Trigger Point Therapy for Myofascial Pain (36 page)

Stretch exercise: Peroneals

Extensor digitorum longus

Extensor hallucis longus

Long extensors of the toes and trigger points

L
ONG
E
XTENSORS
OF THE
T
OES

E
XTENSOR
D
IGITORUM
L
ONGUS AND
E
XTENSOR
H
ALLUCIS
L
ONGUS

Proximal attachment:
Extensor digitorum longus:
lateral condyle of the tibia, proximal three-quarters of the fibula, interosseus membrane.
Extensor hallucis longus:
middle one-third of the anterior surface of the fibula, interosseus membrane.

Distal attachment:
Extensor digitorum longus:
middle and distal phalanges of the four lateral toes.
Extensor hallucis longus:
distal phalange of the great toe.

Action:
Extensor digitorum longus:
extension of the four lateral toes; assists in dorsiflexion and eversion of the foot; works very strongly in a vertical jump from a standing position.
Extensor digitorum longus:
extension of the great toe; assists in dorsiflexion and inversion of the foot.

Palpation:
Extensor digitorum longus and extensor hallucis longus, along with tibialis anterior and peroneus tertius, comprise the anterior compartment of the leg.

To palpate extensor digitorum longus, identify tibialis anterior anteriorly and peroneus longus posteriorly to locate extensor digitorum longus. Palpate taut bands approximately 3 inches distal to the head of the fibula. Extensor hallucis longus lies between and deep to tibialis anterior and extensor digitorum longus throughout the upper two-thirds of the lower leg. It can be palpated where it becomes superficial just distal to the level of the lower one-third of the leg, anterior to the fibula.

Pain pattern:
Extensor digitorum longus:
Pain on the dorsum of the foot and the central three digits. Sometimes pain can be experienced at the ankle; the pain may move upward as far as the lower one-half of the lower leg.
Extensor hallucis longus:
Pain at the first metatarsal and the great toe. It may also extend toward the ankle, following the course of the muscle. Symptoms include pain on the dorsum of the foot, “foot slap” during walking, and night cramps along the course of the muscle. Presence of taut bands and trigger points over time may lead to the development of hammertoes or claw toes.

Causative or perpetuating factors:
L4-L5 radiculopathy; acute stress overload caused by walking in soft sand; walking or jogging on uneven ground or crowned roads; tripping or falling; using the lengthened muscle in continual plantar flexion position (such as wearing high-heeled shoes or driving with a steep accelerator pedal); prolonged plantar flexion; prolonged immobilization as a result of wearing a cast; very tight gastrocnemius and soleus muscles.

Extensor digitorum longus

Extensor hallucis longus

Long extensors of the toes pain pattern

Satellite trigger points:
Peroneus longus, peroneus brevis, peroneus tertius, tibialis anterior.

Affected organ systems:
Digestive system.

Associated zones, meridians, and points:
Lateral zone; Foot Yang Ming Stomach meridian; ST 40 and 41.

Stretch exercise:
Position a strongly pointed foot over the ankle of the standing leg, placing the toes of the leg to be stretched beside the heel of the standing leg. Bend the knee of the standing leg into the back of the knee of the bent leg to stretch the dorsum of the foot.

Strengthening exercise:
Work the extensors by alternating plantar flexion and dorsiflexion of the foot and toes. Begin with your legs extended in front of you and your foot and ankle in a neutral, relaxed position. Plantarflex the foot and toes strongly. Hold for a count of three to five. Beginning with the toes, slowly extend the toes and dorsiflex the foot. Hold for a count of three to five. Repeat these two actions five to seven times, moving through each position slowly and without allowing the foot to evert or invert.

Stretch exercise: Long extensors of the toes

Flexor digitorum longus

Flexor hallucis longus

Long flexors of the toes and trigger points

L
ONG
F
LEXORS OF
THE
T
OES

F
LEXOR
D
IGITORUM
L
ONGUS AND
F
LEXOR
H
ALLUCIS
L
ONGUS

Proximal attachment:
Flexor digitorum longus:
middle one-third of the posterior surface of the tibia.
Flexor hallucis longus:
lateral aspect of the posterior surface of the fibula.

Distal attachment:
Flexor digitorum longus:
passing behind the medial malleolus to attach to the distal phalanges of the four lateral toes.
Flexor hallucis longus:
passing behind the medial malleolus, deep to flexor digitorum longus, to attach to the distal phalanx of the great toe.

Action:
Flexor digitorum longus:
flexion of the four lateral toes; acts weakly in plantar flexion; assists inversion and supination (adduction) of the foot.
Flexor hallucis longus:
flexion of the great toe. Both muscles serve to maintain balance when the body weight is on the forefoot and help stabilize the ankle during walking. Both are vigorously active during the take-off and landing in a vertical two-legged jump.

Palpation:
These muscles lie deep to gastrocnemius and soleus and medial to tibialis posterior. Along with tibialis posterior, they comprise the deep posterior compartment of the leg. Flexor digitorum longus may be palpated with the patient lying on the involved side with the knee flexed to 90 degrees and the foot relaxed. Pressure is applied to the posterior aspect of the shaft of the tibia, approximately 3 inches below the joint line. The gastrocnemius is moved laterally to identify the posterior tibia. Pressure is directed laterally to palpate the flexor digitorum longus.

Flexor hallucis longus can only be palpated through the overlying aponeurosis of the gastrocnemius and soleus muscles. The patient lies in the prone position with his foot off the table. Pressure is applied to the posterior fibula at the junction of the middle and lower thirds of the calf, just lateral to its midline.

Pain pattern:
Flexor digitorum longus:
Pain radiates to the middle of the sole of the foot and possibly over the plantar surface of the four lateral toes. Occassionally pain may be experienced at the medial ankle and calf.
Flexor hallucis longus:
Pain radiates to the plantar surface of the great toe and the head of the first metatarsal. Symptoms include pain in the sole of the foot and the plantar surface of the toes, particularly when weight bearing. Hammertoes and/or claw toes may develop as a result of the presence of taut bands in these muscles.