Myofascial sequence of EXTRAmotion. Course. Dr Antonio Stecco M.D. 16/06/2014

Transcription

1 The Fascial Manipulation Association has been formed to serve as a point of reference for research concerning the fascia, myofascial pain, and visceral dysfunctions related to the physiology of the fascia. Course Dr Antonio Stecco M.D. Myofascial sequence of EXTRAmotion 1

2 MF unit of er-cp1 Site of pain or CP: headache, opening eyes wide or rolling eyes is difficult. Origin of dysfunction or CC: if these ophthalmic disturbances are related to the superior oblique muscle then it is possible to manipulate its fascial insertions around the superior orbit area. Movement verification: Ask patient to look upwards and outwards, to the left and to the right; note any difference between the two eyes. Er-cp 1 Patient supine; therapist palpates over the forehead area, just above the external part of the eyebrow, using fingertip to feel any tissue variations. Comparative palpation of the cc on both sides is useful. 2

3 MF unit of er-cp2 Site of pain or CP: hyperesthesia of the scalp, hemicrania with burning sensation, cephalea Origin of dysfunction or CC: the spasm of the superior auricularis muscle is transmitted to the galea aponeurotica onto which it inserts. This determines anomalous traction to the embedded nerve terminations. Movement verification: Very few people can contract their auricularis muscles actively, therefore, passive movement verification is indicated; by stretching the helix of the ear downwards, the superior auricularis is elongated and, at times, pain or paraesthesia is accentuated. Er-cp 2 Patient supine with head turned to the opposite side; the therapist uses fingertips to palpate the area above the ear that provokes the patient s symptoms. Given that the area is superficial, a small amount of pressure is sufficient. 3

4 MF unit of er-cp3 Site of pain or CP: hemicrania that extends from the nuchal area to forehead; at times, it also continues into the teeth. Vertigo, tinnitus. Origin of dysfunction or CC: traction of the neck muscles converges in the mastoid region with traction of the posterior auricularis muscle. Movement verification: Often cervicalgia and cephalea are associated; in this case, the movement tests for the neck will indicate the cc of the head. If pain is only in the head then the posterior auricularis muscle is tested by stretching the helix of the ear forwards. Er-cp 3 Patient seated, head resting on hands; the therapist uses knuckle over the mastoid notch area, palpating for the most densified point, which can be near the greater occipital nerve. 4

5 MF unit of er-cl Site of pain or CP: pain in the neck, shoulders and often head and throat. Origin of dysfunction or CC: when pain is acute, an antalgic spasm causes torcicollis; when pain is chronic there is limited range of neck movement which tends to avoid involving the nerve terminations. Movement verification: Ask patient to rotate their head to the left and right and to report which side is more painful; where appropriate, the therapist can apply passive over pressure to overcome motor limitations or stiffness that may be masking the problem. Er-cl Patient supine with head turned to opposite side; the therapist uses their knuckle over the second and third transverse processes where the elevator of the scapula muscle inserts, manipulating this point until tissue changes are felt. 5

6 MF unit of er-th Site of pain or CP: pain at the base of the neck, sharp nuchal pain, interscapular block with breathing difficulties. Origin of dysfunction or CC: pain remains local when only the fascia of the serratus posterior superior is altered, whereas it extends to the nuchal region if the imbalance extends along the ipsilateral splenius muscle. Movement verification: With hands behind the head, ask the patient to rotate trunk to the left and right. This mf unit can also be tested passively: with one hand, the therapist rotates and extends the patient s neck while the other hand blocks the ipsilateral shoulder. Er-th Patient prone; therapist uses elbow against the medial border of scapula, where the scapular spine finishes, manipulating the point that refers pain. Once local pain has diminished, examine the fascial tissues with knuckle, penetrating between the various muscular layers. 6

7 MF unit of er-lu Site of pain or CP: pain localises in the ipsilateral gluteal region or, at other times, in the side or in the inguinal region Origin of dysfunction or CC: the two obliques and quadratus lumborum insert onto the inferior border of the twelfth rib; referred pain pattern varies according to which fascia is densified. Movement verification: The patient, seated on the table with both arms folded, is asked to rotate the trunk to the left and the right. This position tends to concentrate the rotatory movement in the lumbar region. Er-lu Patient side lying on opposite side; the fascial therapist uses their elbow against the inferior border of the twelfth rib, shifting towards the end of the rib to locate the more densified area. 7

8 MF unit of er-pv Site of pain or CP: pain in the sacroiliac joint or, at times, pain extends down the posterolateral region of the lower limb. Origin of dysfunction or CC: alteration of the gluteus medius fascia can cause incoordination in pelvic rotation, with subsequent irritation of the sacroiliac ligament, or else compensatory tension can develop in the hamstring muscles. Movement verification: The therapist holds the patient s shoulders firm and asks the patient to advance one iliac crest at a time, alternating between the two sides. When the implicated hemipelvis rotates posteriorly, pain is felt in the sacrum or along the thigh. Er-pv Patient side lying on opposite side; the therapist uses the elbow over the gluteus medius fascia, immediately below the summit of the iliac crest; referred pain may be felt in the sacrum, the thigh or towards the inguinal region. Note how the therapist is using body weight partially, to facilitate manipulation of this very dense fascia. 8

9 MF unit of er-cx Site of pain or CP: coxalgia, or diffuse pain in the lateral and anterior regions of the hip; sciatictype pain Origin of dysfunction or CC: below the gluteus maximus there are the small extrarotator muscles of the hip; if the fascia that unites all these muscles does not glide then incoordinate movements can occur causing joint conflict. Movement verification: Patient seated on table raises one foot over opposite knee, repeat on the opposite side; verify if hips extrarotate equally, noting if flexed knees are the same distance from the table. Er-cx Patient is side lying on opposite side; therapist uses elbow halfway between the greater trochanter and the sacrum, shifting pressure to find the most altered point and manipulating until it dissolves. 9

10 MF unit of er-ge Site of pain or CP: pain, sometimes a burning sensation, localises around head of fibula or lateral knee region. Origin of dysfunction or CC: biceps femoris, which inserts onto the head of the fibula, is hypertonic due to fibrosis of its altered epimysial fascia. Movement verification: Ask the patient to squat; if rotation of the tibial condyle is inadequate, this movement is either impossible or it provokes a strong pain in the lateral region of the leg. Er-ge Patent prone with knee flexed; therapist uses elbow over distal third of biceps femoris muscle belly, palpating for point that provokes referred pain to the knee before starting to manipulate. 10

11 MF unit of er-ta Site of pain or CP: tenovaginitis of the peroneal muscles or ankle pain with post-traumatic algodystrophy Origin of dysfunction or CC: ankle sprain often involves the fascia of the peroneal muscles as well; however, pain does not manifest halfway on the lower leg, the dysfunction is felt in the ankle joint. Movement verification: Ask patient to rotate their foot outwards against resistance placed externally; if the peroneal tendons are inflamed movement is impeded, but if ankle pain is due to the extensor muscles this movement is not painful. Er-ta Patient prone; therapist uses knuckle or elbow halfway on the lower leg behind the fibula, directly over muscle bellies of the peroneal muscles; manipulate this point, alternating with other points along the same sequence. 11

12 MF unit of er-pe Site of pain or CP: pain and deformation of the last two toes, callus formations between these two toes. Origin of dysfunction or CC: the extensor digitorum brevis muscle regulates the movement of the more potent extensor digitorum longus; if finer movements are lacking then anomalous friction between the toes can lead to callus formations. Movement verification: Ask patient to rotate toes externally, against a manual resistance; as can be seen in this photograph, this test causes the extensor digitorum brevis to contract, giving it a cyst-like appearance. Er-pe Patient rests internal border of foot on the table; the therapist uses their knuckle over the extensor digitorum brevis, palpating for the altered point while being guided by the patient s sensations. 12

13 MF unit of er-sc Site of pain or CP: neck pain, scapula, shoulder; pain referred from neck to arm. Origin of dysfunction or CC: fibrosis in elevator of the scapula s fascia causes asynchrony between neck, scapula and humerus movements during extrarotation of the shoulder. Movement verification: Ask patient to touch the thoracic vertebrae by passing over the head with one hand at a time; observe the level to which each hand can reach, even if the patient claims to feel they are equal. Er-sc Patient seated; the therapist uses their elbow in the posterior region of the trapezius, directly above the superior angle of the scapula. At times, this point is more proximal, over the distal part of the elevator of the scapula. 13

14 MF unit of er-hu Site of pain or CP: the site of pain is always around the glenohumeral joint region. Origin of dysfunction or CC: apart from the site of pain, to trace back to its origin it is always useful to ask which movement is most painful; e.g. the patient cannot reach for the seat-belt in the car (extrarotating the shoulder). Movement verification: Ask patient to widen arms against a manual resistance placed at the forearms; sometimes the movement is not painful but a difference in strength between the two limbs is noticeable. Er-hu Patient in side lying on opposite side; the therapist uses elbow or knuckle just behind the rotator cuff and, guided by the patient s sensations, palpates for the point that provokes symptoms. 14

15 MF unit of er-cu Site of pain or CP: pain is localised around radial head or near the lateral epicondyle. Origin of dysfunction or CC: this form of epicondylitis is accentuated above all by rotation of the arm (supinator and brachioradialis) rather than by lifting a weight ( see la-cu). Movement verification: Ask patient to supinate forearm from the pronated position, against a manual resistance. At times, other movement verifications can be used but it is always important to highlight pain or weakness prior to treatment to identify the mf unit requiring treatment and to compare results afterwards. Er-cu Patient prone with extended arm along side; the therapist uses their knuckle placed laterally to the tendon of triceps, palpating in the fascia and lateral septum (origin of supinator and brachioradialis mm.) for the more densified point. 15

16 MF unit of er-ca Site of pain or CP: cysts over the extensor tendons, pain on extension-extrarotation of the wrist. Origin of dysfunction or CC: extensor digitorum and extensor pollicis longus participate in extrarotation of the wrist; manipulation over their muscle bellies aims at improving the tendinous trajectories; Ask patient to extrarotate their wrists against a manual resistance or to press the dorsum of their hands onto the table, indicating which tendons are the more painful; at times, it is the extensor digitorum and pollicis tendons (extra), other times extensor ulnaris tendon (retro), or, yet again, the extensor radialis tendon (latero). Er-ca Patient prone with palm of hand resting on table; the therapist uses their knuckle or elbow halfway on the forearm over the muscle bellies of the extensor muscles; if the patient does not tolerate this position then they can rest their arm above their head. 16

17 MF unit of er-di Site of pain or CP: rigid fingers, interphalangeal nodules, fine finger movements are limited. Origin of dysfunction or CC: as finger movements are actuated by the more potent forearm muscles and regulated by the small hand muscles, treatment is to be carried out both on the cc of er-di as well as the cc of er-ca. Movement verification: Ask the patient to open their fingers as they simultaneously extrarotate their wrist; at times, it is noted that the extension of one finger is not complete. Er-di Patient prone, arm along side; the therapist manipulates the dorsal fascia of the hand between the fourth and fifth, or the third and fourth, metacarpal bones with the knuckle; once this point has been resolved, verify the previously painful movement immediately. 17