PREFERRED PRACTICE PATTERN
4D: Impaired Joint Mobility, Motor Function, Muscle Performance, and ROM Associated with Connective Tissue Dysfunction
The patient is a 28-year-old woman who presents with complaints of an insidious onset of pain and tightness along the last lower rib on the left side that started 2 to 3 years ago and has been getting worse since. The pain is worse with rotation and side bending at the waist; with frequent exacerbations of pain in the morning after exercising the night before, after prolonged walking, and rollerblading. The pain is better with heat and rest. She states that performing her job as a group exercise instructor is becoming very difficult and she has had to take several days off this month. She denies any specific episode of trauma and any systemic symptoms or pain anywhere else in her body.
The patient is a direct access, self pay, without a physician’s referral. Initial physical therapy examination did not reveal any systemic symptoms or signs of a sinister pathology. She demonstrated reduced lumbar curvature, a posterior pelvic tilt, and a slight left rotation at L4–5 in standing posture. Range of motion (ROM) testing revealed reduced left rotation (30 degrees) and left side bending (15 degrees) due to pain with soft tissue guarding along the left paraspinals, left thoracolumbar fascia, and left quadratus lumborum. Palpation examination revealed presence of a taut palpable band of tissue with a localized area of painful hypersensitivity 4/10 at the proximal insertion of the left quadratus lumborum. manual muscle test findings: thoracolumbar extension 5/5; left hip elevation 4+/5; left hip extension 5/5.
Chronic, persistent, deep aching pains in the muscle; nonarticular in origin
Characterized by well-defined, highly sensitive tender spots (trigger points)
Usually caused by sudden overload, overstretching and/or repetitive/sustained muscle activities
Pain associated with activities, and generally relieved with rest
Can be in localized areas affecting any muscle or fascia
Techniques for trigger point palpation. (A) With flat palpation, fingertips stroke across the muscle surface. (B) With pincer palpation. The muscle is grasped and palpation for trigger points is completed as the muscle slips through the fingers. (From Hoffman BL, Schorge JO, Schaffer JI, et al. Williams Gynecology. 2nd ed. www.accessmedicine.com. Copyright © The McGraw-Hill Companies, Inc. All rights reserved.)
An extensive pattern of referred pain (red shading in the left image) can be created by trigger points in the obturator internus muscle (...