Trigger Point Therapy for Myofascial Pain (30 page)

Rectus femoris

Vastus lateralis

Vastus medialis

Vastus intermedius

Quadriceps and trigger points

Q
UADRICEPS

R
ECTUS
F
EMORIS
, V
ASTUS
L
ATERALIS
, V
ASTUS
M
EDIALIS
, V
ASTUS
I
NTERMEDIUS

Proximal attachment:
Rectus femoris:
via two tendons, one at the anterior superior iliac spine (ASIS) and the other at the ilium, superior to the acetabulum.
Vastus lateralis:
lateral side of the upper three-quarters of the posterior femur and the linea aspera on the posterior femur.
Vastus medialis:
full length of the posteromedial aspect of the shaft of the femur.
Vastus intermedius:
anterior and lateral surfaces of the upper two-thirds of the shaft of the femur.

Distal attachment:
All quadriceps attach to the patella by means of a common tendon via the patellar ligament to the tibial tuberosity.

Action:
Rectus femoris:
extension of the leg; flexion of the thigh on the pelvis when the pelvis is fixed; flexion of the pelvis on the thigh when the thigh is fixed.
Vastus lateralis, vastus medialis, and vastus intermedius:
extension of the leg at the knee. Vastus lateralis and vastus medialis working together help to maintain normal position and tracking of the patella.

Palpation:
The quadriceps group, the “great extensor,” is the heaviest muscle in the body, weighing approximately 50 percent more than the next largest muscle, the gluteus maximus. Rectus femoris, vastus lateralis, and vastus medialis are readily palpable. Vastus intermedius lies deep to rectus femoris and cannot be directly palpated.

Of the four muscles that comprise the quadriceps group, only rectus femoris crosses two joints (the knee and the hip). Therefore, in addition to being an extensor of the leg, rectus femoris is a flexor of the thigh and pelvis.

To locate the quadriceps, identify the following structures:

• Anterior superior iliac spine (ASIS)—Anterior bony projection lying somewhat below the iliac crest, readily palpable. The ASIS serves as the proximal attachment of the inguinal ligament.
  
• Greater trochanter—Bony prominence of the lateral aspect of the femur, approximately one hand-length below the iliac crest. From the anterior plane the greater trochanter lies horizontal with the pubic crest.
  
• Iliotibial band—A long, thin, flat band of fascia lying on the outer surface of the thigh. The iliotibial band is a thickening of the normal fascia that surrounds the thigh; its distal end inserts onto the lateral condyle of the tibia. The insertion onto the lateral condyle can be palpated anterior to the insertion of the biceps femoris tendon (see muscle description on page 173). The iliotibial band can be palpated in the seated position by raising the heel of your foot off the floor while keeping your knee flexed.
  
• Patella—A sesamoid bone in the common tendon of the quadriceps group
  
• Tibial tuberosity
  

Locate rectus femoris, vastus lateralis, and vastus medialis when the leg is extended against resistance. Palpate rectus femoris from its attachment on the anterior superior iliac spine (ASIS) to its attachment via the common tendon to the tibial tuberosity.

The bulk of vastus lateralis lies proximal to the bulk of vastus medialis. Palpate the fleshy portions of vastus lateralis along the anterolateral aspect of the thigh, anterior to the iliotibial band, from the greater trochanter through its attachment via the common tendon. Palpate the fleshy portions of vastus medialis along the anteromedial aspect of the thigh through its attachment via the common tendon.

Rectus femoris

Vastus lateralis

Vastus medialis

Vastus intermedius

Quadriceps pain pattern

Constrictions in rectus femoris must be reduced before an attempt is made to identify and reduce constrictions in vastus intermedius. Once rectus femoris is free of constriction, taut bands may be located in vastus intermedius by locating the proximal lateral border of rectus femoris. Follow this border distally until the fingers can palpate vastus intermedius, deep to rectus femoris, close to the femur.

Pain pattern:
Pain from active trigger points is experienced at various locations relative to the muscle most involved.
Rectus femoris:
Pain is experienced in the anterior knee, sometimes deep in the joint. Pain may be experienced at night; walking down stairs may be difficult.
Vastus lateralis:
Pain is referred to the posterolateral aspect of the knee; it can refer throughout the full course of the lateral thigh to the knee and as high as the crest of the ilium. Distal trigger points may immobilize the patella, causing pain while walking. Symptoms may include difficulty lying on the same side at night.
Vastus medialis:
Anteromedial knee pain; pain extends through the distal one-half of the medial thigh; buckling of the knee.
Vastus intermedius:
Pain is referred over the anterior thigh, extending anterolaterally over the upper thigh. Pain may be most intense at midthigh level. Walking up stairs may be difficult, as is straightening the leg after sitting.

Causative or perpetuating factors:
Sudden overload through misstep or fall; sustained overload due to excessively tightened hamstring muscles.

Satellite trigger points:
Each muscle of the quadriceps group may develop satellite trigger points in response to the presence of trigger points in any other muscle of the group. Additional satellite trigger points could also appear in semimembranosus, semitendinosus, biceps femoris, tensor fasciae latae, and iliopsoas.

Affected organ systems:
Rectus femoris, vastus lateralis, and vastus intermedius:
digestive system.
Vastus medialis:
genitourinary and reproductive systems.

Associated zones, meridians, and points:
Rectus femoris:
ventral zone; Foot Yang Ming Stomach meridian; ST 31–34, SP 10 and 11.
Vastus lateralis:
ventral and lateral zones; Foot Yang Ming Stomach meridian, Foot Shao Yang Gall Bladder meridian; ST 31–34, GB 31.
Vastus medialis:
ventral zone; Foot Tai Yin Spleen meridian; SP 10 and 11.
Vastus intermedius:
ventral zone; Foot Yang Ming Stomach meridian; ST 31–34, SP 10 and 11.