Legs & Arms unit 3



Welcome to Beyond Trigger Points Seminars Module 3 on the Biceps Brachii, Brachialis, Triceps Brachii and Supinator Muscles. Since our livelihood as manual therapists and many of our recreational passions are built upon the health of our arms, elbows, wrists, and hands, ask yourself the following question as you are listening to this module: what more can I do to prevent injury to my arms while I’m working? We're going to drill deeply into this idea as well as widening your ability to treat tennis and golfer’s elbow.

On page 20 of the student study guide the actions of the bicep brachii (and for clarity I’m going to shorten that name to biceps) are:

1. Flexes at the elbow

2. Supination of the forearm at the elbow when it’s bent. For example when holding a bucket of water to the side in the carrier position, the bicep can powerfully assist supination of the forearm.

3. Assists flexion and abduction of the arm

So this two-headed muscle crosses three joints and assists in flexion at the shoulder and elbow and assists in supination when the elbow is partly bent but not straight.

On page 21 of the study guide or page 649 of our textbook, you'll see two centrally located trigger points in the biceps. On the body scan on page 20, draw one TrP in the long head and the other in the more medially positioned short head. Those two documented trigger points refer sensation upward over the bicep region and into the anterior shoulder. A lesser pain sensation in the antecubital space may also be present.

To show you where it hurts, a client will usually take one or two of their fingers and draw a straight line up and down over the bicep area.

The second muscle is the brachialis. It lies deep to the biceps. Its primary action is elbow flexion. Because it only crosses one joint, it is the work horse of elbow flexion.

The brachialis’ pain pattern is also shown on page 21 or on page 661 of the text. The bicep has been retracted to show four of the brachialis’ documented trigger points. The brachialis has some interesting pain patterns. The secondary pain pattern is very similar to what you just drew for the biceps. However the primary pain complaint is over the base of the thumb. Clients may show you were it hurts by grasping their entire thenar eminence. When the patient’s elbow is flexed 30 or so degrees, the biceps can be pushed medially to palpate for taut bands harboring the four TrPs in the distal half of the brachialis muscle.

Now on page 22 of the study guide, let's answer the question, what factors activate and perpetuate the biceps and the brachialis muscles?

There are two categories:

1. Acute or repetitive overexertion - as when shoveling snow after a big storm. My mother had this pain complaint into her thumb and a defined line of pain up her bicep area persisting for months after pulling her suitcases off a conveyor belt. Other activities include a strong backhand tennis stroke with the elbow straight or repetitive supination as when using a screwdriver.

2. Static loading also referred to as sustained exertion. My instructor in school developed pain from a bicep TrP after a heavy patient schedule and teaching. With that shared, I still think the best tool for working TrPs is with the tip of your elbow even if it does require sustained flexion of the arm. We’ll discuss strategies for that shortly. Playing a violin or the flute also requires static loading of the elbow flexors.

Static loading is essentially an isometric muscle contraction. According to some studies, as the muscle is contracted fluid pressure inside the muscle increases. When the contraction is sustained at maximum effort, even for a few seconds, the fluid pressure inside a muscle can be four times higher than the fluid pressure of the surrounding capillaries. It's speculated that this pressure prevents blood from flowing into the muscle. This results in ischemia. So again, even moderate durations of strong static muscle contraction may be enough to reduce blood flow into the working muscle. Ischemic muscles are more likely to fatigue quicker placing them and the structures around them at risk for injury.

I want us to start thinking about how we can minimize the fatigue caused from the static loading we place on our bodies. Cause hey- we do an incredible amount of static loading as massage therapists. As my colleague/friend says, does it look like I can take a coffee break here? No! When we are working around the table we are generally applying pressure to our client’s body for a long period of time. You might ask yourself - why would one massage therapist experience static loading injury while another therapist is just fine?

One answer to this is the amount of force and effort being applied. Force and effort are often interchanged terms but in fact they are two different concepts. Force is what you, and the fill-in is, create by applying pressure on a trigger point, for example. Effort is what you experience in your body as you generate the force. So how can you apply force while minimizing your effort?

I'm going to suggest three things. Begin applying them tomorrow because as we move down the arm into the forearm and hands during the next module, I will be layering on more suggestions.

1. Use large, strong muscles, such as the biceps and brachialis. They are much stronger than the smaller muscles of the forearm. And the legs and hips are much stronger than the arms. A good ratio I think between standing and sitting during a one-hour massage is 45 minutes of standing and 15 minutes of sitting. This keeps our larger muscles working more when we stand and allows them to rest when we sit; thus saving our smaller arm muscles for the more detailed work.

Another way we can reduce the effort used around the table is -

2. Find neutral positions. Less effort is required to apply force when our body is aligned. There is a postural exercise for you and your clients called the 5 Point Stance on the resource tab of the website, . When really understood and applied, great posture can be used in every position you assume around the table. It's much easier for our body to apply force to a TrP for example when our shoulder is aligned over our elbow. However in most massage strokes we are moving from one position to the next. A jewel of an idea is this; try hitting the neutrally aligned position as often as you can. We will always come off of neutral but then we discipline ourselves to move back into the more effortless aligned position as soon as our body awareness recognizes the imbalance. Think about what more you can do to move through and back into alignment. Don’t forget to check out the postural awareness exercise on the website. Performing the exercise regularly will help create a muscle memory.

3. A third way to apply force with less effort is simply to stay relaxed. Having confidence helps. When you know you are appropriately treating a client and feel confident about your ability to be helpful, confidence follows. In my experience as a teacher, I have observed how it takes a thousand massages, doesn't it, till you can call yourself a true beginner. The difference between a beginner and a true beginner is the level of confidence. So, for those of you who are new with the trigger point work, and are just familiarizing yourself with lay of the land; I'm going to suggest one thing, fake it till you make it. If you stay relaxed you will use less effort while doing your work. At the very least the confidence you express while working will not only be experienced as a more relaxing massage for the receiver but it will also be easier on your body.

Staying relaxed also implies leaving our emotional tension at home. As a friendly reminder, what we're thinking and feeling is brought to the table and is transmitted through our hands. Professionals leave their personal problems on the other side of the treatment room. A colleague friend of mine deposits her problems at a tree outside our office door. She tells the tree, Tree I’ll be back for these problems later. She tells me Cathy; I always forget to pick them up. After two decades of working, I am still amazed by how restorative massage can be for both the giver and the receiver.

The next question on page 22 is, describe some tests used to determine involvement of these two elbow flexors. Box A in the picture below shows the initial test positioning of the Biceps-extension Test with the patient seated, forearm pronated, elbow straight and the arm abducted to about 45 degrees. The solidly outlined arm shows normal range of motion. The dashed line shows the elbow bending to compensate for shortened biceps. Placing your hand on the shoulder while extending the arm back will also prevent a compensatory medial rotation. Again, if the elbow bends as the arm is moved into extension at the glenohumeral joint, then there may be tightness in the biceps.

What are the corrective actions? I’ll mention three.

1. Sleep with a pillow positioned to prevent elbow flexion. My mom sleeps on her belly. She curls her arm up tight by her head. Straightening her elbow at night helped her bicep pain. At the top of the next page is a picture of some correctives for this muscle. One of the pictures shows the stretch for the bicep. So number 2 is:

2. Teach an Against-doorjamb Stretch. Grab hold of a doorjamb, thumb down, and lean away until you feel it into your anterior deltoid and down the bicep region.

3. Unload the bicep by carrying objects close to the body with the hands in a neutral position as described at the bottom of page 23.

I think this is an easy muscle to treat because it responds well to treatment and the home corrective protocol.

Let’s move on now to the actions of the triceps.

The main action is to extend the elbow. The long head of the triceps crosses two joints. Along with extending the elbow, it adducts and extends the arm at the shoulder joint. Let me repeat, the long head adducts and extends the arm at the shoulder joint. Looking at the picture on page 25 of the study guide you see how the long head attaches onto the scapula. The medial and lateral heads only cross one joint. The medial head lies deep against the entire posterior surface of the humerus bone and hence is also referred to as the deep head. In the same way the brachialis was the workhorse of flexion at the elbow, the deep or medial head of the tricep is the workhorse of extension at the elbow.

Dr Travell’s nickname for the tricep was the Vague Posterior Arm Pain Muscle. The three heads of the tricep each have their own documented TrPs. Why don’t we start with the more medially located long head? There are two centrally located TrPs in region 1 of the long head. The TrPs are numbered in order of highest prevalence based on the authors’ experience. So a common pain pattern originating from the triceps is pain and tenderness upward over the posterior deltoid with some possible spillover across the trapezius and downward to the lateral epicondyle with some possible spillover over the dorsum of the forearm.

TrP2 lies in the lateral portion of the medial head. It is a distal attachment trigger point with a referred pain pattern into the lateral epicondyle.

TrP3 is a centrally located trigger point in the lateral head of the triceps. Its pain pattern is a vague posterior arm pain. Your clients will describe it by taking their hand and covering the back of their arm. TrP3 might have some spill over into the back of the forearm and into the 4th and 5th digits. Taut bands in the lateral head may entrap the radial nerve. I really want to encourage you to draw the pain patterns and begin memorizing them.

TrP4 is an attachment TrP in the musculotendinous region of the elbow. Its referral is over the olecranon process. This is a good example of how unrelieved tension from a taut band produced by a central TrP causes trouble at the attachment. So, TrP4 might be the result of tension caused from TrPs 1, 3 or 5. An attachment TrP characteristically has enthesopathy associated with it. Enthesopathy is a disease process occurring at muscle insertions because of the recurring concentration of muscle stress. It provokes inflammation with the strong tendency towards fibrosis and calcification. A crunchy, broken glass like feeling over the osseous attachment site may be indicative of enthesopathy due to a central TrP.

I don’t mind telling you, our athletes are the luckiest people on the planet having us to take care of their arms. Many sports activities require intense contraction of the dominant hand’s tricep. Batting a baseball and swinging a golf club are the two notable exceptions. The non-dominant arm’s tricep acts as the prime mover during golfing and batting. In my practice I’ve treated scores of right-handed individuals with left sided elbow pain from a nearby golfing community. If tension is allowed to build up in the tricep muscle, I think your clients will have fewer elbow problems if we are treating the triceps. That applies to massage therapists too!

Finally TrP5 shown on page 26 is more medially positioned in the medial/deep head than TrP2. TrP5 is centrally located and easily palpated from an anterior approach. Draw its pain pattern along the medial epicondyle and a spillover into the fourth and fifth digits. Golfer’s elbow is frequently associated with pain on the medial side of the elbow such as caused from this muscle.

The factors activating and perpetuating the tricep are acute and repetitive stress. I’ll use three examples.

1. A golf and batting swing particularly on the non-dominate arm. So the repetition of hitting balls in a batter’s cage or on a driving range can cause an overload stress leading to TrP formation.

2. Backhand “mis-hits” in tennis. I’ll discuss this more with the supinator.

3. Repetitively pressing down on something like the shifting gears of a manual transmission, or excessive push-ups. I had a paralegal woman who spent a lot of time pressing down heavy law books onto a copy machine.

One of my dear clients had an acute activation of his left tricep following a near crash of a private airplane he was piloting. The steering system broke. As he watched the ground approaching quickly thinking how his wife in the back seat would kill him if he killed them, he extended his arms with all his might to keep the plane from nose-diving. A day or two after that, he noticed a terrible pain in his left lateral epicondyle preventing him from playing golf. Months went by and after seeing an orthopedic surgeon who said he needed surgery, a physical therapist that did strength training and an acupuncturist, he found his way into my office. Sure enough, he had trigger points in the medial head of his tricep and also in the extensor carpi radialis longus reproducing his pain complaint to the lateral epicondyle. After that one treatment, he became an angel to my new practice in Florida by referring lots of his golfing buddies. He also knew a reporter who did a full page article on massage with a picture of the two of us. As I remember, that free article generated nine new clients.

At the bottom of page 27, you can see a picture of someone raising their arms. The right arm tests positive for tricep shortness of the long head because it falls short of being able to squeeze tight against the ear. The shortened long head prevents full elevation of the arm at the shoulder joint.

Three corrective actions to restore the triceps to their normal resting position are:

1. Use arm rests for elbow support. When you're reading a book, for example, rest the forearms on a pillow placed across the lap.

2. Change the grip on the tennis racket or golf club. Golfers may need a lighter club or a wider grip. This might apply to a tennis racket as well.

3. Avoid chin-ups and push-ups while the muscle is initially being treated. Emphasize the following stretch for the triceps. I’ll talk you through it now. Raise one arm up straight as if you're raising your hand. Then drop that same hand down to the shoulder blade on the same side. Take your other hand and move the stretching arm closer to your ear while pushing the arm back to pick up the slack in the tricep. Go ahead and stretch the other arm too.

On the next page of your student study guide we have another very interesting muscle to exam. The supinator has been nicknamed the Tennis Elbow muscle, as we shall see why. Its action is to supinate the forearm at the radioulnar joint and secondarily assist flexion at the elbow.

On page 729 of the text or page 29 of the study guide, you see its one documented trigger point. The primary pain complaint is to the lateral epicondyle and to the surrounding lateral area of the elbow. Spillover pain may project to the webbing of the thumb. It’s been my experience that your client may not tell you about the thumb discomfort because the elbow pain is so much more intense. I think you will find the supinator to be the more commonly involved muscle of lateral epicondyle pain

The term “tennis elbow” is often a wastebasket term used to describe pain in the lateral epicondyle. Statistically however, 40-50% of recreational tennis players, primarily between the ages of 30-55 years of age, do develop tennis elbow. Let me tell you, when that pain happens in your elbow - you do NOT swing a tennis racket. It's just too painful.

Like the tricep attachment to the posterior elbow, the supinator TrP muscle, if left untreated, can cause fibrotic changes at its elbow attachment. Chronic inflammation is not good for the health of the tissue. It can cause degenerative tissue damage and more permanent problems at the joint. Our job is to reduce the tension on the belly of the muscle so the tension on the joint is reduced.

On page 28 let’s answer the question, what tests could you perform to determine supinator involvement?

1. Pain during supination of the forearm against resistance. In other words, when lying supine with the arm straight and the palm in neutral, your applied resistance against their hand or wrist will limit full supination of the forearm.

2. Tapping the lateral epicondyle might also elicit pain if enthesopathy has developed.

What activates and perpetuates symptoms of tennis elbow? The stories we hear when people present with supinator problems are these:

1. Tennis mis-hits. Drs Travell & Simons were both avid tennis players and talked quite a bit about this work while playing. One way a person injures their elbow is from a one handed backstroke. Two handed backstroke players have less trouble. A straight elbow and a dropped wrist overload the supinator and weaken the wrist. When the ball mis-hits off the center of the racket the wrist will flip the ball back causing supinator strain.

2. Carrying heavy suitcases might be another activation factor.

3. Wringing out rags or scrubbing walls or unscrewing tight lids using only your wrist.

The corrective actions are straightforward. Along with stretching and strengthening exercises, I want to share the best advice I have for my tennis players. Take a tennis lesson. That might be the best advice you can give. Professional tennis coaches know how to correct the stroke to create less injury and less awkward positions. Also learning to carry packages with the forearm supinated as shown in Box A on page 23 unloads the supinator muscle and uses bicep strength.

That concludes our lesson on the arm. In the next module we will explore the forearm, wrist and hand. Until then, stay in touch.

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