myofascial Pain of the Elbow Wrist and Hand Paul Bonzani MHS, OTR/L , CHT
What is Myofascial Pain? Muscle Pain Caused by Trigger Points Associated with:
Fibromyalgia Associated with Tender Points Related to articular dysfunction.
Spasm Muscle stiffness Muscle pain related to: Active TrP
Widespread pain duration lasting more than 3 months. 11 of 18 tender point sites are painful to 4 Kg of pressure.
Latent TrP Taut bands. Twitch responses
Myofascial TrP Definition A hyperirritable spot in skeletal muscle associated with a palpable nodule in a taut band. The spot is painful and has characteristic pain referral patterns, motor dysfunction y and possible p autonomic changes. g There are central and attachment points and they can be active or latent. They can be a primary point or a satellite point associated with a primary point.
1
4/15/2015
Development of Trigger Points (TrP) Stimulation of muscle nociceptors. Release of Bradykinin, Prostaglandin and Serotonin Stimulation of group III and IV muscle fibers Lowers the firing threshold of group IV afferents (C-fibers) Leads to hypersensitivity of the muscle tissue causing pain associated with TrP.
Acute overload, Overwork fatigue
X
Nociceptive sensory input
TrP
X
Pain referral zone
Peripheral Sensitization Decreased threshold and increased responses to repeated stimuli. Sensitization of p peripheral p nerve endings g byy inflammatory mediators. Changes in voltage-gated sodium channels. Lowers activation of threshold of the neuron
2
4/15/2015
Factors Causing Sensitization Postural
Repetitive Activity
Sensitization of TrP Lesion Sensitization Vasoneuroactive Substance release
Edema
Ischemia
Release of SP
Venous Congestion
Central Sensitization Repetitive C-Fiber discharge leads to progressive increase of second order neuron discharge. This is called “Wind Up”. Temporal summation of these discharges occur in the dorsal horn. Brief C fiber input results in rapid changes in membrane excitability in WDR cells. Post stimulus changes may last for hours.
3
4/15/2015
Central Sensitization
Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013. Author OpenStax College
Dorsal Horn Sensitization
Drdla and Sandkühler Molecular Pain 2008 4:18 doi:10.1186/1744-8069-4-18 (http://www.molecularpain.com/content/4/1/18)
Central Sensitization
Anatomy & Physiology, Connexions Web site. http://cnx.org/content/col11496/1.6/, Jun 19, 2013. Author OpenStax College
4
4/15/2015
Peripheral Sensitization/Central Sensitization https://www.youtube.com/watch?v=4LEy8B1D3QE h // b / h? 4LE 8B1D3QE
Muscle Fiber Arrangements
Motor End Plate
By OpenStax College [CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons
5
4/15/2015
Referred Pain Convergence theory: Convergence of nociceptive fibers (of the same dermatome) onto a single ascending tract.
16
Symptoms of Myofascial TrP’s Active TrP Clinical pain complaint. Aching Referred Activation is associated muscle overload.
Latent TrP Symptoms are similar to an active TrP however the degree of symptoms is generally less. Primary symptoms are decreased motor activity or stiffness. TrP become latent in later years
Occurs in middle years.
Physical Examination and Findings Taut Band. Tender Nodule. Local L l Twitch T i h Response. R Limited ROM. Painful Contraction. Weakness
6
4/15/2015
Trigger Point Examination Principles of exam: Stretch the taut band Palpate along the band to the area of maximum tenderness Flat palpation Pincer palpation Local twitch response
Principles of Treatment Trigger point pressure release. Stroking massage B hi technique h i Breathing Muscle Stretching Contract-relax Cold application
Triceps: Long Head TrP
By Anatomography (en:Anatomography (setting page of this image)) [CC BY-SA 2.1 jp (http://creativecommons.org/licenses/by-sa/2.1/jp/deed.en)], via Wikimedia Commons
7
4/15/2015
Triceps: Lateral Head TrP
Triceps Brachii: Medial Head TrP
By Anatomography (en:Anatomography (setting page of this image)) [CC BY-SA 2.1 jp (http://creativecommons.org/licenses/by-sa/2.1/jp/deed.en)], via Wikimedia Commons
Anconeus TrP
8
4/15/2015
Triceps TrP’s Symptoms Vague posterior shoulder and upper arm pain. Pain with forceful elbow extension. Associated A i d with: ih Medial epicondylitis-medial head Lateral epicondylitis-long head
Triceps LH Examination
Triceps L/M Head
9
4/15/2015
Triceps Intervention
Biceps Brachii TrP
By Niwadare (Own work) [CC BY-SA 4.0 (http://creativecommons.org/licenses/bysa/4.0)], via Wikimedia Commons
Biceps TrP Symptoms Superficial anterior shoulder pain. Distinguish from deltoid insertion pain.
Pain occurs with shoulder elevation and abduction. abduction Pain when carrying heavy objects with a supinated forearm. Associated with sprain/partial distal biceps tendon injury.
10
4/15/2015
Biceps Examination
Biceps Mobilization Program
Pronator Teres
11
4/15/2015
Pronator Teres TrP Symptoms Pain with supination and cupping of the hand. Pain can increase with wrist flexion.
Stiffness of digital extension with the forearm in supination. Associated with medial epicondylitis/median nerve compression.
Pronator Examination
Pronator Mobilization Program
12
4/15/2015
Flexor Carpi Radialis/Ulnaris
By Anatomyczar (Own work) [CC BY-SA 4.0 (http://creativecommons.org/licenses/by-sa/4.0)], via Wikimedia Commons
Flexor Carpi Radialis/Ulnaris Symptoms Pain at the radial volar forearm and cramping at the common flexor origin. Palpation of the FCR/FCU tendon is negative for pain Associated with FCR ganglion. Must assess for ganglion prior to treating the TrP. Must clear Guyon’s canal compression.
FCR/FCU Examination
13
4/15/2015
FCR/FCU Mobilization
Brachioradialis/ECRL Referral Zones
ECRB/ECU Referral Zones
14
4/15/2015
Brachioradialis/ECRL/ECR B/ECU Symptoms Weakness of grip with large handle items. Activated with forceful motion of the wrist Pain P i to the h lateral l l epicondyle. i d l All but the ECU are associated with lateral epicondylitis and can be satellite points to each other .
Brachioradialis Examination/Mobilization Program
ECRL/Supinator Examination
15
4/15/2015
ECRL/ECRB Release and Mobilization
Extensor Digitorum
Extensor Digitorum/Examination Release
16
4/15/2015
Common Hand TrPs
By LeftHand.jpg: Ludor derivative work: AS990 (LeftHand.jpg) [GFDL (www.gnu.org/copyleft/fdl.html) or CC-BYSA-3.0 (http://creativecommons.org/licenses/by-
See page for author [CC BY 4.0 (http://creativecommons.org/licen ses/by/4.0)], via Wikimedia Commons
Adductor and 1st DI Exam and Release
The End
17
