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Beyond Trigger Points Seminar UPPER TORSO & SHOULDER UNIT MODULE 1

Welcome to Beyond Trigger Point Seminars Module 1 on the Upper Torso and Shoulder. This is Cathy Cohen. In this presentationyou will be studying the muscles of the rotator cuff. Our five learning objectives for this module are one: improving your ability to identify which muscles are involved by just listening to your client’s story of injury.Next you will be able to recognizea number of pain patterns and dysfunctions associated with the shoulder. Hopefully, your level of confidence inidentifying perpetuating factors will increase so you can design a home program for your client. Fourth, you will be able to answer this commonly asked question, “Why didn’t my shoulder heal on its own?”Finally, you will be studying the 11 documented trigger points associated with these four muscles.Starting tomorrow, you can begin locating these trigger points on your clients. For those of you registered for a workshop, the hands-on portion of this program will further enhance your palpation skills.

A little housekeeping first, have you printed out the study guide for this unit? Even writing with the palest ink will help you remember what you are hearing. The study guide is also loaded with pictures found in our textbook. If you have the textbook, Myofascial Pain and Dysfunction the Trigger Point Manual by doctors Janet Travell and David Simons, you might prefer having it or some other text on trigger points nearby.Also, if you haven’t already listened to the introductory online lecture, I encourage you to do that now. It can be found at

So as review,a trigger point(TrP) is a hyperirritable spot within a taut band of skeletal muscle. The spot is painful on compression and gives rise to predictable referred pain, tenderness, motor dysfunction and autonomic phenomena.An active trigger point reproduces the client’s pain patterns; when compressed the client can tell if the referred pain pattern is familiar. A latent trigger point also produces a predictable referral pattern but only hurt if you’re pressing on it. So latent trigger points are producing increased tension levels in the muscle but not spontaneously referring pain. However, it may not take much injury or strain to turn a latent TrP into an active one.

When one or more trigger points are present a physician would diagnosis the condition as amyofascial pain syndrome (MPS).When I was in training, the origin of trigger points was unknown. Now, thanks primarily to histological and electromyographic studies, researchers have proven trigger points to be a neuromuscular disease entity.

My first position out of training was with a neurologist, Dr. Byrd. He was very excited when I first met him.He had stayed up all night long reading our textbook,Myofascial Pain and Dysfunction the Trigger Point Manualby doctors Janet Travell and David Simons. He said to me I just figured out a third of all of my chronic pain patients have myofascial pain syndromes due to trigger points. Then he said with a gloomier face, I don’t have the time to treat them. That’s why he hired me. As a massage therapist we have the time to care for our clients. We have the time to treat soft tissue. We have the time to identify perpetuating factors and thoroughly treat the pain and dysfunction associated with myofascial pain syndromes due to trigger points.

There are a number of ways you canbegin identifying trigger points.One way is tomemorize where the documented trigger points are so you can make educated guess as to where to find them. Two of the rotator cuff muscles’ trigger pointsare located at attachment sites. The other 9 are central trigger points. By definition, an attachment trigger point is found in the muscle fibers merging into tendons or periosteal insertions. By definition, a central trigger point is found in the belly of a muscle. If youmentally chop off the tendons and then guess where the middleportions of the muscle fibers are, you can make good educated guesses on the central TrP location.The rotator cuff muscles have long parallel fiber arrangements. I think you’ll find these trigger points easy to locate.

I’ve saved the most important method for identifying a trigger point till now because, as a massage therapist, you are already trained and practiced in palpating for taut bands. How many times have you used a cross-fiber or longitudinal stripping strokeand felt a cord like speed bump of bunched up muscle fibers? If you have, then you already know how to look for a trigger point.By intentionally palpating along the taut band, you may locate an eighth of an inch to quarter of an inch exquisitely tender spot. Starting tomorrow slowly and gently compress that spot and ask your client, “Do you feel sensation traveling elsewhere?” If you are able to reproduce their pain complaint, then you can assure your client you may be able to help them.

At the top of page 2 of your student study guide, you can now fill in the blanks for thefive criteria used in identifying active or latent trigger points.

  1. Palpable taut bands. The fill-in is palpable. When we’re trying to assess if the source of pain is from a trigger point, remember to first find the taut band.
  2. Exquisitetenderness.Remember we said by definition a trigger point istender when you press on it otherwise it's not a trigger point.
  3. Patient recognition of their pain complaint when pressure is applied over the trigger point. I know this is a somewhat subjective finding; your client needs to recognize and report the sensations they are having while you are applying pressure. If we don’t ask them to communicate with us, they might not tell. So we need to be talking with our client about their pressure tolerance, and referred sensations.
  4. Restrictedrange of motion. We’ll review ROM in our workshop. You’ll become experts at different types of assessment tests for the shoulder. If you're not already doing ROM testing, I want to encourage you to do ROM testing before and after a treatment. What you can measure makes such a difference in how a client perceives the work you just performed on them. If you can show and document measurable results, then you will instill in your client’s mind trust in your work. Also being able to document ROM improvements is helpful for the referring physician or insurance company.
  5. Finally a local,and the fill-in is, twitch response, an LTR. When you're dead on the trigger point, the muscle may twitch. Have you seen this? A reflexive contraction of the muscles fibers within the taut band produces the LTR. With deeper muscles this response isn’t as observable. Nor will your client necessarilyfeel it twitch. However with a superficial musclelike the infraspinatus, an LTR is noticeable and thus a useful criteria for identifying the location of the trigger point.

Before we begin identifying the 11 trigger points of the rotator cuff, we need to regress for a moment and consider the bones forming the joints of the shoulder.The fill-ins at the bottom of page 2 are: scapula, humerus, clavicle andmanubrium. These bones form the four joints.

The glenohumeral jointis the primary shoulder joint. Because the articulation between the head of the humerus and the glenoid cavity on the scapula form a fairly shallow ball and socket joint, the shoulder is extremely mobile but not as stabile as say the hip joint. The most common dislocations causing ligament strain and tears occur with anteromedial movement such as when swinging a child under your legs or doing a dip type of push-up with a non-fixed scapula. All four of the rotator cuff muscles stabilize the glenohumeral joint by pulling the humerus head into scapula socket.

Another joint is formed where the acromion of the scapula articulates with the clavicle creating theacromioclavicular joint.On the bottom of page 3 of the study guide, do you see the lateral spine of the scapula articulating with the clavicle bone? This joint is also a reduced ball and socket joint and allows for a smooth gliding movement.

The sternalclavicular joint is formedwhere the sternum joins the medial head of the clavicleas seen on the top picture.This saddle joint allows for secondary movement of the scapula.

One more joint useful to assess when identifying problems of the subscapularisin particular is referred to as a pseudo joint. Itis the area between the scapula and the ribs. It’s not a true joint in the sense that two bones are articulating. However the scapula should be able to float and move on top of the ribs. Some scapulas lift and move with freedom while others don’t. We’ll come back to that during the portion on the subscapularis.

On page 4 of study guide, the action to remember for the infraspinatus islateral rotation.

Do you have colored pens or pencils ready? On page 533 of our textbook, 2nd edition Volume 1, you see the documented trigger point sites for the infraspinatus. If you’re participating in this program without the textbook, that’s ok, just look at page 5 of your study guide with the infraspinatus picture and its four documented trigger points. Using a colored pencil or pen, draw on the body scan on page 4 of the study guide where you think the trigger pointsare located. Again, I suggest drawing an “X” on the body scan picture on page 4 where you think the trigger pointsare located and then draw the pain patterns just as you see them on page 5. The solid colored area you are drawing to the front and side of the deltoid and a little down the front of the bicep area is the primary pain complaint area. The client will take their hand and cup their deltoid to show you where it hurts. Now draw thedotted area extending down the arm, into the hand and possibly up to the base of the skull. These patterns are calledsecondary or spillover patterns. These spillover patterns may or may not be present when you compress on any of the three trigger points you just drew. So if you were to begin memorizing the pain pattern for the infraspinatus, commit the solidly colored area to memory first. Now draw the fourth trigger point shown on picture B. Its primary pain complaint is along the medial shoulder blade.

To help clinicians remember the pain pattern of the infraspinatus, Dr Travell nicknamed this muscle Shoulder Joint Pain. There is room on page 5 for you to write Shoulder Joint Pain if you think that might help you remember a key characteristic of this muscle.

Let’s move on to answer the question at the bottom of page 4, how is the infraspinatus activated and perpetuated?

The client usually knows how they injured this muscle because the onset is quick. You could think of the infra as theshoulder whip lash muscle.It is commonly involved in car accidents. If the hand is on the dash board or steering wheel,the shoulder will whip forward and rebound back again. The infraspinatuscould then develop a TrP.

A tennis serve is another activating or perpetuating factor.Reaching out and back like when a person is falling, can activate the infraspinatus.

A woman presented to my office. She had a TrP in her infraspinatuswhich reproduced her pain complaint when compressed. She told me on the first visit she had no idea how this happened.During the second visit,because I was curious, I questioned her again about onset.She then sheepishly admitted trying to back slap her troublesome child in the back seat. One of my classes now refers to this as the “slapping the kid in the back seat” muscle!

Let’s go to page 6 now and answer the question,what findings and tests confirm involvement of the infraspinatus?

Do you see the picture of the Hand to Shoulder Blade test? That movement requiresthe shoulder to adduct and medially rotate. When you place your dominate hand behind your back, do your fingertips reach within an inch of the opposite shoulder blade’s spine? If you do the same with your non-dominate hand, do the fingertips touch the spine of the scapula? So assuming you have a normal arm length, you would test negative for infraspinatus involvement if the fingertips come close to the mark. Because the range of motion shown in the picture is significantly diminished, we say that is a positive finding for infraspinatus involvement. If a person tells you they are having adifficult time fastening their bra or tucking in their shirt-tail, thenyou have another clue for an infraspinatus problem. Again, infraspinatus causes restriction ofmedial, also called internal, rotation.

It’s fun doing the detective work! Another finding to query your client about is their sleep position. People tend to sleep on the pain free side with infra involvement. It hurts too much to lie on the painful shoulder if they are a side sleeper.It causes too much medial rotation. According to one study, this is the third most common muscle to have a latent trigger point; the upper trapezius is the most common. So now because you know where to find the trigger points, you may begin encountering that front of the shoulder pain with more frequency.

Because the referred pain of an infraspinatus TrP is felt deep into the anterior joint; your client will want to dig at it to describe where it hurts.Bicep Tendonitis is a common diagnosis given for what really might be a myofascial pain syndrome. That diagnosis, Bicep Tendonitis, is the last finding for you to jot down.

This brings us to corrective actions. Theinfraspinatus responds beautifully to moist heat and self applied pressure such as rolling on a tennis ball or using a backknobber. For other ideas on self massage tools you could sell or use in your practice, visit the resource tab of We also need to teach anatomical sleep positions to our clients. Picture A at the bottom of page 6 shows how to place the shoulder in neutral by resting the arm on a pillow placed near the chest. Picture B shows how most side lying sleepers rest until you train them otherwise. Having the shoulder rolled forward at night might have been fine before they developed a problem however if they want to maintain the muscular relieve gained from your great therapy, it’s absolutely critical they correct faulty sleep positions. Teaching anatomical sleep positions might be the most important life long tool you give your client.

The other critical piece distinguishing you from an ordinary therapist is your ability to motivate and teach your client how to enhance your therapy with a home stretching program. You could give the Hand to Shoulder Blade position as one home stretch repeated three to five times through out the day. The resource tab of the website will have several suggestions and the workshop spends a great deal of time educating on corrective actions. For now, to make your notes complete, write down stretches.

Spending the extra time to educate your clients on self care will distinguish you from the crowd of other therapist doing relaxation work. What will also put you a head above the others is completing your education on the Travell and Simons’ methodology of treating myofascial pain through this program or through some other school of neuromuscular therapy and then sitting for the National Board Examination of Certified Myofascial Trigger Point Therapists. If you decide you enjoy the challenge of being a clinical detective and are suited for motivating your clients to take care of themselves, consider gearing your studies towards this exam. At click on the Courses tab at the top and then follow the accreditation tab on the right side of the page where you will find more information on the Board Exam and the National Association of Myofascial Trigger Point Therapists. You want to be listed on their website. The number of certified trigger point therapistsis relatively small now, but based on the impressive traffic visiting the National site, the public is looking to find therapists specializing in this proven, evidenced based protocol of trigger point treatment. So you want to be listed on their therapist directory to increase your business. Again, check out the link on my website and find out more about the National Association and the Board Exam.

Now let’s move on to the teres minor beginning on page 7 of the study guide.

As you may remember,teres minor is the little brother to infra.It has the same action of lateral rotation just like the infraspinatus but with a different innervation. We can nickname the teres minorthe Silver Dollar Pain. On page 8 of the study guide or page565 in the book, you will see one documented trigger point. The pain pattern is a patch of pain to the back of the shoulderabout the size of a coin with some possible spillover down the back of the arm but not to the elbow. Now that you’ve drawn that and committed it to memory, I can say to you- this is the least involved. It’s usually involved in conjunction with other shoulder muscles.