Travell & Simons' myofascial pain and dysfunction : the trigger point manual

1052 Pages·1999·60.06 MB·English

by  David G Simons

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Pain Patterns
Page Page
Abdominal Muscles 942, 944, 945 Multifidi 917
Abdominis Obliqui Obliqui Capitis Superior
and Transversus 942 and Inferior 473
Abductor Digiti Minimi 787 Occipitalis 428
Adductor Pollicis 775 Occipitofrontalis 428
Anconeus 670 Opponens Pollicis 775
Anterior Neck Muscles 398 Orbicularis Oculi 417
BicepsBrachii 649 Palmaris Longus 744
Brachialis 661 Pectoralis Major 820,822
Brachioradialis 693 Pectoralis Minor 845
Buccinator 418 Platysma 417
Coracobrachialis 639 Posterior Cervicals 447
Deltoid 624 Pronator Teres 757
Diaphragm 863, 864 Pyramidalis 945
Digastric 398 Rectus Abdominis 944
Extensor Carpi Radialis and Recti Capitis Posteriores
Extensor Carpi Ulnaris 692 Major and Minor 473
Extensor Digitorum 715 Rotatores 917
Extensor Indicis 715 Rhomboid Major and Minor 614
Facial Muscles 417, 418 Scaleni 506
Finger Extensors 715 Semispinalis Capitis and
Flexores Carpi Radialis and Cervicis 447
Ulnaris 756 Serratus Anterior 888
Flexores Digitorum Superficialis Serratus Posterior Inferior 909
and Profundus 756 Serratus Posterior Superior 901
Flexor Pollicis Longus 757 Splenius Capitis and Splenius
Frontalis 428 Cervicis 433
Hand and Finger Flexors 756,757 Sternalis 858
Hand Extensors 692 Sternocleidomastoid 310
Iliocostalis Thoracis and Subclavius 823
Lumborum 915 Suboccipital Muscles 473
Infraspinatus 553 Subscapularis 598
Intercostal Muscles 863 Supinator 729
Interossei of the Hand 787 Supraspinatus 539
Lateral Pterygoid 380 Temporalis 351
Latissimus Dorsi 573 Teres Major 588
Levator Scapulae 493 Teres Minor 565
Longissimus Capitis 446 Thoracolumbar Paraspinals 915,917
Longissimus Thoracis 904 Trapezius 279, 280, 281
Masseter 331 Triceps Brachii 668, 669
Medial Pterygoid 366 Zygomaticus Major 417
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HEAD AND NECK
PAIN-AND-MUSCLE GUIDE
CHAPTER 5
UPPER BACK,
SHOULDER AND ARM
PAIN-AND-MUSCLE GUIDE
CHAPTER 18
FOREARM AND HAND
PAIN-AND-MUSCLE GUIDE
CHAPTER 33
TORSO
PAIN-AND-MUSCLE GUIDE
CHAPTER 14
Pictorial index. The muscles that are likely to refer pain to an illustrated region
of the body are listed in the Pain-and-muscle Guide to the corresponding Part of
the Manual. A Guide is found at the beginning of each Part, which is marked by
red thumb tabs.
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Travell & Simons'
Myofascial Pain
and Dysfunction:
The Trigger Point Manual
VOLUME 1. Upper Half of Body
Second Edition
Copyrighted Material
Travell & Simons'
Myofascial Pain
and Dysfunction:
The Trigger Point Manual
VOLUME 1. Upper Half of Body
Second Edition
DAVID G. SIMONS, M.D., FAAPM&R, M.S., DSC (HON.)
Clinical Professor, Rehabilitation Medicine
Emory University School of Medicine
Atlanta, Georgia
Clinical Professor
Department of Physical Medicine and Rehabilitation
University of California, Irvine
Formerly Clinical Chief
Electromyography and Electrodiagnosis Section
Rehabilitation Medicine Service
Veterans Affairs Medical Center
Long Beach, California
JANET G. TRAVELL, M.D. t
LOIS S. SIMONS, M.S., P.T.
Consultant, Myofascial Pain and Dysfunction
Illustrations by Barbara D. Cummings
with contributions by Diane Abeloff and Jason Lee
Williams &: Wilkins
A U'AVKKLY ( OMPANY
BALTIMORE • PHILADELPHIA • LONDON • PARIS • BANGKOK
BUKNOS AIKI-.S • HOW. KOW, < MUNICH • SVHNHV • I'OKYO • WROCLAW
t Dr. Janet Travell's genius and medical insight identified in the first edition the clinical picture of individual myofascial
pain syndromes and many perpetuating factors. In addition, we were most fortunate to have had the benefit of her advice
in preparing some of this edition. She emphasized the importance of including a new chapter that covers the respiratory
muscles and supplied unique pearls of clinical wisdom that sprinkle this revision.
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Editor: Eric Johnson
Managing Editor: Linda Napora
Project Editor: Jeffrey S. Myers
Marketing Manager: Chris Cushner
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The publisher is not responsible (as a matter of product liability, negligence or otherwise) for any injury re
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ciples of medical care which should not be construed as specific instructions for individual patients. Man
ufacturers' product information and package inserts should be reviewed for current information, including
contraindications, dosages and precautions.
Printed in the United States of America
First Edition, 1983
Library of Congress Cataloging-in-Publication Data
Simons, David G.
Travell & Simons' myofascial pain and dysfunction : the trigger point manual / David G. Simons, Janet
G. Travell. Lois S. Simons ; illustrations by Barbara D. Cummings, with contributions by Diane Abeloff and
Jason Lee. — 2nd ed.
p. cm.
Rev. ed. of: Myofascial pain and dysfunction / Janet G. Travell, David G. Simons. cl983-cl992.
Includes bibliographical references and index.
Contents: v. 1. Upper half of body.
ISBN 0-683-08363-5 (v. 1)
1. Myofascial pain syndromes—Handbooks, manuals, etc.
I. Travell, Janet G, 1901- . II. Simons, Lois S. III. Travell, Janet G., 1901- Myofascial pain and dys
function. IV. Title.
[DNLM: 1. Myofascial Pain Syndromes. WE 500S611t 1998]
RC925.5.T7 1998
616.7'4—dc21
DNLM/DLC
for Library of Congress 98-36642
CIP
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Copyrighted Material
This Volume is dedicated to
Janet G. Travell, M.D.
1901 - 1997
To whom we all owe a great debt of gratitude
for her inspirational pioneering of this field
and for heading us in the right direction.
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Foreword
In my 1992 Foreword to the now-fa mits me to predict a magnificent success.
mous mate, Volume 2, of the Trigger Point This is a gargantuan publishing effort that
Manual Volume 1,1 boldly opined that Vol would have done Rabelais credit. But this
ume 2 was "... even better than the other Gargantua is not fantasy; it is hard-headed
[Vol.1] because it reflects an enormous new facts and a wise explication of many cur
recharging of energy that further experi rent ideas and new findings.
ence, interaction, and thought have stimu The new edition clarifies for me the
lated.... This new volume," I went on to overlap of confusing similar conditions
say, "has the distinction of going beyond that must be distinguished. It illuminates
those areas [emphasized in the first edition improved testing methods and clearly puts
of Volume 1] to discuss rationale, new others into their place, often outside. The
principles arising from a ground-swell of authors are forthright and precise in the di
experience, and the unique place of myo agnostic criteria for an active trigger point
fascial pain syndrome in the spectrum of for general clinical use as a "... circum
musculoskeletal disorders." scribed spot tenderness in a nodule of a
"Myofascial trigger points and their sig palpable taut band and patient recognition
nificance in painful conditions are no of the pain evoked by pressure on the ten
longer the rather controversial subject they der spot as being familiar."
were before Volume 1 appeared, nor are the The thorough discussion of the nature of
treatment methods taught by Drs. Travell trigger points and their electrodiagnostic
and Simons. These are firmly established characteristics is very valuable and timely,
and are increasingly being validated by as is the coverage of the histogenesis of
once skeptical clinical investigators ...[Vol trigger points. Updating and expansion
ume 2] goes beyond and opens up new throughout the volume now make the two
ground in sensitizing clinicians to the im volumes together one of the most impres
portant interfaces between myofascial pain sive medical publishing efforts of modern
syndromes and articular (somatic) dys times. Truly it becomes a tour de force. I
functions on the one hand and fibromyal am proud to be its "godfather."
gia on the other hand. I applaud the wise
manner in which these issues are ad
dressed, assessed, and integrated."
How can this scribbler do any better John V. Basmajian, O.C., O. Ont, MD,
than that eulogy to summarize his opinion FRCPC, FRCPS (Glasg]
of the macho younger mate of Volume 1 FACA, FAADMR, FSBM, FABMR,
when the latter now produces an offspring FAFRM-RACP (Australia), Hon Dip (St L C)
that outshines both its parents? My scan Professor Emeritus, McMaster University
ning of the manuscript before its birth per Hamilton, Ontario, Canada
vii
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At present, the only way to make a definite diagnosis Each muscle has individual characteristics which the
of a trigger point is by physical examination. This fig examiner needs to learn. When active trigger points in
ure emphasizes the fact that the ESSENTIAL first step any muscle fail to respond to treatment, with few ex
is to learn how to recognize by palpation the nodule ceptions one or more perpetuating factors need to be
and taut band that are characteristic of a trigger point. identified and resolved.
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Preface
The passing of Janet Travell, M.D., on 1 matic." In none of these patients did the
August 1997 at the age of 95 marked the doctors find objective evidence of disease
end of the era when she gave life to the to account for the patient's pain, but the
concept of myofascial trigger points (TrPs) skeletal muscles had not been examined.
and nurtured it through childhood. Others When Dr. Travell examined these patients,
must now lead the concept through adoles all three groups had isolated tender spots
cence to maturity. in muscles which, when compressed, re
As a memorial and tribute to Dr Travell's produced the patient's pain in the shoul
unique contribution, the following selec der, arm or chest. The common ailment
tion is quoted from the preface of the first was an unrecognized myofascial trigger
edition of this volume: "Dr. Travell de point syndrome.
scribes in detail her introduction to myo "Fortunately, these observations were
fascial trigger points in her autobiography, made in an environment rich in experi
Office Hours: Day and Night. Although she mental expertise. She regularly taught
was brought up on the unitary concept of pharmacology to medical students whom,
disease that all of the patient's symptoms to answer their questions, she inspired to
should be explained by one diagnosis, she perform the appropriate experiments for
soon learned that life is not like that. The themselves in the laboratory. The inquisi
man who has both heart disease and pul tive students and faculty at the Cornell
monary tuberculosis may suddenly die of University Medical College helped Dr.
cancer of the lung. Patient complaints that Travell formulate her investigation of the
originate in the musculoskeletal system nature of trigger points and how they func
usually have multiple causes responsible tion.
for the total picture. "She herself was inspired by the inter
"Early in her medical career, Dr. Travell change of ideas and the criticism of leaders
served simultaneously on pulmonary, car in basic and clinical research at the New
diology, and general medical services. On York Hospital, Cornell Medical College
all the services, the major complaint she Center. Foremost among these were Drs.
encountered among the patients was pain. Harry Gold, McKeen Cattell, Vincent du Vi-
The patient might be dying of a serious ill gneaud, Ephraim Shorr, Harold G. Wolff,
ness, but when asked, "How are you?" Eugene F. Dubois, and the renowned neu
would answer, "Well, ok, except I have this rologist, Frank Fremont-Smith, Director of
terrible pain in my shoulder. I can't sleep. the Josiah Macy Foundation. During the
I can't lie on that side." When asked the many years of their association, she was es
cause of the pain, the resident on the pul pecially indebted to her cardiologist col
monary service would say that it was reflex laborator, Seymour H. Rinzler.
from the lung. On the cardiology service, "The successful care rendered Senator
in another hospital, patients had the same Kennedy five years prior to his election as
complaint of shoulder pain, but the resi President led Dr. Travell to the position of
dent explained the pain as reflex from the White House Physician under Presidents
heart, of course. In the general medical John F. Kennedy and Lyndon B. Johnson.
clinic, a secretary who spent all day typing Except for that one short detour, she never
and pulling heavy file drawers would de strayed from her primary focus on the di
scribe precisely the same pain complaint; agnosis and management of myofascial
but its origin was said to be "psychoso pain syndromes due to trigger points."
ix
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