The Concise Book

of Trigger Points
second edition

Simeon Niel-Asher

Lotus Publishing
Chichester, England

North Atlantic Books

Berkeley, California
 Contents
About this Book 5 Chapter 4
Muscles of the Face, Head and Neck 53
Copyright 2005, 2008 by Simeon Niel-Asher. All rights reserved. No portion of this book, except for brief review, may be A Note About Peripheral Nerve Supply 6 Epicranius (Occipitofrontalis) 54
reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying,
recording, or otherwise without the written permission of the publisher. For information, contact Lotus Publishing or North
Orbicularis Oculi 56
Atlantic Books. Chapter 1 Masseter 58
Skeletal Muscle, Muscle Mechanics Temporalis 60
First published in 2005. This second edition published in 2008 by
Lotus Publishing and Fascia 7 Pterygoideus Lateralis 62
Apple Tree Cottage, Inlands Road, Nutbourne, Chichester, PO18 8RJ, UK and Overview of Skeletal Muscle Structure 8 Pterygoideus Medialis 64
North Atlantic Books Muscle Shape 13 Digastricus 66
P O Box 12327
Berkeley, California 94712 Musculo-skeletal Mechanics 15 Scalenus Anterior, Medius, Posterior 68
Muscle Attachment 20 Sternocleidomastoideus 70
All Drawings Amanda Williams Fascia and Myofascia 22 Temporomandibular Joint (TMJ) 72
Text Design Wendy Craig
Models Jonathan Berry, Galina Asher Embryological Development of Fascia 23
Photography Sean Marcus Chapter 5
Cover Design Paula Morrison
Chapter 2 Muscles of the Trunk and Spine 75
Printed and Bound in the UK by Scotprint
Trigger Points and Trigger Point Formation 25 Erector Spinae 76
The Concise Book of Trigger Points is sponsored by the Society for the Study of Native Arts and Sciences, a nonprofit Trigger Point Definition 26 Posterior Cervical Muscles 78
educational corporation whose goals are to develop an educational and crosscultural perspective linking various scientific,
Acupuncture or Acupressure Points Multifidis/Rotatores 80
social, and artistic fields; to nurture a holistic view of arts, sciences, humanities, and healing; and to publish and distribute
literature on the relationship of mind, body, and nature. and Trigger Points 27 Splenius Cervicis/Splenius Capitis 82
Fibromyalgia 28 External Oblique 84
Dedication
To my parents, my wife Galina, for her support, beauty and wisdom, my wonderful patients and my sons Gideon and
Nutritional and Biochemical Factors 29 Transversus Abdominis 86
Benjamin who make every day an adventure. Fibre Type and Trigger Point Manifestation 29 Rectus Abdominis 88
Trigger Point Formation and Posture 30 Quadratus Lumborum 90
British Library Cataloguing in Publication Data
A CIP record for this book is available from the British Library
Postural Trigger Points and Iliopsoas (Psoas Major/Iliacus) 92
ISBN 978 1 905367 12 2 (Lotus Publishing) Cross Patternation 31 Diaphragm 94
ISBN 978 1 55643 745 8 (North Atlantic Books) Trigger Points Within Sarcomeres 32
The Library of Congress has cataloged the first edition as follows: Trigger Point Development 32 Chapter 6
Trigger Point Classification 36 Muscles of the Shoulder
Niel-Asher, Simeon. Trigger Point Symptoms 37 and Upper Arm 97
The concise book of trigger points / by Simeon Niel-Asher.
p. ; cm. Physical Findings 37 Trapezius 98
Includes bibliographical references and index. Levator Scapulae 100
Summary: A manual for understanding and treating chronic pain Chapter 3 Rhomboideus (Minor and Major) 102
associated with trigger points, the tender, painful nodules that form
in muscles and connective tissuesProvided by publisher. Therapeutic Technique Protocols 43 Serratus Anterior 104
ISBN 1-55643-536-3 (pbk.) 1. Myofascial pain syndromesTreatmentHandbooks, manuals, Palpation 44 Pectoralis Major 106
etc. 2. Chronic diseaseTreatmentHandbooks, manuals, etc.
Injections vs Dry Needling 45 Latissimus Dorsi 108
I. Title.
[DNLM: 1. Myofascial Pain SyndromestherapyHandbooks. Spray and Stretch Technique 46 Deltoideus 110
2. Chronic DiseasetherapyHandbooks. 3. Myofascial Pain Synd- Hands-on Therapy Supraspinatus 112
romesphysiopathologyHandbooks. WE 39 N667c 2005]
Trigger Point Release Protocols 48 Infraspinatus 114
RC927.3.N45 2005
616.74dc22 Modifications: Muscle Energy/ Teres Minor 116
2005024075 Positional Release Techniques 49 Subscapularis 118
Massage Techniques 50 Teres Major 120
Manual Lymphatic Drainage Biceps Brachii 122
Techniques (MLD) 50 Triceps Brachii 124
4 The Concise Book of Trigger Points

Chapter 7
Muscles of the Forearm and Hand 127
Chapter 9
Muscles of the Leg and Foot 169 About this Book
Pronator Teres 128 Tibialis Anterior 170
Palmaris Longus 130 Extensor Digitorum Longus/ This book is designed in quick reference format to offer useful information about the trigger points relating
Wrist Flexors 132 Extensor Hallucis Longus 172 to the main skeletal muscles, which are central to massage, bodywork and physical therapy. The information
Brachioradialis 134 Fibularis (Peroneus) Longus, about each muscle is presented in a uniform style throughout. An example is given below, with the meaning
Wrist Extensors 136 Brevis, Tertius 174 of headings explained in bold (some muscles will have abbreviated versions of this).
Extensor Digitorum 138 Gastrocnemius 176
Supinator 140 Plantaris 178
Opponens Pollicis/Adductor Pollicis 142 Soleus 180
X Marks the Spot
Small Hand Muscles 144 Popliteus 182
Whilst I have included dots/markings in the regions of the most common trigger points, please note that
Flexor Digitorum Longus/
these are not exact locations, but are approximations. A number of factors influence the exact location of
Chapter 8 Flexor Hallucis Longus 184
any given trigger point. Myofascia is a continuum, and minor variations in, for example, anatomy,
Muscles of the Hip and Thigh 147 Tibialis Posterior 186
posture or weight bearing will have an impact on the location and formation of trigger points. In the
Gluteus Maximus 148 Superficial Muscles of the Foot 188
clinical setting, you may well find the trigger point location varies. Varying the direction, amplitude and
Tensor Fasciae Latae 150 Deep Muscles of the Foot 190
Gluteus Medius 152 applicator force will also have an impact on locating the trigger point.
Gluteus Minimus 154 Chapter 10
Piriformis 156 Putting It All Together:
Hamstrings 158 Trigger Points and Beyond 193
Adductors 160 Holding Patterns 194
The name of Some fundamental The derivation The attachment
Pectineus 162 Four New Laws 194 the muscle exercises to of the muscle that remains
Sartorius 164 Treat Trigger Points in Reverse 203 strengthen the name relatively fixed
Quadriceps 166 muscle during muscular
The attachment that
contraction
Manual Therapy and Self-help 205 moves

The movement or
Resources 220 effect caused when
General Index 222 the muscle contracts

The nerve that

activates the muscle

Everyday activity/activities
to which the muscle
contributes

Presenting symptoms
or areas of dysfunction

Zone of pain related to

specific trigger points

What else could the

problem be?

Other muscle trigger

points with similar
patterns

Zone of pain A good example, but there are The main methods for treating
Things for you and
distribution also many other ways to stretch trigger points (see pages 4551)
your patient to consider
associated with the muscle. If exercises are
specific trigger shown on one side, they should = strongly indicated
point(s) be repeated on the other side = indicated
A Note About Peripheral Nerve Supply
The nervous system comprises:

The central nervous system (i.e. the brain and spinal cord).
The peripheral nervous system (including the autonomic nervous system, i.e. all neural structures
outside the brain and spinal cord).

The peripheral nervous system consists of 12 pairs of cranial nerves and 31 pairs of spinal nerves (with
their subsequent branches). The spinal nerves are numbered according to the level of the spinal cord
from which they arise (the level is known as the spinal segment).

The relevant peripheral nerve supply is listed with each muscle presented in this book, for those who
need to know. However, information about the spinal segment* from which the nerve fibres emanate
often differs between the various sources. This is because it is extremely difficult for anatomists to trace
the route of an individual nerve fibre through the intertwining maze of other nerve fibres as it passes
through its plexus (plexus = a network of nerves: from the Latin word meaning braid). Therefore, such
information has been derived mainly from empirical clinical observation, rather than through dissection
of the body.

In order to give the most accurate information possible, I have duplicated the method devised by
Florence Peterson Kendall and Elizabeth Kendall McCreary (see Resources: Muscles Testing and
Function). Kendall & McCreary integrated information from six well-known anatomy reference texts,
namely those written by Cunningham, deJong, Foerster & Bumke, Gray, Haymaker & Woodhall and
Spalteholz. Following the same procedure, and then cross-matching the results with those of Kendall &
McCreary, the following system of emphasising the most important nerve roots for each muscle has been
adopted in this book.

Let us take the supinator muscle as our example, which is supplied by the deep radial nerve, C5, 6, (7).
The relevant spinal segment is indicated by the letter [C] and the numbers [5, 6, (7)]. Bold numbers [e.g. 6]
indicate that most (at least five) of the sources agree. Numbers that are not bold [e.g. 5] reflect agreement
by three of four sources. Numbers not in bold and in parentheses [e.g. (7)] reflect agreement by two
sources only, or that more than two sources specifically regarded it as a very minimal supply. If a spinal
segment was mentioned by only one source, it was disregarded. Hence, bold type indicates the major
innervation; not bold indicates the minor innervation; and numbers in parentheses suggest possible or
infrequent innervation.

Spinal cord Dorsal root

Dorsal
primary
Spinal nerve
ramus

Ventral
* A spinal segment is the part of the spinal cord that
primary
gives rise to each pair of spinal nerves (a pair consists
ramus of one nerve for the left side and one for the right side
of the body). Each spinal nerve contains motor and
sensory fibres. Soon after the spinal nerve exits
through the foramen (the opening between adjacent
Ventral vertebrae), it divides into a dorsal primary ramus
root (directed posteriorly) and a ventral primary ramus
(directed laterally or anteriorly). Fibres from the dorsal
rami innervate the skin and extensor muscles of the
Figure 1: A spinal segment, showing the nerve roots combining to form a neck and trunk. The ventral rami supply the limbs,
spinal nerve, which then divides into ventral and dorsal rami. plus the sides and front of the trunk.
92 ILIOPSOAS (PSOAS MAJOR/ILIACUS) ILIOPSOAS (PSOAS MAJOR/ILIACUS) 93

Greek, psoas, muscle of loin; major, large; iliacus, pertaining to the loin.
Muscles of the Trunk and Spine

Muscles of the Trunk and Spine

Strengthening
exercises
The psoas major and iliacus are considered part of the posterior abdominal wall due to their position and
cushioning role for the abdominal viscera. However, based on their action of flexing the hip joint, it would
also be relevant to place them with the hip muscles. Note that some upper fibres of psoas major may insert
by a long tendon into the iliopubic eminence to form the psoas minor, which has little function and is absent
in about 40% of people. Bilateral contracture of this muscle will increase lumbar lordosis.

Origin
Psoas major: bases of transverse processes of all lumbar vertebrae, (L1L5). Bodies of twelfth thoracic and all
lumbar vertebrae, (T12L5). Intervertebral discs above each lumbar vertebra.
Hanging leg raise
Iliacus: superior two-thirds of iliac fossa. Internal lip of iliac crest. Ala of sacrum and anterior ligaments of the
lumbosacral and sacroiliac joints.

Insertion
Psoas major: lesser trochanter of femur.
Iliacus: lateral side of tendon of psoas major, continuing into lesser trochanter of femur.

Psoas major Iliacus Action

Main flexor of hip joint (flexes and laterally rotates thigh, as in kicking a football). Acting from its insertion,
flexes the trunk, as in sitting up from the supine position.

Nerve
Psoas major: ventral rami of lumbar nerves, L1, 2, 3, 4. (psoas minor innervated from L1, 2).
Multi-hip machine Iliacus: femoral nerve, L1, 2, 3, 4.
(hip joint flexion)
Basic functional movement
Example: Going up a step or walking up an incline.
Self stretches
Indications
Low back pain. Groin pain. Increased (hyper) lordosis of lumbar spine. Anterior thigh pain. Pain prominent
in lying to sitting up. Scoliosis. Asymmetry (pelvic).

Referred pain patterns

a) Strong vertical ipsilateral paraspinal pain along lumbar spine, diffusely radiating laterally 37cm;
b) strong zone of pain 58cm top of anterior thigh, within diffuse zone from ASIS to upper half of thigh.

Differential diagnosis
Osteoarthritis of hip. Appendicitis. Femoral neuropathy. Meralgia paresthetica. L45 disc. Bursitis.
Push right hip forward to
stretch right iliopsoas.
Quadriceps muscle injury. Mechanical back dysfunction. Hernia (inguinal/femoral). Gastrointestinal.
Keep low back flat and Rheumatoid arthritis. Space occupying lesions.
Posterior referred pain distribution
maintain upright posture.
Also consider
Quadratus lumborum. Multifidis. Erector spinae. Quadriceps. Hip rotators. Pectineus. Tensor fasciae latae.
Adductors (longus and brevis). Femoropatellar joint. Diaphragm.

Psoas major Advice to patient

Avoid prolonged sitting. Avoid sleeping in foetal position. Treat low back. Avoid overuse in sit ups.
Iliacus Strengthen transversus abdominis. Stretching exercises.

Conjoined tendon
Techniques

Spray and stretch Dry needling

Injections Trigger point release