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Ростовский Государственный Медицинский Университет
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Медицина общая
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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5548_Библиотеки_им_академика_М_И_Перельмана.pdf
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1.
Perform effleurage strokes on the top leg from the knee to the iliac crest.
2. Perform circular friction with the heel of your hand from the knee to the iliac crest.
Connective Tissue
MYOFASCIAL SPREADING
Place the heels of your hands on the midline of the thigh at the knee. Stroke outward with both hands, spreading the tissues in opposite directions. Continue, working in strips, to the iliac crest.
Chapter 9 Stabilizing the Core 205
Along the anterior portion of the vastus later­alis, a group of trigger points may be found at
midthigh level that refer pain along the length of the muscle. The majority of trigger points form along the lateral aspect of the muscle. They may be spaced just above the knee, in the middle of the thigh, and at the attachment on the upper femur.
Trigger points in the superficial fibers fire more lo­cally. Trigger points in the deeper layers shoot pain throughout the muscle and down to the side of the knee.
Deep Tissue/Neuromuscular Therapy
POSITION
r The client remains in side posture. r
The therapist stands at the front side of the table and faces the client’s flexed thigh.
Vastus Lateralis
Origin: Intertrochanteric line, greater trochanter, gluteal
tuberosity, lateral lip of the linea aspera, lateral inter­muscular septum.
Insertion: Lateral border of the patella, patellar ligament
to the tibial tuberosity.
Action: Extension of leg at the knee joint.
Strokes
r Perform elongation strokes with the forearm or knuckles
along the lateral thigh in the space between the rectus femoris and iliotibial tract. Pause to treat trigger points (Fig. 9-49A).
r Perform elongation strokes with an elbow or the thumbs
along the distal half of the lateral thigh, in the space be­tween the iliotibial tract and biceps femoris (Fig. 9-49C).
r Pause to treat trigger points.
Iliotibial Tract
Strokes
r With your thumbs or elbow, press a line of points along
the iliotibial tract, from the knee to the greater trochanter (Fig. 9-49B).
C
B
A
DAR
FIGURE 9-49 Deep tissue strokes on
the vastus lateralis and iliotibial tract.
206 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
Tensor Fascia Latae
Origin: Anterior part of the outer lip of the iliac crest,
ASIS.
Insertion: Iliotibial tract. Action: Flexion, abduction, medial rotation of the hip.
Trigger points in this muscle usually refer pain along the iliotibial tract.
Strokes
r Standing behind the client at the level of the hip, place
your elbow on the anterior surface of the hip. Apply short, up-and-down and side-to-side strokes along the fibers of the muscle, between the iliac crest and greater trochanter (Fig. 9-50).
r Pause to treat trigger points.
◗ INNER THIGH
Swedish/Cross Fiber
POSITION
r The client remains in the same position as above. r The therapist works on the inner thigh muscles of the leg
that is against the table.
1. Perform effleurage strokes from the knee to the pelvis.
2. Perform circular friction on the muscle attachments at the knee. Perform cross-fiber fingertip raking on the adductor
3. muscles.
Connective Tissue
MYOFASCIAL SPREADING
Standing at the front side of the table and facing the client’s bottom leg, place the fingertips of both hands along the fibers of the adductor muscles, slightly above knee level. Using the spreading technique, slowly glide the fingers in a posterior direction, perpendicular to the direction of the fibers. Con­tinue, working in strips, to the pelvis.
Deep Tissue/Neuromuscular Therapy
POSITION
r The client remains in side posture. r The therapist stands at the front of the table and faces the
inner thigh of the client’s leg, which lies against the table.
Pes Anserinus (Attachment Points of Sartorius, Gracilis, and Semitendinosus)
Location: on the medial side of the proximal end of the
tibia.
DAR
FIGURE 9-50 Position for
contacting the tensor fascia latae.
Chapter 9 Stabilizing the Core 207
Strokes
r 1SFTTEPXOPOUIFJOTFSUJPOQPJOUTPOUIFCPOFXJUIZPVS
UIVNCTPSGJOHFST.PWFTMPXMZVQBOEEPXOBOETJEFUPTJEF
r
1BVTFBUUIFUFOEFSBSFBTVOUJMUIFQBJOEFDSFBTFTPSTVCTJEFT
Adductor Muscles
Adductor Magnus
Origin:*OGFSJPSSBNVTPGUIFQVCJTJOGFSJPSSBNVTPG
UIFJTDIJVNJOGFSJPSBOEMBUFSBM QBSUPGUIFJTDIJBM UVCFSPTJUZ
Insertion:-JOFBBTQFSBPGUIFGFNVS Action:)JQBEEVDUJPOBTTJTUTJOIJQFYUFOTJPOBOEMBUFSBM
SPUBUJPO
The trigger points in this muscle will probably be found in the middle portion. They project pain deep into the groin and pelvic region.
Adductor Brevis
Origin: Insertion:1SPYJNBMUIJSEPGUIFNFEJBMMJQPGUIFMJOFBBT-
Action:)JQBEEVDUJPO
Adductor Longus
Origin:"OUFSJPSQBSUPGUIFQVCJT Insertion:.JEEMFUIJSEPGUIFNFEJBMMJQPGUIFMJOFB
Action:)JQBEEVDUJPOBTTJTUTJOMBUFSBMSPUBUJPOXIFOUIF
Gracilis
Origin:*OGFSJPSSBNVTPGUIFQVCJTOFBSUIFTZNQIZTJT Insertion:.FEJBMTVSGBDFPGUIFTIBGUPGUIFUJCJBCFMPXUIF
Action:)JQBEEVDUJPOLOFFGMFYJPOBTTJTUTJONFEJBMSPUB-
*OGFSJPSSBNVTPGUIFQVCJT
QFSBEJTUBMQFDUJOFBMMJOF
BTQFSB
IJQJTJOFYUFOTJPO
Trigger points in these muscles are frequently located near their attachment on the pubis.
Pain is referred to the upper medial thigh and into the groin region. Trigger points in the section of the muscles closer to the femur attachment refer pain down to the knee and perhaps over the upper tibia.
UJCJBMDPOEZMF
UJPOPGUIFLOFFXIFOUIFMFHJTGMFYFE
Insertion:'FNVSGSPNUIFMFTTFSUSPDIBOUFSUPUIFMJOFB
BTQFSB
Action:)JQBEEVDUJPOBTTJTUTJOIJQGMFYJPO
The common trigger point is palpated on the attachment of the muscle on the pubis. It sends pain deep into the groin.
Strokes
r 1MBDFUIFGJOHFSUJQTPGCPUIIBOETBMPOHUIFGJCFSTPGUIF
BEEVDUPSNVTDMFTBTJOUIFDPOOFDUJWFUJTTVFUFDIOJRVF BCPWF6TFTIPSUVQBOEEPXOBOETJEFUPTJEFTUSPLFTPO UIFNVTDMFCFMMJFTUPSFEVDFUFOTJPOJOBEIFSFOUGJCFSTBOE MPDBUFUSJHHFSQPJOUT'JH
r
'JOEUIFCPSEFSTPGUIFNVTDMFTXJUIZPVSGJOHFST4MJEFJO CFUXFFOUIFNVTDMFTBOENPWFUIFGJOHFSTVQBOEEPXO BMPOHUIFCPSEFSTUPTFQBSBUFUIFNVTDMFTGSPNFBDIPUIFS 8PSLGSPNUIFLOFFUPUIFQFMWJT
Avoid any pressure in the femoral triangle, which is located in the upper third of the medial thigh. The femoral nerve, artery, and vein pass through this area.
r 1MBDFZPVSGJOHFSTPSUIFCSPBETJEFPGUIFUIVNCBHBJOTU
UIFQVCJTBOENPWFTMPXMZTJEFUPTJEFBDSPTTUIFCPOFUP DPOUBDUUIF BEEVDUPS NVTDMFBUUBDINFOUTPOUIFQFMWJT 'JH
Obtain the client’s permission during the presession interview, and again during the session before per-
forming this stroke. Some clinicians find that inviting the client to make contact through the therapist’s hand can be a helpful way for the client to feel safe and in control.
STRETCH
Tensor Fascia Latae
Position
5IFDMJFOUJTMZJOHJOTJEFQPTUVSF XJUI UIF MFHUPCF
r
TUSFUDIFEQPTJUJPOFEPOUPQ
r 4UBOEJOHCFIJOEUIFDMJFOUUBLFIPMEPGUIFBOLMFPGIJT
PSIFSUPQMFH"CEVDUUIFMFHNFEJBMMZSPUBUFUIFUIJHI CZMFUUJOHUIFLOFFESPQTPNFXIBUUPXBSEUIFCPUUPNMFH BOEFYUFOEUIFUIJHIVOUJMBTUSFUDIJTGFMUPOUIFGSPOUPG UIFIJQBUUIFMPDBUJPOPGUIFUFOTPSGBTDJBMBUBF'JH
There may be a trigger point found halfway up the length of the muscle and another found three-
quarters of the way up to the pubis. Pain from these trigger points can be intense and burning, travel­ing along the entire muscle.
Pectineus
Origin:1FDUJOFBMMJOFPOUIFTVQFSJPSSBNVTPGUIFQVCJT
Adductors
Position
r
5IFDMJFOUJTMZJOHTVQJOFPO UIF UBCMFXJUICPUI MFHT FYUFOEFE
r 5IFUIFSBQJTUTUBOETBUUIFGPPUPGUIFUBCMF)PMEJOHUIF
DMJFOUTBOLMFMBUFSBMMZSPUBUFUIFMFHTMJHIUMZBOENPWF UIFMFHJOUPBCEVDUJPOLFFQJOHJUTUSBJHIUVOUJMUIFDMJFOU GFFMTBTUSFUDIJOUIFBEEVDUPSNVTDMFT'JH
208 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
Energy
POSITION
The client is lying supine, with the leg to be worked on
fully extended. A bolster may be placed under the knee of the other leg, if desired.
The therapist is standing at the side of the table and is fac-
ing the client’s pelvis.
POLARITY
The palm of the superior hand contacts the ASIS. The palm of the inferior hand rests on the knee. Envision the thigh lengthening and the tissues reorganizing themselves along the vertical axis running along the center of the
FIGURE 9-51 Direction of strokes on the adductor muscles.
thigh. Be sensitive to any subtle movements occurring in the thigh, and let your hands softly follow them. Hold for 30 to 60 seconds.
SHIATSU
With the palms or fists, compress the thigh from the hip to the knee. These compression movements stimulate the stomach and spleen channels, running approximately along the lateral and medial borders of the rectus femoris muscle.
FIGURE 9-52 Contacting the adductor muscle attachments on the
pubis.
◗ ANTERIOR THIGH/ILIOPSOAS
ROUTINE
Objectives
r To relax and lengthen the quadriceps muscles r To help correct anterior tilt of the pelvis r
To complete the opening and balancing of the pelvic region
r
To achieve more efficient movement patterns, originating from the core muscles
Swedish/Cross Fiber
1.
Perform effleurage strokes on the anterior thigh and knee.
2.
Perform kneading strokes on the anterior thigh muscles.
3. Perform friction strokes on the anterior thigh and knee.
4.
Apply cross-fiber strokes to the quadriceps muscles using the broad side of the thumb and/or the heel of the hand.
Connective Tissue
MYOFASCIAL SPREADING
Place the heels of the hand on the midline of the thigh, just above the patella. Slowly draw the hands apart, spreading the tissues. Continue, working in horizontal strips, to the hip.
Deep Tissue/Neuromuscular Therapy
SEQUENCE
1. Patellar ligament
2.
Quadriceps (vastus lateralis, rectus femoris, vastus inter­medius, and vastus medialis)
3. Abdominal warm-up
4. Iliacus
5. Psoas
Chapter 9 Stabilizing the Core 209
FIGURE 9-53 Stretch for the
tensor fascia latae.
FIGURE 9-54 Stretch for the
adductor muscles.
210 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
Patellar Ligament
Strokes
r Place your thumbs on the tibial tuberosity below the pa-
tella. Do short, up-and-down and side-to-side strokes on the ligament (Fig. 9-55D).
Quadriceps (Vastus Lateralis, Rectus Femoris, Vastus Intermedius, and Vastus Medialis)
Vastus Lateralis
Origin: Intertrochanteric line, greater trochanter, gluteal
tuberosity, lateral lip of the linea aspera, lateral inter­muscular septum.
Insertion: Lateral border of the patella, patellar ligament
to the tibial tuberosity.
Action: Extension of leg at the knee joint.
Along the anterior portion, a group of trigger points may be found at midthigh level that refers
pain along the length of the muscle. The majority of trigger points form along the lateral aspect of the mus­cle. They may be spaced just above the knee, in the mid­dle of the thigh, and at the attachment on the upper femur.
Trigger points in the superficial fibers usually fire more locally. Trigger points in the deeper layers refer pain throughout the muscle and down to the side of the knee.
Vastus Medialis
Origin: Lower half of the intertrochanteric line, medial lip
of the linea aspera, medial intermuscular septum, me­dial supracondylar line.
Insertion: Medial border of the patella, tibial tuberosity via
the patellar ligament.
Action: Extension of the leg at the knee.
The most frequently occurring trigger point is located in the lower, thick fibers on the medial
thigh, slightly above the knee. Pain may be exhibited along the medial side of the muscle. A second trigger point may form about halfway up the thigh. Left untreated, these trigger points may cause a weakening in the quadriceps and bouts of buckling of the knee when the person is walking.
Strokes
r
Using the forearm or knuckles, perform elongation strokes from the knee to the AIIS. Cover the area thoroughly between the sartorius muscle and the iliotibial tract (Fig. 9-55A).
r With the thumbs or elbow, trace the lateral and medial
borders of the rectus femoris muscle, from the patella to the AIIS (Fig. 9-55B).
Rectus Femoris
Origin: Anterior head—AIIS. Posterior head—groove of
the ilium above the acetabulum.
Insertion: Patella and tibial tuberosity via the patellar
ligament.
Action: Extension of the leg at the knee joint, flexion of
the thigh at the hip joint.
The most commonly occurring trigger point in this muscle is found just below its attachment on the AIIS. It refers pain to the knee area.
Vastus Intermedius
Origin: Anterior and lateral surfaces of the upper
two-thirds of the shaft of the femur, lower part of the lat­eral intermuscular septum.
Insertion: Deep aspect of the quadriceps tendon, patella,
and tibial tuberosity via the patellar ligament.
Action: Extension of the leg at the knee.
Trigger points in this muscle are difficult to pal­pate because of its position deep to the rectus
femoris. These trigger points tend to develop in clusters rather than singly. The pain referral zone is most concentrated at midthigh level but may extend down over the knee or to the upper thigh, depending on the location of the trigger point.
B
FIGURE 9-55 Sequence of deep tissue strokes on the quadriceps.
C
A
DAR
D
r
6TJOHUIFUIVNCTPSFMCPXUIPSPVHIMZXPSLTNBMMTFDUJPOT PGUIFNVTDMFTXJUIVQBOEEPXOBOETJEFUPTJEFTUSPLFT JO'JH$
Chapter 9 Stabilizing the Core 211
Insertion:-FTTFSUSPDIBOUFSPGUIFGFNVS Action:)JQGMFYJPOUSVOLGMFYJPOIJQFYUFSOBMSPUBUJPOJO
DPOKVODUJPOXJUIUIFQTPBT
Massage to the psoas group can be challenging to receive. Before proceeding, describe what will hap­pen next and secure the client’s permission.
Abdominal Warm-Up
Position
r
5IFDMJFOUJTMZJOHTVQJOFXJUI BCPMTUFSQMBDFEVOEFS CPUILOFFT
r 5IFUIFSBQJTUJTTUBOEJOHBUUIFTJEFPGUIFUBCMFOFYUUP
UIFDMJFOUTXBJTU  1FSGPSNDJSDVMBSFGGMFVSBHFPOUIFBCEPNFO  8BWFTUSPLF1MBDFUIFIFFMTPGCPUIIBOETBHBJOTUUIF
CPSEFSPGUIFSFDUVTBCEPNJOVTNVTDMFPOUIFTJEFPGUIF CPEZZPVBSFTUBOEJOHOFYUUPXJUIZPVSGJOHFSTDVSMFE BSPVOEUIFPQQPTJUFFEHFPGUIFNVTDMF'JH(FOUMZ QVTIBHBJOTUUIFBCEPNFOXJUIUIFIFFMTPGUIFIBOET DSFBUJOHBCVMHFJOGSPOUPGZPVSQBMNT8JUIZPVSGJOHFST SFBDIBDSPTTUPUIFPQQPTJUFTJEFPGUIFXBWFBOEQVMM UIFBCEPNJOBMUJTTVFCBDLUPXBSEZPV3FQFBUTFWFSBM UJNFTDSFBUJOHBGMVJEDPOUJOVPVTNPUJPO

6TJOHUIFIFFMPGUIFIBOEBQQMZDJSDVMBSGSJDUJPOBSPVOE UIFBCEPNFOJOBDMPDLXJTFEJSFDUJPO
Iliacus
Origin:4VQFSJPSUXPUIJSETPGUIFJMJBDGPTTBJOOFSMJQPGUIF
JMJBDDSFTUBOUFSJPSTBDSPJMJBDBOEJMJPMVNCBSMJHBNFOUT
A trigger point in the iliacus is frequently found in the upper portion of the muscle, slightly superior to the ASIS.
Strokes
1MBDFZPVSGJOHFSTBHBJOTUUIFJOOFS CPSEFS PGUIFJMJBD
r
DSFTUKVTUBCPWFUIF"4*4'JH"MMPXZPVSGJOHFST UPNFMUJOUPUIFUJTTVFTBTJGCFJOHESBXOJOUPRVJDLTBOE
r "QQMZTIPSUTJEFUPTJEFTUSPLFTXJUIZPVSGJOHFSTTJOLJOH
GVSUIFSJOUPUIFNVTDMF1BVTFBUBSFBTPGSFTJTUBODFBOE PSUFOEFSOFTT
Remain above the ASIS at all times. Avoid putting pressure on the inguinal ligament, which attaches to the ASIS and the pubis.
Psoas Major
Origin:*OGFSJPSCPSEFSTPGUSBOTWFSTFQSPDFTTFTPGUIF
-m-WFSUFCSBFCPEJFTBOEJOUFSWFSUFCSBMEJTLTPG UIF 5m-WFSUFCSBF
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The psoas major may manifest an active trigger point at the level of L3. The pain pattern for
the iliopsoas complex is along the side of the lumbar spine and into the sacral and buttock region. Pain may also be felt in the groin and down the front of the thigh.
When pressed, these trigger points usually refer pain to the back of the body. If the trigger points are on one side only, the pain zone is more vertical, along the lum­bar spine. If the trigger points are bilateral, pain may refer in a horizontal pattern across the low back.
FIGURE 9-56 Beginning hand position for the wave stroke.
Strokes
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212 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
DAR
DAR
FIGURE 9-57 Contacting the iliacus on the inner rim of the
tubercle of the iliac crest.
foot toward the ceiling, and then lower the straight leg to the table to alternately shorten and lengthen the muscle. Repeat a few times, moving your fingers along the length of the psoas.
r
With the client’s leg flexed, slide your arm under the client’s knee, and lift the leg off the table. The fingers of your other hand remain in contact with the psoas. Adduct the client’s thigh to access the lateral portion of the psoas. Abduct the thigh to reach the medial fibers of the muscle next to the spine (Fig. 9-59).
STRETCH
The client slides toward the end of the table so that the hips are against the edge of the table. The client then lies back on the table and holds the flexed knee of the nonstretched leg to his or her chest. The leg to be stretched is hanging off the end of the table, with the knee flexed.
Place one hand over the client’s hands that are holding the flexed knee. Assist in pressing the client’s thigh toward his or her chest as your other hand holds the thigh on the stretched side slightly above the knee. Press the thigh toward the floor (Fig. 9-60). This stretches the psoas muscle.
To stretch the rectus femoris, the client remains in the same position as above. Kneel down, and hold the ankle of the leg to be stretched. Slowly bring the heel in the direction of the
FIGURE 9-58 Contacting the psoas, starting with fingertips along
the border of the rectus abdominus.
table as the client tucks the hips under. A stretch should be felt in the belly of the rectus femoris muscle.
ACCESSORY WORK
1. This session may be balanced with deep tissue work on the erector spinae, quadratus lumborum, gluteals, and hamstrings.
2. The muscles around the temporomandibular joint are sometimes sensitive to changes to the pelvis and psoas. They should also be massaged to balance the upper pole of the body with the pelvis.
3. On the foot, the heel is the reflex area corresponding to the pelvis. Points in the heel region on the sole of the foot may be pressed with the thumb tip. The therapist may then hold the foot around the metatarsal region with one hand while the other hand cups the heel (Fig. 9-61). With the fingers of the hand supporting the heel, the therapist may reach around to the side of the foot to press points below the malleolus. Switching hand positions allows the therapist to work on the other side of the heel.
CLOSING
Sitting at the foot of the table, lightly hold the heels of the client’s feet in your hands for 30 to 60 seconds. Remove your hands slowly to complete the session.
Chapter 9 Stabilizing the Core 213
FIGURE 9-59 Position for addressing the
psoas with the client’s leg flexed.
FIGURE 9-60 Stretch for the psoas.
214 Scheumann’s The Balanced Body: A Guide to the Integrated Deep Tissue Therapy System
David Rini
SESSION IMPRESSION
RECTUS FEMORIS AND ILIOPSOAS
he client is a 27-year-old man named Eric, who is an
T
actor. Eric is in good physical health. He enjoys reading about and becoming involved in activities that contribute to his health and self-improvement. He participates in yoga and dance classes regularly, and he tries to maintain a low-fat diet. Eric enjoys outdoor activities like bicycling and hiking. He has been receiving a series of deep tissue therapy sessions as part of his health and high-level wellness regimen. This case describes the session that focused on his hip flexors.
Eric has a well-balanced musculature overall. His anterior thigh and gluteal muscles, however, appear to be overdeveloped in relation to the rest of his body. He exhibits an anterior pelvic tilt and slight pelvic rotation, with the left iliac crest drawn both forward and downward. Observing his walking pattern reveals that he initiates thigh movements primarily with the rectus femoris mus­cles. This is apparent on observation because instead of
FIGURE 9-61 Reflex zone for the pelvis on
the heel.
allowing his thighs to swing from a mobile pelvis when he walks, he lifts his knees toward his chest and remains rigid in the pelvic region.
Eric complains that his thighs become very sore after dance classes and after hiking. He also gets winded sooner than he feels he should during strenuous activities, and he sometimes experiences cramp­ing (a “stitch”) under his rib cage. At irregular intervals, he experiences pain in his low back, more concentrated on the left side, near the sacrum.
Eric provides an example of someone who does not move from his core. His rectus femoris muscles overwork during hip flexion movements, and his psoas muscles are underactive. Eric has gained fairly good control of his body, but his movements are not as fluid as they could be if initiated from the pelvic center. His poor stamina reflects the lack of coordinated action between the ex­trinsic and intrinsic muscles. This is the fourth session dealing with the core; the abdominal and thigh muscles
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