Archive for the ‘Manual Therapy’ Category

Trigger points are a hot button issue in manual medicine. The research on their existence is sparse and there is considerable amount of subjectivity in the ability to find a Trigger point (TrP). Although their true nature is uncertain, the dominant theory is that a TrP is a small patch of tightly contracted muscle, an isolated spasm affecting just a small patch of muscle tissue (not a whole-muscle spasm like a “charlie horse” or cramp). That small patch of knotted muscle cuts off its own blood supply, which irritates it even more — a vicious cycle called “metabolic crisis.” And when we have a lot of these Trps in various muscles within the body, we call it myofascial pain syndrome…a diagnosis given a lot!

TrP’s are tricky in that they can be elusive to find. For example, did you know anterior wrist pain that is often diagnosed as carpal tunnel actually stems from a TrP in the subscapularis muscle! (a muscle located under your armpit). Therefore, carpal tunnel release surgery may do nothing to help with wrist pain if the TrP of the subscap isn’t released (how that is done is highly debatable and will be discussed a bit).

How do we find these TrP’s?

Pragmatically speaking, I find them by trial and error. For example, if someone comes in with radiating pain down the leg stemming from their butt and I press on one of the hip external rotators (specifically the inferior gemellus muscle….what? You don’t know how to isolate that muscle? Shame on you 😉 and it reproduces their leg pain I can be reasonably assure that they have  TrP causing their symptoms. How these tender points developed is also up for debate. But there are schools of thought that say that a TrP can be caused by being sedentary (sitting on your ass all day), over activity within a certain muscle (think over training), trauma to a muscle (think falling down or car accident) or nutrition deficits (such as lacking vitamin D). In all honesty, if someone comes in with pain of insidious onset (no known injury), I have to look for trigger points…It’s a must!

 Okay, so I think I have found a TrP in a muscle, how do I get rid of it? 

This is a hard question to answer as there is no good evidence that any one method is superior to another. In my experience, pinning a muscle at the site of the TrP and having the client actively move through a non to minimally painful range of potion while the TrP is under compression tends to help..similar to ART I would say (?). I also employ proprioceptive neuromuscular facilitation (PNF) stretching to help “trick” the nervous system into letting go of tight bands of muscle. This ‘contract-relax’ method works only after manual “release” of the TrP in question has been achieved (that is my opinion only, FYI). I also know some physiotherapists who use intramuscular stimulation (IMS) to destroy TrP’ whereby a muscle is stabbed at various angles using an acupuncture needle…sound fun, right? Again, the science behind IMS is hit or miss, but anecdotally I have heard great success stories with its use. I commonly hear “it hurt more than pregnancy but it really helped my pain!”

To end off this small introduction on TrP’s I wanted to share with you the top 5 Trigger Points I treat and have had great success with. The “X” on the muscle shows where the trigger point is and the red dots show you where the trigger point can refer pain into….pretty cool pics from

1) Subscapularis  (posterior shoulder, lateral arm and anterior wrist pain)

Subscapularis Trigger Point Diagram

2) Levator Scapulae (chronic neck pain/tightness), pain along the medial scpaular border
Levator Scapulae Trigger Point Diagram

3) Pec minor (anterior shoulder and medial arm pain..symtoms of TOS or numbness into fingers 4 and 5 can be helped with pec minor relase)
Pec Min Trigger Point Diagram

4) Gluteus Medius ( “Sacroiliac joint” pain…always check glute med first! It’s rarely the joint itself causing the pain)

Glut Med Trigger Point Diagram

5) Solues (Plantar facitis..check the solues)
Soleus Trigger Point Diagram

Next time you have a patient with pain without any one particular reason, look for TrP’s…It just might help!

Have you ever had someone tell you that before? I get asked questions like this all the time in my practice. People who crack their hands, spine, knees, feet etc ask me if they are causing damage to themselves by cracking their joints. I always ask them if there is any pain/numbness/tingling associated with the crack. If they say no, I tell them not to worry about it as there is no evidence that says cracking is bad for you or will give you arthritis. (Authors note: The studies I am referring to were only conducted on the hands and I don’t know of any literature that addresses this question for any other part of the body).

In short, there are a few reasons why joints “crack”. It could be because of a tendon snapping over a bone (snapping hip syndrome). Or it could be a bone moving over another bone (snapping scapula syndrome). A true joint crack occurs when joint surfaces of an encapsulated joint (say a facet joint in the spine) are separated. This in turn creates a reduction in pressure within the joint cavity. In this low-pressure environment, some of the gases that are dissolved in the synovial fluid (which are naturally found in all bodily fluids) leave the solution, making a bubble,,which rapidly collapses upon itself, resulting in a “clicking” sound. This process is known as a cavitation and is the same sound you hear when a physiotherapist, chiropractor etc manipulates your spine.

The common advice that “cracking your knuckles gives you arthritis is not supported by any evidence to date. A 2011 study from the Journal of the American Board of family Physicians examined the hand X-rays of 215 people (aged 50 to 89) and compared the joints of those who regularly cracked their knuckles to those who did not. The study concluded that knuckle-cracking did not cause hand osteoarthritis, no matter how many years or how often a person cracked their knuckles. “The prevalence of OA in any joint was similar among those who crack knuckles and those who do not”

In 2009 a doctor by the name of Donald Unger won a Nobel Prize for a study of one participant…HIMSELF! He cracked the knuckles of his left hand every day for more than sixty years (that’s dedication), but he did not crack the knuckles of his right hand. In the end, no arthritis or other ailments formed in either hand after 60 years of cracking his left hand.

So all in all, cracking the hands is not a problem, and there is nothing that would lead me to say stop doing it. However (and it’s a big one)…If you have ANY pain or limitation with joint cracking, it is best to seek consultation with a health care professional. You may have a joint instability or hypermobility which may cause you problems down the road if not properly addressed.

Have a great week!

Jesse Awenus B.A Hons (Kin), MSc.PT
Registered Physiotherapist

DeWeber, Kevin, and Rebecca Ortolano. “The Journal of the American Board of Family Medicine.” Knuckle Cracking and Hand Osteoarthritis (2011): n. pag. Knuckle Cracking and Hand Osteoarthritis. Web. 22 July 2012. <;.

Manual Therapy in Canada

Posted: April 14, 2012 in Manual Therapy

This blog post will be a little different from ones I have written in the past. Today I want to explain the manual therapy system of education as I see it in Canada. This post will hopefully be informative and useful for both other young Canadian therapists and those abroad who have an interest in manual and manipulative therapy.

As I sit at my desk writing this post I am looking at my clock because in about 2 hours time I have to head to downtown Toronto to be a mock patient for the Orthopaedic Division intermediate manual and manipulative therapy practical exam. You will know exactly what that is once you have finished reading this article. I also chose to write this piece because I am currently a student enrolled in the level 3 upper manual therapy course…again, you will know exactly what that is momentarily.

Let’s take a step back and assess why someone would want to do MORE course work after just finishing almost 7 years of post secondary education to become a registered physiotherapist in Canada. I think the answer to that question is a personal one and many people will have different answers. For me it boils down to wanting to do better for my patients. As much as I learned in P.T school, I still feel I lacked the request knowledge to understand the gamut of clinical presentations I was seeing in practice. I know from having placements with manual therapists that have been through the system that their clinical reasoning (problem solving) skills were superior to those who did not do any manual therapy con-ed (just my opinion). So for me, it boils down to learning as much as I can about the field I have chosen to specialize in. When I know more I can treat more and get more people better…this makes for a much for fulfilling career as far as I’m concerned. Because applying ice, stim, and ultrasound to everything that walks in my door just doesn’t do it for me. It also gives me a great sense of specilization…that I have done more to boost my career to the level I want it to be at.

Here is a diagram of the manual therapy system in Canada taken from the ortho division website . It shows a schematic representation of the “level system” and all that needs to be done to navigate through it. I have NOT done the entire system yet as this takes years and I have only been in practice since 2010. However, I have completed the level 1 exam (you can do a course for level 1, but many just choose to do the exam), level 2 upper quadrant course and exam, level 2 lower quadrant course and exam and am now on my level 3 upper quadrant course. The level 2 courses take about 4 months each to complete (you are in class for one full weekend a month for 4 months). Yes, you heard me…an entire Friday, Saturday and Sunday of each month for 4 months is devoted to manual therapy. Each of the 4 weekends deals with a different body area (for example, the first level 3 weekend was dealing with the craniovertebral, mid cervical spine and cervicothoracic junction areas). Not only that but it is essential to study before and after each weekend because the amount of info you are given is overwhelming at times. Personally, I spend on average 30-40 mins/day looking at the notes, reviewing videos online, etc… If I didn’t I would be lost come course time.

Lumbar spine flexion Mobilization

The courses themselves and exams are what are needed to be done to be able to do the practical (hands on) exams. Oh wait, you also need to accumulate a crap load of mentorship hours with a therapist who has already completed the level system to be allowed to sit for the intermediate and practical exams….writing it all out like this really makes it look like an exhausting process haha.

As per the diagram, once you do levels 1-3, gotten mentorship hours, passed the intermediate exam, done levels 4-5, got more mentorship hours, and finally passed the advanced practical exam you get the designation FCAMPT (Fellow of the Canadian Academy of Manipulative Physiotherapists). This is the classical route to take but there is a newer masters program at the University of Western Ontario that fast tracks this processes by giving you level 3-5 and the FCAMPT designation by doing 1 solid year of study…there are pros and cons to this program as what I’ve been told (many of the cons have to do with the huge loss of income incurred by taking the time away from work to complete the in class sessions in London).

To finish this article off I want to give you a glimpse into what exactly is taught on these courses. I have randomly chosen to give some highlights of my last level 3 upper weekend where we talked about the neck. We reviewed:

Subjective assessment of dizziness, cranial nerve symptoms, cord signs, headache, pain etc

Objective assessment of active mobility tests in the neck (including combined contralateral for CV region and ipsilateral coupling for mid cervical region), passive mobility tests for the OA and AA joints, passive accessory testing for the OA, AA, and mid cervical joints (e.g bilateral and unilateral anterior glide at the OA joint), stability testing of the neck using compression, distraction, anterior, posterior lateral and rotational shear—this tests the passive restraint systems in the neck like the alar and transverse ligaments. We learned how to length tension test the suboccipitals (debatable if you can actually isolate these muscles), SCM, lev scap, and all 3 scalene muscles. We talked about treatment techniques in the form of mobilizations for the neck as well as locking techniques and exercise for the deep neck flexors. We also talked about pathologies like thoracic outlet syndrome, spondylosis, nerve entrapment and so on…

Manuals all ortho div students have seen

Overall I love these courses because they really challenge my clinical reasoning skills and force me to critically reflect on my clinical practice. I sometimes fear I have fallen into a “comfort zone” of treatment and do similar techniques for various conditions. This a common trap for therapists and I refuse to be a one trick pony. These courses help me identify issues with my patients I would have never even thought to have looked at prior to taking the courses. Do I agree with everything that they are teaching me? NO! I could do a whole rant on how I really don’t think we can be as specific to a spinal segment (with palpation or grading of mobs) as they want us to be. But hey, you have to take the good with the bad I guess.

Please let me know if I missed anything in this article or if you want any more detailed info on what was said.

Thanks for reading!

Jesse Awenus, P.T