The 4-Faced Troublemaker: The Frustrater (Part 2)
The 4-Faced Troublemaker: The Frustrater (Part 2)
In my last article I talked about the rectus femoris (two-jointed puzzler) and the vastus medialis (buckling knee muscle). In this second part of the "4-Faced Troublemaker" I will discuss the vastus intermedius, fondly named the "frustrater" by Dr. Travell.
I will be sharing with you how a simple injury developed this client's trigger points, along with three things you might want to think about as a therapist. First, how to use the principles of the post isometric relaxation technique to redirect pain signals, second —whether or not foam rolling and stretching is good for all trigger points, and third when deep tissue therapy isn't (always) the answer.
Once you gather the client's health history it's important that you don't jump right in and start with a hands-on approach. Too many therapists make this mistake because they would rather feel what is in the tissue rather than correlate their palpation skills with evaluation skills.
This can lead to jumping to conclusions and picking the less efficient modality for treatment. Your conclusion should be based on a thorough evaluation, which should involve assessments looking at muscle length, range of motion, manual muscle test to see if you can reproduce the pain, and of course palpation of the area to see if there is an active trigger point or just a tender point.
It's all in the Details
The client was a female in her late 50s. Her chief complaint was left mid-quadriceps pain. The pain would spread and be followed by complete fatigue in the muscle. This was making it impossible for her to continue her daily activities of walking or cycling. She had a MRI of her back. The orthopedic surgeon told her the pain in the front of her quadriceps was coming from her back based on the degeneration he saw on the MRI. He sent her to physical therapy and recommended eventual surgery. She felt there just had to be another answer and was referred to my office.
Here is why listening is really an important assessment tool—her health history revealed that two years ago she had stepped into a small hole while on a downhill hike, at which time she landed on her right knee. She didn't notice anything initially, however after returning from the trip she started a spinning program to try and gain some strength in her legs. Spinning is a cycling class on a stationary bike with fixed pedals that requires a great deal of up stroke from the quadriceps muscles. She gradually noticed that her quadriceps were fatiguing more and more easily in each class. She also began a yoga class to try and stretch the leg.
She had been instructed to use the foam roller to roll the knot out that was causing the pain. She had also received deep tissue therapy about every two weeks thinking this would get the knot out. Unfortunately, the end result from the therapy was that she could hardly walk for the next three days, and had no resolve for the pain.
My Assessment & Testing
I performed the Thomas test, which was normal. I did a quadratus lumborum (QL) assessment (a side bend stretch), to see if the back would refer any pain. It was also normal. Next, I did a manual muscle test of the quadriceps which started to illicit the discomfort. I had her point to where she felt the pain start. She pointed to the mid-section of the rectus femoris.
On palpation of the area it was confirmed, any pressure over this area would reproduce her symptoms. As described by her it started in one area and then would become so diffused that she had to stop her activity. According to the "Myofascial Pain and Dysfunction" manual the vastus intermedius also called the "frustrater" develops trigger points (TrPs) that are hidden beneath the rectus femoris muscle. The pain pattern from these TrPs extends over the front of the thigh nearly to the knee, but is most intense at mid-thigh.
Why didn't she heal? When she went down on the right knee, her left side (the side of complaint) had to decelerate quickly leaving her with tiny micro-tears in this tissue. Over time these micro-tears in the fascia didn't remodel properly allowing this underlying trigger point to form. All of the good things she was trying to do for herself were putting too much compressive forces on the already injured tissue. While foam rolling, cycling, deep tissue therapy and stretching seems like a good thing, in this case they were adding additional compression to the underlying tissues setting off vastus intermedius trigger point.
I chose these treatment modalities based on the thought of the compressive forces being placed on the trigger point deep and underneath rectus femoris.
- I chose the modality of counter strain. I felt by bunching up the tissue over the active trigger point this would help relieve the compressive forces setting off the trigger point. Think of this like needing to fluff up a pillow so it is not so hard to sleep on.
- I used light massage cupping and I want to say this twice light. You want to be very superficial. The cupping uses the negative pressure of pulling up the fascia to take the compression off of the trigger point.
- I used heat to help with blood flow to the area.
- I repeated this as one process over and over again stopping after 45 minutes. I didn't want to aggravate the tissues by doing too much treatment.
- I did not stretch her quadriceps to avoid compression of the trigger point.
Her homework was to discontinue the foam rolling (for now), stretching, and spinning. Also, to use a hot towel to bunch up the tissue 1-2 times a day.
Using Isometrics as Treatment & Resolve
After three hands-on treatments she was 80 percent better. Looking for the 100 percent resolve, I took her to the training room to try and reproduce the trigger point. Within two minutes on the treadmill her symptoms started. I stopped the treadmill, asked her to perform a 20 percent isometric hold with resistance of hip flexion for six seconds, six times through. She walked four more minutes before the trigger point began, we repeated the isometric. This time she said "I feel like I could walk all day."
Next I took her to the bike. The trigger point started in less than one minute, we stopped and performed the isometric treatment. After two minutes more of cycling the trigger point began again. We stopped and I used a manual cup over the area and performed the isometric hold. This time she looked at me and said "I feel like I could do this forever."
We managed 20 minutes of activity which felt like a miracle to her. I explained that the isometric hold was a way of using the body's mechanoreceptors to interrupt and help redirect the pain signals. As therapists we are familiar with the physiological principle called the law of facilitation. The law states that when an impulse has passed once through a certain set of neurons to the exclusion of others, it will tend to take the same course on a future occasion, and each time it traverses this path the resistance will be smaller.
She was an engineer, so she understood the process of redirecting signals. I also told her she might need to keep doing the isometric's during her different activities if it reoccurred. I am extremely happy to report she has resumed normal activities with no pain or fatigue.
Happy Therapy, Debbie
Editor's Note: The final article in this series will continue next month with an explanation of injury and treatment for the vastus lateralis.