Muscle stretching for cervical osteochondrosis

Headaches caused by pathology of the cervical spine and neck muscles are united under the general term "cervicogenic" headache. It includes various cranialgic syndromes that differ in the mechanisms of occurrence and features of the clinical picture.

The source of nociceptive impulses can be the structures of the craniovertebral junction (C0-C1 C1-C2) in the so-called functional blockades and arthrosis of the articulating surfaces, other cervical CVJs, as well as muscular, fascial and ligamentous trigger points (points), especially in the extensor muscles of the head and neck, the upper third of the sternocleidomastoid muscle, etc.

A number of muscles (the pectoralis major and minor, scalene, sternocleidomastoid, sternal, iliac costal muscle of the neck, subclavian) initiate pain in the anterior chest.

We recommend introducing stretching of the affected muscles into the massage procedure immediately after preparing the corresponding muscle with massage techniques (stroking, rubbing, kneading, vibration).

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Muscle stretching technique for cervical osteochondrosis

Trapezius muscle

According to many authors, the trapezius muscle is obviously the most frequently affected muscle by myofascial TPs, and yet it is often ignored as a possible source of headache in the temporal region.

In the upper, middle and lower sections of the muscle, six TPs can be localized (two in each section), from which different pain patterns are transmitted.

Symptoms

• Head and neck rotations are minimally limited (if only the trapezius muscle is affected);
• limited (up to 45° or less) tilt of the head to the side opposite to the affected upper muscle bundles;
• neck flexion and arm abduction are slightly limited;
• an active, maximum possible turn of the head in the opposite direction causes pain, since the muscle contracts from a shortened state;
• active turning of the head towards the affected muscle is not accompanied by pain if the muscle that lifts the scapula on the same side or the upper bundles of the trapezius muscle do not contain TT;
• If the active TT also affects the muscle that lifts the scapula, then the rotation of the head and neck to the affected side is significantly limited and the patient prefers to “keep the neck still.”

Trapezius Stretching Technique

Upper muscle bundles (TT, and TT ₂ ): TTj. The patient's initial position is sitting on a chair, holding the seat with his hands (fixing the shoulders). To stretch the muscle fibers, the doctor (massage therapist) tilts the patient's head to the side opposite the affected muscle (ear to shoulder). To stretch the muscle as much as possible, the patient's head is tilted forward.

At this time, the doctor applies pressure to the patient's head and shoulder, thereby increasing flexion of the spine and lateral displacement of the scapula.

TT _2. To inactivate TT ₂, the muscle is stretched by tilting the patient's head slightly more forward than with TT1.

CAUTION! The trapezius muscle should be stretched on the other side as well to prevent any TTs in it from being activated during its normal shortening during stretching to the maximum length of the affected muscle.

Sternocleidomastoid muscle

Pain patterns and accompanying symptoms are specific for each head of the muscle (medial and lateral). Pain and vegetative or proprioceptive disorders caused by the TT muscle are estimated by dentists as an important component of the most common disease - myofascial pain dysfunctional MBD syndrome. H. Williams and E. Elkins (1950) noted that myalgia of the head is accompanied by pain in the muscles of the neck at the sites of their attachment to the skull.

Symptoms

A. Medial head of the muscle.

• An active TT located at the lower end of the medial head refers pain to the area above the upper sternum. Upper sternum pain is the distinguishing feature of sternocleidomastoid myofascial syndrome from trigeminal neuralgia.
• TTs affecting the mid-level of the medial head refer pain to the ipsilateral side of the face. This pain zone runs in an arc across the cheek, maxilla, above the eyebrow, and ends deep in the orbit.
• TTs located along the inner edge of the middle section of the medial head transmit pain to the pharynx and to the back of the tongue when swallowing (Brody S.), which causes a feeling of “sore throat”, as well as a small area on the top of the chin.
• Pain referred from the TT located at the upper end of the medial head extends to the occipital crest area.

B. Lateral head of the muscle.

• Pain from TT, localized in the middle part of this head, is reflected in the forehead area; severe pain spreads to both sides of the forehead.
• TTs localized in the upper part of the lateral head cause pain deep in the ear and in the postauricular region, in some cases in the cheek and molars on the ipsilateral side.

Proprioceptive disorders caused by TT in the lateral head lead mainly to spatial disorientation. Patients complain of postural vertigo in the form of a misalignment of movement or a sensation of movement "inside the head" (H. Kraus). Attacks of vertigo, lasting from a few seconds to several hours, develop with a change in posture caused by contraction of the sternocleidomastoid muscle or its unexpected stretching.

Sternocleidomastoid muscle stretching technique

The initial position of the patient is sitting on a chair, grasping the seat with his hands (fixation of the shoulder girdle muscles). In the presence of TT in many muscles of the neck, the stretching procedure is first performed for the trapezius muscle and the muscle that lifts the scapula, as a result of which the amplitude of movement in the cervical region increases, which is extremely necessary for complete passive stretching of the medial head of the sternocleidomastoid muscle. To achieve a full range of motion and maximum muscle elongation, it is possible to alternate the treatment of this muscle with stretching of the scalene muscles (H. Kraus).

Gradual stretching of the lateral head of the muscle is achieved by tilting the patient's head back and then turning it to face the side opposite the muscle being stretched.

During passive stretching of the medial head of the muscle, the patient's head is gently turned toward the muscle being stretched. Then, with the head fully turned, the chin is lowered onto the shoulder. During this movement, the occiput and mastoid process are lifted, providing maximum muscle stretching. The head should be held in this position for only a few seconds, since in the presence of atherosclerosis of the vertebral artery, its compression occurs at the base of the skull, which can lead to deterioration of vision and dizziness (J. Travell).

ATTENTION! During these procedures, the muscles of the neck and shoulder girdle must be relaxed.

The stretching procedure is always performed for both the right and left muscles. The increased head rotation as a result of effective therapy of the muscle on one side can cause a reactive spasm of the suddenly shortened muscle on the other side. Such an unusual shortening of the muscle can activate its latent TPs, which will again cause pain and dizziness. After the procedure, it is recommended to apply hot compresses to the muscles.

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Deep muscles of the back of the neck (semispinalis capitis, semispinalis cervicis, multifidus)

Symptoms

Each area of trigger point (TP) localization corresponds to a specific pattern of referred pain.

The area of localization of TT1 is located slightly above the base of the neck at the level of the bodies of the vertebrae C4 _, C5 _. These points cause pain and tenderness in the suboccipital region, sometimes the pain spreads lower along the back of the neck up to the upper part of the medial edge of the scapula. These TT can lie at the depth of the semispinalis muscle of the neck and the multifidus muscle.

• Active TT ₂, localized 2-4 cm below the back of the head, causes pain throughout the back of the head up to the crown.
• TT ₃ is located directly under the occipital crest in the area of attachment of the semispinalis capitis muscle to the occipital bone. The pain from this TT in the form of a half-ring is distributed in the ipsilateral half of the head, manifesting itself maximally in the temporal region and in the frontal part above the eye (EJakson). Often TT localized in the posterior cervical muscles under the back of the head cause pain in both arms and legs or in the trunk (below the shoulder on the ipsilateral side).

Muscle stretching technique

As a rule, the muscles that limit movement the most are subjected to stretching first. Provided that all head movements are limited, it is best to first restore the forward tilt of the head, then the lateral tilts and turns of the head, and only lastly the extension of the head. In this regard, the patient should have the degree of damage to individual muscle groups assessed, taking into account the overlapping functions of these muscles (D. Zohn et al.).

Since a certain movement in the cervical region is provided by several muscles, the stretching procedure in only one direction usually only partially solves this problem. Therefore, adjacent, almost parallel muscle fibers must be subjected to the stretching procedure. To eliminate the limitation of movements in different planes in the cervical region, the stretching procedure often needs to be repeated 2-3 times with the obligatory application of a hot compress to the affected muscles.

To eliminate forward and lateral bending limitations in the cervical spine, the suboccipital and upper cervical muscles are first stretched, then the long-fiber lower neck muscles and upper trunk muscles, and finally the thoracic spine muscles. This procedure primarily stretches the paravertebral muscles, including the rectus capitis posterior minor, semispinalis capitis, and longissimus muscles.

• A. Muscles of the back of the neck.

The patient's starting position is sitting, head tilted, arms down.

The doctor (massage therapist) carefully applies pressure to the patient's head, gradually tilting it together with the shoulder girdle closer to the knees.

• B. Muscles of the anterior region of the neck.

If, with maximum head flexion, the patient's chin does not reach the sternum by the thickness of a finger, then the cause may be the muscles of the anterior region of the neck that are involved in this movement.

The patient's initial position is sitting on a chair. The doctor slowly straightens the head.

ATTENTION! The presence of TT in these muscles and their shortening leads to overload of the posterior group of neck muscles.

The sternocleidomastoid muscle (on both sides) should also be subjected to stretching.

It is recommended to finish the procedure by applying a hot compress to the affected muscle.

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Levator scapulae muscle

The levator scapulae muscle is one of the most frequently affected TT muscles of the shoulder girdle (A. Sola et al.).

Symptoms

The main pain from TT, regardless of localization, is projected to the angle of the neck (the area where the neck transitions into the shoulder girdle), and diffuse pain from TT is distributed along the medial edge of the scapula and in the posterior deltoid region. The lower TT can cause pain in the area of the lower angle of the scapula. Pain caused by TT significantly limits neck rotation (H. Kraus).

Muscle stretching technique

The patient's initial position is sitting on a chair, holding the seat with his hands (fixing the scapula in a lowered position). The doctor (massage therapist) carefully turns the patient's head approximately 30° facing away from the affected muscle, then tilts the head forward (to stretch the more vertical fibers of the muscle) and to the contralateral side.

Scalene muscles

Active TPs localized in any of the scalene muscles (anterior, middle, or posterior) can cause pain in the chest, arm, along the medial border of the scapula, and in the interscapular region.

Symptoms

1. When examining patients:
   • flexion of the head to the contralateral side is limited;
   • there is no pain when turning the head;
   • arm abduction to the side is limited.
2. Muscle spasm test. The patient is asked to turn his head as much as possible in the direction of the pain, then lower his chin into the supraclavicular fossa.

These movements cause a significant contraction of the scalene muscles, activate the TPs localized in them and cause a pattern of referred pain characteristic of these points.

3. Muscle relaxation test. The patient's initial position is sitting on a chair. The patient places the forearm of the affected hand on the forehead and simultaneously lifts and moves the shoulder forward, thereby eliminating the pressure of the collarbone on the scalene muscles and brachial plexus located underneath. The pain from this movement goes away in a fairly short time.

ATTENTION! The test is based on the fact that raising the arm and collarbone relieves referred pain in anterior scalene syndrome.

4. Finger flexion test. The patient must fully extend the fingers at the metacarpophalangeal joints. Normally, when performing the test, which consists of maximum flexion of the fingers at the interphalangeal joints, the fingertips touch the palmar surface of the hand.

This test is considered positive if active TPs are localized in the scalene muscles. In this case, four fingers do not bend completely.

5. The Adson test consists of the following: the patient takes a long breath, lifts the chin and turns it to the affected side.

During this movement, the 1st rib is maximally raised, which begins to press the neurovascular bundle against the contracted muscle.

The test is considered positive if it results in a weakening or disappearance of the pulse in the radial artery or a change in blood pressure.

Muscle stretching technique.

The patient's initial position is sitting, holding onto the seat of the chair with one hand (on the side of the affected muscle) to fix the shoulder blade.

• A. Anterior scalene muscle. In order to stretch the anterior scalene muscle, the therapist (massage therapist) first asks the patient to tilt his head to the side opposite the muscle being stretched and then turns it in the posterolateral direction.
• B. When stretching the middle scalene muscle, the patient's initial position is the same. The doctor (massage therapist) tilts the head in the direction of the contralateral shoulder.
• B. When stretching the posterior scalene muscle, the patient's initial position is sitting on a chair, with his hands fixed to the seat of the chair. The doctor (massage therapist), without turning the patient's head, applies pressure to it in the antero-contralateral direction along the axial line of this muscle. At the same time, vertical traction of the cervical spine can be performed (for the purpose of muscle relaxation).

It is recommended to apply a hot compress immediately after the procedure.

Supraspinatus muscle

Trigger points located in the supraspinatus muscle cause deep pain in the shoulder and girdle: pain is especially pronounced in the middle deltoid region.

Symptoms

• If the muscle is damaged, the test of reaching the scapula from behind the back is limited;
• in a standing position, the patient is unable to fully abduct the shoulder, as this shortens and strains the muscle;

ATTENTION! The same movement in the initial position lying on the back is performed more freely by the patient, since the weight of the arm does not counteract the activity of the muscle.

• On palpation, severe pain is revealed in the tendon of the lateral end of the muscle.

ATTENTION! The tendinous attachment of the lateral end of the muscle is much more accessible for palpation if the arm on the side of the muscle being examined is turned inward and its hand is placed behind the lower back.

Supraspinatus Stretching Technique

Patient's initial position - sitting on a chair, hand behind the lower back. The doctor brings the hand to the shoulder blade.

The patient's initial position is sitting on a chair. The doctor helps raise the patient's arm in front of the chest.

Infraspinatus muscle

Most researchers believe that when this muscle is affected, the main target for referred pain is the anterior region of the shoulder joint. Pain is also projected downwards into the anterolateral region of the shoulder, into the radial part of the wrist, and sometimes into the fingers.

Symptoms

Patients with this lesion usually complain of being unable to reach the scapula on the opposite side with their hand. The patient's inability to rotate the shoulder inward and simultaneously abduct it indicates the presence of an active TP in the infraspinatus muscle. Referred pain prevents patients from sleeping on the affected side.

Tests recommended to detect damage to the muscles of the shoulder girdle:

• reaching the mouth with the hand thrown behind the head and
• getting the shoulder blade from behind the back.

Muscle Stretching Technique: To stretch a muscle, one of three methods can be used:

• test of reaching the shoulder blade from behind the back. Patient's initial position - sitting;
• patient's initial position - sitting. The doctor pulls the arm horizontally towards the patient;
• The patient's initial position is lying on the side opposite the affected muscle. The doctor places the patient's arm behind his back.

Subscapularis muscle

Trigger points localized in this muscle cause severe pain both at rest and during movement. The main pain zone is projected in the area of the posterior projection of the shoulder joint. Zones of diffuse pain cover the scapula and extend down the back of the shoulder to the elbow.

Clinical picture: in the early stages of muscle damage, patients can raise their arm forward and upward, but cannot throw it back (ball throw). As TT activity progresses, shoulder abduction becomes possible only at 45°, patients complain of pain both at rest and under load. Such patients are often diagnosed with "frozen shoulder".

Muscle stretching technique: the patient's initial position is lying on his back, the shoulder blade is fixed by his body weight. The doctor gently abducts the shoulder to the limit of tolerable pain, holding it in a neutral position between outward and inward rotations. Then the doctor should gently rotate the shoulder outward. The doctor gradually increases the passive stretching of the muscle by moving the patient's hand first under the head, then under the pillow and, finally, behind the head end of the couch, thereby increasing the range of such shoulder movements as abduction and outward rotation.

Latissimus dorsi

Myofascial trigger points are usually located in the portion of the muscle that forms the posterior wall of the axilla. There is a constant, dull ache referred to the inferior angle of the scapula and the surrounding area at the level of the mid-thorax. Referred pain may also extend to the back of the shoulder and down the medial aspect of the forearm and hand, including the ring and little fingers.

It should be remembered that the latissimus dorsi is a long, relaxed muscle, which therefore rarely causes pain under loads that only partially stretch it, but it does radiate pain during lowering activities where it bears a large load.

Such patients are often prescribed a whole series of diagnostic procedures (bronchoscopy, coronary angiography, myelography, computed tomography), which do not reveal any pathology.

Muscle stretching technique: muscle stretching is performed in the patient's initial position - lying on the back and on the side.

Teres major muscle

Trigger points are localized in two areas of the muscle: medial - in the area of the back surface of the scapula; lateral - in the area of the back wall of the armpit, where the latissimus dorsi "wraps" this muscle. TPs of both areas cause pain in the back deltoid area and above the long head of the triceps brachii. TPs localized in the large teres muscle can cause referred pain in the back of the shoulder joint.

Muscle stretching technique: the muscle can be stretched in the patient's initial position lying on his back and on his side. In this case, the patient's arm should be maximally abducted and bent at the shoulder joint, which allows the shoulder to be rotated inward or outward. The doctor should gradually move the patient's arm behind his head, while the angle of the scapula is fixed by the body weight.

The clinical picture consists of a pain phenomenon, and when the patient moves the shoulder blade, clicking and crunching sounds may occur.

Muscle stretching technique. Patient's initial position - sitting on a chair, torso and head tilted forward, arms down. In this position, the rounded back and arms down pull the shoulder blades in the anterolateral direction. To increase the stretch, the doctor should press the patient's shoulder forward - down.

Pectoralis major muscle

Myofascial TP of the anterior pectoral muscles can simulate typical cardiac pain in intensity, character and localization. The final diagnosis of active TP based on their characteristic signs and symptoms and their elimination by drug treatment, however, does not exclude heart disease. The difficulty in diagnosis is also evidenced by the fact that pain of extracardiac origin can cause transient changes in the T wave on the ECG. Complaints of unilateral pain in a clearly defined parasternal zone make one suspect the existence of TP localized in the muscle.

The most common somatovisceral manifestations are episodes of supraventricular tachycardia and extrasystole or ventricular extrasystole without other cardiac lesions. The somatic area of referred pain causes boring pain in myocardial ischemia. An example of myofascial viscerosomatic manifestation can be coronary artery insufficiency or other intrathoracic disease, reflecting pain from the affected organ to the anterior chest wall. This results in the development of satellite TPs in the somatic pectoral muscles.

In addition to pain along the anterior shoulder and in the subclavian region, patients with active TPs in the clavicular portion of the pectoralis major muscle may complain of limited shoulder abduction.

Muscle stretching technique. When stretching a muscle, it is important to remember that it covers three joints: the sternoclavicular, the acromioclavicular, and the shoulder. It also covers an area that functions like a joint that allows the scapula to slide along the ribs.

Most effectively, all portions of the pectoralis major muscle are stretched in the initial position of the patient sitting on a chair, since this position allows for free movement of the shoulder blade and arm (the need for the participation of three joints).

The doctor applies traction to the arm, abduction at the shoulder joint, and movement of the shoulder in such a way as to displace the scapula.

To passively stretch the clavicular portion of the muscle, the physician performs external rotation and horizontal abduction of the shoulder.

To stretch the intermedial sternal fibers, the physician raises the arm to approximately 90°, then externally rotates it and moves it back to the position of maximum possible extension.

To stretch the lowest costal portion, it is recommended that the patient's initial position be sitting or lying on his back. The doctor bends the patient's arm at the shoulder joint, performing external rotation. At the same time, the doctor should apply a measured resistance to the possible reverse movement of the arm.

After relieving tension in the pectoralis major, pain and activation of shortening are usually observed in the antagonist muscles (the posterior group of muscles covering the shoulder joint, rhomboids and trapezius). TT (latent) may also be activated in them due to excessive strengthening during stretching of the pectoralis major. Therefore, it is necessary to stretch them as a mandatory procedure.

In order to stretch the pectoralis major muscle, exercises are also recommended that should be included in therapeutic exercise sessions.

Deltoid

Active TPs located in the anterior part of the muscle cause pain in the anterior and middle deltoid areas. Active TPs located in the posterior part of the muscle cause pain in the middle and posterior deltoid areas and sometimes in adjacent areas of the shoulder.

Muscle stretching technique.

Patient's initial position is sitting.

1. Stretching the anterior portion of the muscle. The doctor moves the patient's straight arm to the side by 90°, rotates the shoulder outward and moves it backward.
2. Stretching the posterior portion of the muscle. The doctor rotates the patient's shoulder inward and then moves it to the contralateral side. This movement stretches two more muscles - the supraspinatus and infraspinatus.

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Biceps brachii

Active TPs are localized in the distal part of the muscle. The pain caused by these TPs is superficial and spreads to the upper part of the biceps brachii, in the anterior deltoid region.

Muscle stretching technique

1. The patient's initial position is sitting on a chair, the shoulder blades are pressed to the back of the chair, the arm is extended at the elbow joint. The doctor slowly turns the patient's shoulder outward, abducts it by 90° and then pronates the hand. This movement stretches both the long and short heads of the biceps brachii. The doctor should hold the patient's arm in this position (20-40 sec).
2. The patient's initial position is lying down, the arm is rotated outward, a pillow is placed under the shoulder, the hand is pronated. The doctor extends the patient's arm simultaneously at the elbow and shoulder joints. In order to hold the arm in this position, the doctor fixes the patient's elbow to the couch or to his knee. To ensure full extension of the arm at the elbow joint, the brachial and triceps muscles are stretched.

Triceps brachii

Long head of the muscle. Pain caused by active TT1 spreads upward from the localization zone along the back of the shoulder and shoulder girdle, capturing the areas of the upper bundles of the trapezius muscle (near the neck).

Medial head of the muscle. TT2 is located at the lateral edge of the medial head. Referred pain is projected to the lateral epicondyle and is a common component of epicondylitis.

Lateral head of the muscle. TT3 causes pain in the area of the back of the shoulder. The tight muscle band in which it is localized can compress the radial nerve.

Muscle stretching technique

1. Patient's initial position - sitting on a chair, arm bent at the elbow joint. The doctor bends the arm at the shoulder joint with subsequent pressure on the elbow area (bringing the arm behind the back), pressing the forearm.
2. The patient's initial position is lying on his back. The doctor bends the patient's arm at the elbow and shoulder joints, then places the supinated hand under the shoulder area. At the same time, the doctor's hand applies pressure to the elbow (direction - downwards), thereby increasing flexion at the shoulder joint and, as a consequence, increasing muscle stretching (especially its long head).

Wrist extensors and brachioradialis

Trigger points located in the long extensor carpi radialis muscle cause pain and tenderness in the lateral epicondyle and in the anatomical snuffbox area. Pain from trigger points located in the short extensor carpi radialis muscle is projected to the dorsal area of the wrist and hand. These trigger points are the main source of myofascial pain in the dorsal aspect of the wrist.

Wrist Extensor Stretching Technique

The patient's initial position is sitting or lying on the back. The long and short radial extensors of the wrist are stretched by flexing the pronated wrist of the straightened arm at the elbow joint. When stretching the ulnar extensor of the wrist, the wrist is flexed at the wrist joint and supinated.

Brachioradialis Stretching Technique

The patient's initial position is sitting, the arm is straight, a pad is placed under the elbow joint. Since the muscle crosses the forearm, pronation of the forearm is performed to stretch it.

After the stretching procedure, the arm is covered with hot compresses.

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Extensors of the fingers of the hand

Trigger points (TP) of the finger extensors project pain to the outer surface of the forearm, the back of the hand and fingers. The pain may extend to the distal parts of the fingers, but is never detected in the area of the terminal phalanges and nails.

Finger Extensor Stretching Technique

Patient's initial position: sitting, arm straight, pad placed under the elbow.

The doctor should bend all of the patient's fingers while simultaneously bending the wrist.

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Supinator (tennis elbow)

Trigger points of the supinator refer pain to the area of the lateral epicondyle and the outer surface of the elbow. They also project pain into the tissues of the space between the index finger and thumb, and if the pain is intense enough, it can involve part of the back of the forearm.

Cyriax identifies four types of tennis elbow:

1. Tendinoperiosteal, which is explained as a partial tear of the muscle and its tendons from their attachment sites, resulting in the formation of a painful scar.
2. Muscular, which is close in clinical picture to the described activity of TT, located in the long radial extensor of the wrist and transmitting painful sensations to the area of the lateral epicondyle.
3. Tendinous, which is described as damage to the "body of the tendon". Obviously, we are talking about the tendon of the common extensor at the level of the head of the radius. Morphological examination revealed microscopic ruptures of the short radial extensor of the wrist with phenomena of abortive regeneration.
4. Supracondylar, in which TT is detected, localized in the triceps brachii muscle and transmitting pain to the medial epicondyle.

Muscle stretching technique

The patient's initial position is sitting, the arm is straightened, a pad is placed under the elbow. This position allows the arm to be fully extended in the elbow joint area and, with full pronation of the hand, prevents internal rotation of the shoulder.

Palmaris longus muscle

Trigger points are located in the palmaris longus muscle and refer a superficial stabbing pain, unlike most other muscles, which transmit a deep dull pain. The pattern of referred pain is focused on the palmar surface of the hand.

Muscle stretching technique

The patient's initial position is sitting, a pad is placed under the elbow joint, the fingers are extended. The doctor extends the patient's arm. Stretching can be alternated with ischemic compression to inactivate the TP, after which it is recommended to stretch the entire group of forearm flexor muscles, especially the wrist and finger flexors to inactivate the myofascial TP, the involved parallel muscles.

Flexors of the wrist

An active flexor carpi radialis TT refers pain focused on the radial aspect of the palmar wrist crease to the underlying forearm and palm. An active flexor carpi ulnaris TT refers a similar pain pattern to the ulnar aspect of the palmar wrist.

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Finger flexors

No differences in the patterns of referred pain of the superficial and deep flexors of the fingers were noted. TT localized in the flexor muscles of any finger refers pain to that finger.

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Flexor pollicis longus

When myofascial TT occurs in a muscle, the pain spreads along the palmar surface of the finger to its tip.

Pronator teres

TTs localized in the muscle reflect pain deep into the wrist along the palmar surface and into the forearm.

Muscle stretching technique

The patient's initial position is lying down, the arm is extended, a pad is placed under the elbow joint. The doctor extends the patient's hand and fingers.

Adductor pollicis muscle

Active TT causes dull pain along the lateral aspect of the thumb at its base, distal to the wrist fold. The area of diffuse tenderness includes the palmar aspect of the 1st metacarpophalangeal joint and may also extend to the thumb, the thenar eminence, and dorsal aspect of the interdigital web.

Opposing muscle of the thumb

Pain from TPs localized in that muscle is reflected to the palmar surface of the thumb and to the area of the radial-palmar surface of the wrist, which the patient usually presses with his finger to localize the pain.

Muscle stretching technique

The patient's initial position is sitting or lying down, the hand is supinated and placed on a pad, which allows for full extension and then significant abduction of the thumb.

The patient should also be taught an exercise to stretch these muscles, which is performed in a warm bath.

Interosseous muscles

Trigger points of the 1st dorsal interosseous muscle clearly refer pain along the radial surface of the index finger, deep into the dorsal surface of the hand and through the palm. Myofascial trigger points of the remaining dorsal and palmar interosseous muscles refer pain along the side of the finger to which the muscle is attached. The pain extends to the distal interphalangeal joint. The presence of an active trigger point in the interosseous muscle is often combined with a Heberden node located in the zone of referred pain of myofascial trigger points and soreness.

Muscle stretching technique

With the exception of the 1st dorsal interosseous muscle, stretching treatment is usually ineffective because they are difficult to stretch. These TTs are also inaccessible to ischemic compression. The 1st dorsal interosseous muscle is stretched by strong abduction of the thumb and adduction of the index finger.

The patient is advised to perform exercises to stretch the interosseous muscles of the hand daily at home. It is important that the forearms form one straight line.