Myofascial Decompression Therapy in the Treatment of Latent …30774... · 2018-06-01 ·...

MYOFASCIAL DECOMPRESSION THERAPY

Myofascial Decompression Therapy in the Treatment of Latent Myofascial Trigger Points in a

Minor League Baseball Pitcher: A Case Report

________________________________________________________________________

A Case Report

Presented To

The Faculty of the Elaine Nicpon Marieb College of Health & Human Services

Florida Gulf Coast University

In Partial Fulfillment

of the Requirements for the Degree of

Doctor of Physical Therapy

________________________________________________________________________

By

Devlin A. Dizacomo

2018


APPROVAL SHEET

This case report is submitted in partial fulfilment

of the requirements for the degree of

Doctorate of Physical Therapy

Devlin A. Dizacomo

Approved: April 2018

Dr. Eric Shamus, PhD, DPT Committee Chair/Advisor

Dr. Tom Pitney, DPT, SCS, ATC

Committee Member

The final copy of this case report has been examined by the signatories, and we find that both the content and the form meet acceptable presentation standards of scholarly work in the above mentioned discipline.


Acknowledgements

This scholarly paper would not have been possible without the supportive roles fulfilled

by my family and friends, as well as by the faculty and staff of the Florida Gulf Coast University

Department of Rehabilitation Sciences. You have all had a substantial influence on my

educational success, and in helping me become the physical therapist I am today.

I am especially indebted to Dr. Eric Shamus, department chair, for his expertise,

guidance, and willingness to impart on my behalf throughout the course of both this independent

study and the physical therapy program. He has had a substantial influence on my success as a

student, and his commitment to excellence is reflected by the quality of this author’s work. I

would also like to thank Dr. Mollie Venglar for her enthusiasm and positivity as an educator, and

for helping me understand how intrinsically rewarding and thoroughly cool neurological physical

therapy can be. Furthermore, I would like to thank Dr. Stephen Black for his willingness to

always have an open mind and for encouraging me to think outside of the traditional physical

therapy box. His clinical expertise and understanding of how to globally address the human body

has made a lasting impression on me that I intend to carry forward in my clinical practice. I

would also like thank Dr. Tom Pitney for his role in overseeing the facilitation of my independent

study activities by finding time for me to present during he and Dr. Shamus’ PDS I class, and for

being a positive influence on my continued educational success.

Lastly, I would like to thank both of my parents for the continuous love and support they

provide. You are both amazing and your efforts are reflected in the person I am today. Thank you

for always believing in me and for being my guiding light. I love you both and will always

remember the countless life lessons you have taught me.

MYOFASCIAL DECOMPRESSION THERAPY 1

Table of Contents

Abstract ............................................................................................................................................. 2

Background and Purpose .................................................................................................................. 3

Case Description ............................................................................................................................... 6

Patient History and Systems Review ................................................................................................ 6

Clinical Impression #1 ......................................................................................................... 7

Examination – Tests and Measures ................................................................................................... 8

Clinical Impression #2 ......................................................................................................... 9

Interventions ................................................................................................................................... 11

Myofascial Decompression Therapy ................................................................................. 11

Self-Myofascial Manipulation ........................................................................................... 12

Manual Therapy ................................................................................................................. 13

Therapeutic Exercise .......................................................................................................... 14

Outcomes ........................................................................................................................................ 14

Discussion ....................................................................................................................................... 15

References ....................................................................................................................................... 20

Appendix A. Myofascial Trigger Point Diagnostic Cluster ............................................................ 23

Appendix B. Systems Review Summary ........................................................................................ 25

Appendix C. Tests & Measures ...................................................................................................... 25

Appendix D. Myofascial Interventions ........................................................................................... 27

Appendix E. Manual Therapy Interventions ................................................................................... 29

Appendix F. Therapeutic Exercise Interventions ............................................................................ 31

Appendix G. Myofascial Decompression Cups & Suctioning Device ........................................... 41


Abstract

Background and Purpose: Myofascial trigger points (MTrPs) are a common source of

musculoskeletal pain, deficits in range of motion (ROM), muscle weakness, and autonomic

phenomena. Myofascial decompression therapy (MDT) has been proposed as an effective method

for treating myofascial trigger points, though little research exists to support this claim. The

purpose of this case report is to describe the application of myofascial decompression therapy in

the treatment of two latent myofascial trigger points as part of the initial care plan for a minor

league baseball pitcher following right elbow arthroscopic surgery.

Case Description: The patient was a 22-year old male baseball pitcher referred to

physical therapy after undergoing elective arthroscopic surgery of his right elbow. He was chosen

based on the finding of latent myofascial trigger points in his right infraspinatus and levator

scapulae. The patient received physical therapy care six days a week for five weeks. The physical

therapy plan of care consisted of myofascial decompression therapy, self-myofascial

manipulation, manual therapy, and therapeutic exercise. A second year physical therapy student

performed the initial evaluation, reassessments, and treatments of the patient, under the direction

and supervision of a board certified orthopedic physical therapist.

Outcomes: After five weeks of intervention, the patient demonstrated improvements in

right upper extremity pain, range of motion, strength, and function, and was able to begin a return

to throwing program. Latent myofascial trigger point characteristics were decreased but not

alleviated.

Discussion: A significant increase in right upper extremity function was observed

following five weeks of myofascial decompression therapy combined with an impairment based

plan of care. Myofascial decompression therapy in combination with confounding treatment

variables was effective in reducing latent myofascial trigger point pain, range of motion deficits,

and strength deficits in this patient. Future clinical trials are required to determine the isolated

effects of myofascial decompression therapy on latent myofascial trigger points.


Background and Purpose

Pitching is a common cause of injury in baseball players. The incidence of elbow and

shoulder injuries in baseball pitchers is twice as high as that of position players (Krajnik, Fogarty,

Yard, & Comstock, 2010). The mechanics of overhead throwing in baseball pitchers imposes

supra-physiological forces on the musculoskeletal structures of the shoulder, leading to repetitive

microtrauma (Seroyer et al., 2009). Chronic, repetitive muscular overload and microtrauma are

two common precipitating factors in the development of myofascial trigger points (MTrPs)

(Unverzagt, Berglund & Thomas, 2015). There is general agreement in the literature that MTrPs

develop when muscle use exceeds muscle capacity and normal recovery is disturbed (Bron &

Dommerholt, 2012).

MTrPs are a common source of musculoskeletal pain, deficits in range of motion (ROM),

muscle weakness, and autonomic phenomena. MTrPs are present in up to 85% of the general

population (Bron et al., 2011; Simons, 1996; Travell et al., 1998, p. 11). They are defined as

hyperirritable spots in skeletal muscle associated with a hypersensitive palpable nodule within a

taut band (Travell et al., 1998). MTrPs in skeletal muscle often produce pain locally, and are

associated with specific referred pain patterns. Affected muscles are often tender to palpation and

have a decreased ability to produce contractile force, leading to decreased available ROM in the

joints they cross (Alvarez & Rockwell, 2002). MTrPs are sub-classified as being either active or

latent. Active trigger points are symptomatic at rest and with direct palpation, while latent trigger

points are asymptomatic at rest and only reproduce symptoms with compressive palpation

(Travell et al., 1998, pp. 1-3).

The current standard for clinical detection of MTrPs is palpation. Most available

evidence on the reliability of palpation for MTrP detection has demonstrated poor outcomes in

terms of diagnostic accuracy (Lucas, Macaskill, Irwig, Moran, & Bogduk, 2009). An

observational study demonstrated that trained physical therapists can reliably detect MTrP

presence via palpation, which speaks for its potential use as a clinical diagnostic tool (Bron,


Franssen, Wensing, & Oostendorp, 2007). Early diagnostic criteria for the diagnosis of MTrPs

included the presence of a palpable tender nodule within a taut band of skeletal muscle, focal

point tenderness, a local twitch response, and specific pain referral patterns (Travell et al., 1998,

p. 11). Presence of a local twitch response has since been deemed of little clinical importance in

the diagnosis of MTrPs. This is reflected in a recently proposed diagnostic test cluster for the

clinical detection of MTrPs which is listed in Appendix A (Fernández-de-las-Peñas &

Dommerholt, 2018).

The pathophysiological mechanism behind the development and perpetuation of MTrPs

is debated in the literature (Jafri, 2014). Simons’ integrated hypothesis attributes MTrP presence

to the excessive release of acetylcholine from dysfunctional motor endplates, causing focal,

sustained sarcomere contraction in the belly of the affected muscle (Simons, 1996). This

prolonged state of focal, sustained sarcomere contraction decreases intramuscular perfusion rate

and disrupts mitochondrial metabolism leading to local tissue hypoxia and ischemia (Bron &

Dommerholt, 2012). Disruption of mitochondrial metabolism causes the release and stagnation of

inflammatory substances including adenosine triphosphate, bradykinin, serotonin, prostaglandins,

potassium, lactic acid, and increased concentrations of hydrogen ions in the extracellular fluid,

causing peripheral nociceptor sensitization (Jafri, 2014).

The most important factor in the successful management of myofascial pain syndrome is

identifying and treating the primary contributing etiological mechanism (Wong & Wong, 2012).

Etiology of MTrP development is multi-factorial and may result from prolonged postural

abnormalities, dysfunctional biomechanics, acute trauma, repetitive micro-trauma, vitamin

deficiency, leading a sedentary lifestyle, and/or psychological stress/anxiety (Bron &

Dommerholt, 2012). Identifying the causative factor(s) for MTrP development and designing an

individualized plan of care consisting of direct MTrP interventions, neuromuscular re-education,

and interventions treat the underlying etiological dysfunction, will increase the effectiveness of

treatment (DaPrato & Kennedy, 2017; Travell et al., 1998, pp. 547-548; Wong & Wong, 2012).


A plethora of invasive and non-invasive intervention techniques are described in the

literature for treating MTrPs in non-athletic populations. Invasive treatments include myofascial

dry needling, and local MTrP injection with local anesthetics, corticosteroids, or botulinum toxin

(Ong & Claydon, 2014; Wong & Wong, 2012). Non-invasive interventions include instrument

assisted soft tissue mobilization (IASTM), ischemic MTrP compression, low level laser therapy

(LLLT), myofascial decompression therapy (MDT), manual myofascial manipulation, self-

myofascial manipulation, spray and stretch techniques, therapeutic ultrasound, and transcutaneous

electrical nerve stimulation (Rickards, 2006; Travell et al., 1998, p. 150). Several recent

systematic reviews and randomized control trials have demonstrated moderate to high level

evidence supporting the use of heterogeneous manual therapy interventions combined with an

individualized therapeutic exercise program in treating MTrP symptoms in the short term (Bron

et al., 2011; Ong & Claydon, 2014; Renan-Ordine, Alburquerque-SendÍn, Rodrigues De Souza,

Cleland, & Fernández-de-las-Peñas, 2011; Rickards, 2006; Vernon & Schneider, 2009).

Myofascial decompression therapy (MDT), commonly referred to as myofascial dry

cupping, has been proposed as an effective method for treating MTrPs (DaPrato & Kennedy,

2017). MDT involves using negative pressure within a plastic cup to introduce a suctioning effect

over targeted soft tissues, without skin perforation (Appendix G). Cups are typically applied for

between one and five minutes, and create a circular-shaped ecchymosis that may last from days to

weeks (Rozenfeld & Kalichman, 2016). MDT is proposed to increase local circulation, improve

lymphatic flow, mobilize connective tissue dysfunctions, release trigger points, and provide

symptomatic pain relief. The application of MDT for MTrP treatment consists of static, single

cup placement directly over MTrPs (DaPrato & Kennedy, 2017). This method is suggested to

superficially flush stagnant toxins into the circulatory system via negative pressure to restore a

normal metabolic environment and break the pattern of local sustained sarcomere contraction. A

neurophysiologic response is hypothesized to occur due to mechanoreceptor stimulation

following removal of the negative pressure stimulus and the introduction of healthy blood into the


ischemic tissue. Endogenous opioid neuropeptide (endorphin) and enkephalin production occurs

which exerts pain inhibiting effects on the limbic system, brain stem, and central nervous system

(DaPrato & Kennedy, 2017; Rozenfeld & Kalichman, 2016).

Contraindications for using MDT include: over areas of active inflammation, open cuts or

wounds, acute muscle spasms, and in cases of high fever. Precautionary considerations for using

MDT include: pregnancy – over the lower abdomen, medial thigh, and lumbosacral regions, and

over areas of herniation or where herniation has occurred previously (DaPrato & Kennedy, 2017).

The purpose of this case report is to describe the application of MDT in the treatment of

two latent MTrPs as part of the initial care plan for a minor league baseball pitcher following

right elbow arthroscopic surgery.

Case Description

The case patient was a 22-year old male right handed minor league baseball pitcher referred to

physical therapy within his baseball organization after undergoing elective arthroscopic surgery

of his right elbow to remove loose osteophyte bodies and shave the posterosuperior aspect of the

olecranon process. Past surgical history included elective arthroscopic debridement of the right

elbow to remove loose osteophyte bodies 5 years ago. Prior to this most recent surgery the patient

experienced a 2-month period of right shoulder and elbow pain during and after throwing, and

was unable to achieve full active right elbow extension in comparison to the left elbow.

Radiographic imaging demonstrated the presence of bone spurs on the olecranon process, and the

loose osteophyte bodies within the humero-radio-ulnar joint space. MRI of the patient’s right

shoulder was unremarkable for labral or rotator cuff pathology. The patient underwent successful

elective arthroscopic debridement surgery in May 2017, and reported to physical therapy wearing

an over the shoulder elbow sling two days later.

Patient History and Systems Review

The patient reported 5/10 pain in his right elbow at initial evaluation. His pain was better

with rest, worse with activity, and was described as being “achy” in nature. He described the


location of the pain in his posterior elbow extending from the olecranon process proximally into

the triceps tendon, at the lateral epicondyle and surrounding soft tissues, and at the medial

epicondyle and surrounding soft tissues. The patient reported that his right shoulder felt “tight”

but was not painful at rest. Prior to this surgery the patient reported experiencing elbow and

shoulder pain after intensive pitching which improved with rest. The patient stated he was taking

two (2) oral Percocet 2.5 mg/325 mg tablets approximately every 6-hours for pain relief as

prescribed by his surgeon. He reported minor nausea from the medication. The patient was

performing ball squeezes in his right hand and self-cold pack application for 20-minutes every 2-

3 hours when awake to limit swelling in the right upper extremity. He denied any tingling or

numbness in his right upper extremity. Beyond the chief complaint of post-surgical elbow pain

the patient was an otherwise healthy minor league baseball pitcher with an unremarkable past

medical history. His primary goal was to return to a high level of competitive throwing without

elbow or shoulder pain. Appendix B demonstrates the results of the systems review.

Clinical Impression #1

The patient presented to physical therapy to begin his rehabilitation protocol following

elective arthroscopic elbow surgery. He concurrently presented with a history of clinical signs

and symptoms commonly associated with MTrPs. His impairments included: postural deviations,

decreased right upper extremity ROM, strength, and neuromuscular control, tenderness to

palpation in the right elbow and right periscapular musculature, and right elbow swelling.

Differential diagnosis for the patient’s pre-surgical complaints of shoulder pain included:

subacromial impingement syndrome, glenohumeral instability, labral tear, rotator cuff tear,

rotator cuff tendinopathy, MTrP referred pain, and cardiac referred pain. Tests and measures

confirming the diagnosis included: palpation for provocation of MTrPs. Tests and measures

ruling out other shoulder pathologies included: MRI results, painful arc test, Neer’s impingement

test, and cross body adduction test. Additional assessments included: Numeric Pain Rating Scale


(NPRS), active range of motion (AROM) and passive range of motion (PROM), and manual

muscle testing (MMT).

The patient was chosen for this case report due to the presence of latent MTrPs in his

right infraspinatus and right levator scapulae. No contraindications or precautions for using MDT

with the case patient were identified.

Examination - Tests and Measures

Objective data from the initial physical therapy examination and subsequent

reassessments is listed in Appendix C. Initial inspection of the patient presented a healthy male

wearing an over the shoulder elbow sling on his right upper extremity. Postural assessment in

standing revealed an elevated right shoulder girdle when compared to the left, with mild upper

trapezius guarding. Removal of the elbow sling demonstrated a compressive ace bandage over

the patient’s right elbow. The patient was next placed in supine with a towel roll positioned under

the distal humerus of his right upper extremity to float the post-operative elbow.

Inspection of the right elbow showed five surgical portal holes approximated with sutures

to close the arthroscopic incision sites. Two portal holes were located on the lateral aspect of the

elbow, two were located on the medial aspect of the elbow, and one was located proximal to the

postero-superior aspect of the olecranon process over the tendon of the triceps brachii. Mild

yellow and purple ecchymosis was present around the patient’s entire elbow with mild post-

operative swelling.

Right upper extremity presentation at initial evaluation included 5/10 elbow pain at rest,

decreased elbow flexion/extension AROM (36o to 102o), decreased elbow pronation AROM

(68o), decreased right elbow supination AROM (66o), decreased shoulder flexion AROM (164o),

decreased shoulder internal rotation (48o), and positive empty can/full can test. MMT

demonstrated decreased right upper extremity gross muscle strength for elbow flexion (3-/5),

elbow extension (3-/5), elbow pronation (3-/5), elbow supination (3-/5), shoulder flexion (3-/5),

shoulder abduction (3-/5), shoulder internal rotation (3-/5), and shoulder external rotation (3/5).


MMT testing position for BUE strength was 0o shoulder abduction and 90o elbow flexion with the

patient sitting. Palpation revealed hypersensitive nodules within a taut bands of skeletal muscle in

the right infraspinatus and right levator scapulae. Compressive palpation of the infraspinatus

nodule produced referred pain that was familiar to the patient and reported as similar to his pre-

surgical shoulder pain complaints. Compressive palpation of the levator scapulae nodule

produced referred pain that was unfamiliar to the patient.

The patient received private physical therapy care within his baseball organization’s

rehabilitation department for six consecutive days each week, followed by one day of full active

rest, for five weeks. The care plan consisted of MDT, self-myofascial manipulation, manual

therapy techniques, therapeutic exercise, and cryotherapy with primary goals of decreasing pain,

decreasing post-operative swelling, and increasing ROM, increasing strength, reestablishing

neuromuscular control, and beginning a return to throwing program.

Clinical Impression #2

The patient’s signs, symptoms, and examination confirmed the physical therapy diagnosis

of MTrP referred pain. His past medical history and subjective complaints bolstered the clinical

diagnosis. The presence of a hyperirritable nodule within a taut band of skeletal muscle that

produces referred pain with compressive palpation is the current proposed diagnostic criteria for

confirming MTrP presence (Fernández-de-las-Peñas & Dommerholt, 2018). Decreases in right

shoulder ROM and strength are associated with MTrPs in the infraspinatus and levator scapulae

muscles (Travell et al., 1998, p. 556). MDT was deemed an appropriate intervention to include in

the plan of care to treat the latent MTrPs in the patient’s infraspinatus and levator scapulae based

on the examination findings and the proposed effect of MDT on MTrPs. With the case patient we

would expect see improvements in the right upper extremity for shoulder ROM, strength,

neuromuscular control, posture, sensitivity to MTrP palpation, and shoulder pain after throwing.

MDT has been proposed as an effective intervention for alleviating MTrPs to decrease

associated pain and restore normal tissue mechanics (DaPrato & Kennedy, 2017). However, there


is little evidence in existence for the use of MDT in the treatment of MTrP pain and dysfunction.

MDT was therefore included as an intervention to directly treat the latent MTrPs in conjunction

with impairment based manual therapy interventions and an individualized therapeutic exercise

program to restore normal upper extremity function.

The patient’s prognosis was determined to be good based on prior successful physical

therapy from a similar surgery, high pre-surgical physical fitness level, availability of resources,

high nutrition level, high motivation level, and a lack of co-morbidities. Negative prognostic

factors included a past medical history surgery to the same elbow within five years of the first

surgery. The patient was willing to attend physical therapy six times a week until the successful

completion of a return to throwing program.

The planned procedural interventions included: MDT to latent MTrPs to improve muscle

function, self-myofascial manipulation to improve ROM and muscle function, manual therapy

techniques to improve ROM and decrease pain, therapeutic exercise to improve upper extremity

ROM, strength, and neuromuscular control, and cryotherapy for managing post-operative pain

and swelling. Based on the patient’s occupation as a minor-league baseball pitcher, interventions

were focused on restoring full upper extremity function with neuromuscular re-education of

throwing motion. The patient’s primary goal was to return to competitive throwing without

experiencing shoulder or elbow pain.

Coordination of care included submission of all objective data via daily progress notes

through a centralized electronic medical records system (EMR) within the organization. The

EMR was accessible by the physical therapist, operating surgeon, athletic trainers, coaches, front

office personnel, and other authorized users. Three reassessments were performed over the course

of the initial five weeks of treatment, and occurred on treatment days seven, twenty-one, and

thirty-five. Objective values for elbow pain (NPRS), MTrP referred pain with compression

(NPRS), ROM, and strength were used as the primary determinants of objective patient progress,

along with palpation for MTrP characteristics.


Patient communication included: discussing initial evaluation findings and significance,

outlining the expected plan of care timeline including expected date to begin a return to throwing

program, patient education on post-operative precautions and MTrP pain and dysfunction, and

activity modification. During each visit the patient was asked about current pain level in the

elbow, response to the previous treatment session, signs and symptoms of infection, and

consistency with post-operative precautions and instructions. Prior to surgical intervention the

patient was educated on post-operative expectations and the scheduled start date for physical

therapy. The patient agreed to participate in all treatment sessions and interventions. He attended

a total of thirty physical therapy treatment sessions over the initial five weeks of treatment.

Interventions

The course of physical therapy consisted of 90-minute treatment sessions, six consecutive

days per week, for five weeks. The primary interventions that the patient received have been

placed into four categories: Myofascial Decompression Therapy, Self-Myofascial Manipulation,

Manual Therapy, and Therapeutic Exercise.

Myofascial Decompression Therapy

The frequency and description of myofascial interventions, including MDT, is presented

in Appendix D. MDT was selected to treat the latent MTrPs in the patient’s right infraspinatus

and levator scapulae. The patient received MDT treatment one time per week for five weeks, with

six days passing between each session. The patient was positioned prone on a treatment table with

arms resting his sides. The clinician then performed palpation for MTrP identification and

location. Small, flat edged, 1.5-inch plastic decompression cups for were selected during each

treatment. A single decompression cup was applied directly over each identified MTrP with the

targeted muscle at rest. Each cup received between two and three pumps of pneumatic pressure.

The number of pneumatic pressure pumps used during each treatment was dependent on the

patient’s tolerance of negative pressure at that point in time. In theory, application of increased

negative pressure has a stronger flushing effect on MTrPs (Daprato & Kennedy, 2017). Each cup


was left on for between two and five minutes before being removed by the clinician. The patient

was asked to lie still throughout each MDT treatment.

Each treatment session began with an active warm up with the upper body ergometer

(UBE) to improve circulation in the upper extremities in preparation for treatment. Myofascial

treatments consisting of MDT or self-myofascial manipulation immediately followed active

warm-up. Manual therapy techniques were applied after myofascial work was completed.

Therapeutic exercise followed manual therapy intervention to improve right upper extremity

ROM, strength, and neuromuscular control. Each treatment during the initial two weeks of

treatment session concluded with Cryotherapy to manage post-operative elbow pain and swelling.

After two weeks, the patient received cryotherapy as needed following treatment. Self-myofascial

manipulation was not performed on the same day as MDT treatment sessions.

Self-Myofascial Manipulation

The frequency and description of myofascial interventions, including self-myofascial

manipulation treatment, is presented in Appendix D. Self-myofascial manipulation is the

application of slow, compressive forces in a direction perpendicular to the targeted muscle fibers

via foam roller, lacrosse ball, tennis ball, handheld roller massage stick, or other manual massage

tool. It is proposed to improve soft tissue length, improve joint ROM, decrease pain, and release

myofascial restrictions (Healey, Hatfield, Blanpied, Dorfman, & Rieb, 2014). A recent systematic

review demonstrated that self-myofascial manipulation from foam rollers and handheld roller

massage sticks is effective for improving joint ROM and improving muscle performance both pre

and post exercise (Cheatham, Kolber, Cain, & Lee, 2015). Pitching is a motion requiring the

transfer of force along a kinetic chain extending from the lower extremities and trunk to the upper

extremity to induce maximum ball velocity. Breakdown at any point in the chain causes the

shoulder to have to generate larger forces in order to maintain ball velocity (Seroyer et al., 2009).

The performance of daily self-myofascial manipulation was included as part of the treatment plan

with goals of maintaining soft-tissue extensibility, joint ROM, and strength in the trunk and lower


extremities to reduce the need for excessive for force generation in the patient’s affected upper

extremity. The case patient was instructed to perform self-myofascial manipulation to each

selected muscle group two times per week with two days of rest in between to allow for recovery

as demonstrated in Appendix D.

Manual Therapy

The frequency and description of manual therapy interventions is presented in Appendix

E. Manual therapy for the case patient included: upper thoracic spine high velocity low-amplitude

(HVLA) thrust manipulation, peripheral joint manipulations, and PROM with overpressure.

Upper thoracic manipulation techniques were selected to improve thoracic spine extension

mobility and decrease the patient’s upper extremity pain complaints. HVLA manipulation to the

upper thoracic spine has been shown to reduce shoulder pain and improve shoulder ROM after a

single treatment (Strunce, Walker, Boyles, & Young, 2009). Joint manipulation techniques of

grades III through V, based on the Maitland Scale of Oscillatory Mobilization, were selected to

improve joint mobility and limit the effects of post-surgical upper extremity immobilization on

muscle function and joint ROM. Targeted peripheral joints included: right scapulothoracic joint,

right glenohumeral joint, and right humeroulnar joint. Scapulothoracic manipulation has been

reported as a useful technique for improving shoulder ROM and pain intensity (Surenkok, Aytar,

& Baltaci, 2009). Graded, directional, glenohumeral joint manipulations have been widely

reported in the literature to improve shoulder joint ROM (Manske, Meschke, Porter, Smith, &

Reiman, 2009; Yu, Jung, Kang, Lee, & Oh, 2015). Posterior glides to the humeroulnar joint with

end-range oscillations are recommended for improving elbow joint extension ROM in overhead

athletes (Wilk, Macrina, Caine, Dugas, & Andrews, 2012). All three of these techniques were

included in the plan of care for the case patient. PROM with overpressure into elbow flexion and

elbow extension was applied to assist with reestablishing full elbow ROM.


Therapeutic Exercise

The frequency and description of therapeutic exercise interventions is presented in

Appendix F. Exercise selection was impairment and function based, and abided by the operating

surgeon’s post-operative protocol. Initial therapeutic exercises specific to the patient’s elbow

were selected to establish pain free AROM, minimize muscle atrophy, control pain and swelling,

and minimize the effects of sling immobilization. Progressive therapeutic exercises aimed to

reestablish full strength, full pain free AROM, and adequate neuromuscular of the post-operative

upper extremity. Therapeutic exercise intervention categories included: static stretching, joint

AROM, isometric/eccentric/concentric strengthening, proprioceptive neuromuscular facilitation

techniques, and self-joint manipulations. There is evidence recommending selection of these

therapeutic exercise techniques to reestablish proprioception and neuromuscular control

following elbow surgery in the overhead athlete (Wilk, Macrina, Caine, Dugas, & Andrews,

2012).

Outcomes

Over the course of the initial five weeks of treatment the patient demonstrated significant

improvements in pain and functional ability, and was able to begin a return to throwing program

on treatment day thirty-three. Gathered objective data used to assess patient progress included:

elbow pain (NPRS), MTrP referred pain with compression (NPRS), ROM (goniometry), and

strength (MMT), along with palpation for MTrP presence per current diagnostic criteria. The

patient experienced reductions in post-operative elbow pain from 5/10 at rest during initial

evaluation to 0/10 at rest during final reassessment. He experienced reductions in pain with

manual MTrP compression from 5/10 at initial evaluation to 1/10 at final reassessment. The

patient demonstrated improvements from initial evaluation in right upper extremity AROM for

elbow flexion (102o to 144o), elbow extension (-36o to -8o), elbow pronation (68o to 80o), elbow

supination (66o to 80o), shoulder flexion (164o to 184o), shoulder abduction (164o to 184o), and

shoulder internal rotation (48o to 56o). He demonstrated improvements in strength per MMT for


elbow flexion (3-/5 to 5/5 with pain), elbow extension (3-/5 to 5/5 with pain), elbow pronation (3-

/5 to 5/5 with pain), elbow supination (3-/5 to 5/5 with pain), shoulder flexion (3-/5 to 5/5),

shoulder abduction (3-/5 to 5/5), shoulder internal rotation (3-/5 to 5/5 with pain), and shoulder

external rotation (3/5 to 5/5 with pain). The pain experienced with MMT was localized to the

patients elbow and was only present with significant manual pressure. After beginning the return

to throwing protocol the patient reported feeling tight in his shoulder and elbow while throwing,

but did not report pain. Latent MTrP presence in the infraspinatus and levator scapulae persisted

throughout the five week course of treatment, though MTrP characteristics were altered. Altered

MTrP characteristics at final reassessment included a lack of taut muscle band presence in the

right infraspinatus and levator scapulae, and significantly decreased intensity with minimal

referred pain for right infraspinatus and levator scapulae MTrP compression. All comparative

objective data from initial evaluation and subsequent reassessments is presented in Appendix C.

Discussion

A variety of proposed treatment options exist in the literature for treating MTrPs, though

the clinical efficacy of these interventions remains unclear due to a lack of high quality studies

and systematic review meta-analyses (Bron et al., 2011; Ong & Claydon, 2014; Renan-Ordine,

Alburquerque-SendÍn, Rodrigues De Souza, Cleland, & Fernández-de-las-Peñas, 2011; Rickards,

2006; Vernon & Schneider, 2009). MDT in conjunction has been proposed as an effective

intervention for alleviating MTrPs, though there is little evidence to support this claim (DaPrato

& Kennedy, 2017). This case report described the application of single static cup MDT in the

treatment of two latent MTrPs as part of the initial five-week care plan for a 22-year old male

minor league baseball pitcher following right elbow arthroscopic surgery. Prior to surgery, the

patient presented with a 2-month history of progressively worsening shoulder and elbow pain that

occurred after pitching.

Results of this case report indicate that MDT in combination with manual therapy, self-

myofascial release, and an individualized therapeutic exercise program, was effective in


decreasing the intensity of latent MTrP characteristics in this patient. MDT did not appear to be

effective in completely alleviating latent MTrP presence when assessed using the current

diagnostic criteria standards found in Appendix A. The case patient reported significant decreases

in intensity of pain with manual MTrP compression (5/10 at initial evaluation to 1/10 at final

reassessment), and did not present with taut bands of muscle in his right infraspinatus and levator

scapulae at final reassessment. MDT is proposed to induce a pain inhibiting neurophysiological

response on the central nervous system, and it is possible that its application had a positive effect

on both this patient’s experience of MTrP related pain and post-surgical elbow pain (Rozenfeld &

Kalichman, 2016). The case patient also demonstrated significant improvements across the board

in terms of right upper extremity ROM, strength, and function, and was asymptomatic for

shoulder and elbow pain when initiating a return to throwing program. Research has shown that

MTrP treatment has positive effects on restoring normal muscle function, and may improve

associated joint ROM and muscle strength (Travell et al., 1998, pp. 30-31). It is therefore

plausible that MDT had a positive effect on the improvements in ROM, strength, and function

demonstrated in this patient’s right upper extremity. Due to the presence of several confounding

treatment variables in the heterogeneous plan of care, it is impossible to determine if MDT alone

induced any positive effects on the objective improvements seen in the right upper extremity

function of the case patient.

Identification and correction of the underlying etiological mechanism responsible for

MTrP development and perpetuation is paramount to developing an effective plan of care for

patients with MTrP pain and dysfunction (Wong & Wong, 2012). With this case patient it is

hypothesized that dysfunctional pitching mechanics led to an increase in force production

demands in his dominant upper extremity. Functional breakdown of the kinetic chain involved in

pitching may lead to increased stresses being placed on the shoulder girdle structures to maintain

adequate ball velocity production (Seroyer et al., 2009). With supra-physiological stresses already

being placed being placed on the shoulder girdle structures during pitching, an increase in these


forces from abnormal pitching mechanics will likely lead to further repetitive muscular overload

and microtrauma, both of which have been identified as contributing factors in MTrP

development (Unverzagt, Berglund & Thomas, 2015). Given the case patient’s history of high

level competitive pitching, it is likely that prolonged repetitive muscular overload and

microtrauma played a role in the development of the latent MTrPs in his right infraspinatus and

levator scapulae, and may also have contributed to the bony changes seen in the patient’s right

elbow. This was reflected in the patient’s plan of care with an approach to restoring and

maintaining full function throughout the body, as opposed to focusing only on the impaired right

upper extremity.

Changes in glenohumeral (GH) ROM have been studied extensively as potential risk

factors for pitching-related injuries (Fortenbaugh, Fleisig, & Andrews, 2009; Post, Laudner,

McLoda, Wong, & Meister, 2015). Unfortunately, no objective data regarding GH ROM prior to

the case patient’s surgery was available. GH ROM values can therefore only be compared to

those gathered at initial evaluation. The following is a list of abnormal right GH AROM values

that the case patient presented with at initial evaluation: GH flexion (164o), GH abduction (164o),

GH internal rotation (48o), and GH external rotation (112o). Considering that the case patient

underwent minimally invasive surgery to elbow and not the shoulder, shoulder ROM deficits of

this magnitude in comparison to established norms of healthy adults should not be present.

However, when compared to elite level pitchers in his age-related cohort, the case patient

presented with relatively normal shoulder AROM values. It is common for pitchers to

demonstrate increased GH external rotation ROM and decreased GH internal rotation ROM in

their dominant arm when compared to established norms, though no significant differences were

found when dominant arm ROM was compared to non-dominant arm ROM (Thomas, Swanik,

Swanik, & Kelly, 2013). This fits the presentation of the case patient as he demonstrated

excessive GH external rotation AROM (112o compared to 90o) and decreased GH internal

rotation (48o compared to 70o - 80o). This may also explain why the patient was unable to


improve shoulder internal rotation to greater than 56o at final reassessment, despite extensive

interventions for improving shoulder ROM in all motions. With this case patient, ROM goals

were based on contralateral upper extremity values as opposed to ROM value for normal adults.

Despite not achieving full ROM and strength in his dominant upper extremity compared to his

non-dominant upper extremity, the patient was cleared to begin a return to throwing program on

treatment day thirty-three. Clinicians working with overhead athletes should consider setting

ROM goals based on the contralateral upper extremity as opposed to normative values for healthy

adults.

Objective data for muscle strength was recorded using Kendall’s MMT grading system. It

is worth noting that per the MMT grading system, a value of 3-/5 indicates only that the

individual is able to produce greater than half of the full ROM against gravity, but cannot achieve

full ROM against gravity. This muscle grading system does not accurately indicate changes in

muscle force production in instances where full ROM is not achieved. The case patient was

unable attain full ROM for elbow extension and shoulder internal rotation when compared to his

contralateral limb. With MMT testing the patient was able to resist significant manual pressure

for all tested motions without breaking from the testing position, indicating he had adequate

upper extremity strength and was graded as a 5/5. However, in accordance with the Kendall

MMT grading system he would technically be graded as a 3-/5 because he could not achieve full

AROM in comparison to the contralateral limb. Positive changes in the strength and function of

the muscles creating these actions were achieved, and are demonstrated by progressive increases

in therapeutic exercise resistance throughout the course of treatment. At initial evaluation the

clinician chose not to apply resistance with MMT due to the acuity of elbow surgery and patient

being unable to achieve full AROM for any of most tested motions (maximum MMT grade of

3/5). At final reassessment the patient reported experiencing minimal pain in his right elbow with

maximum resistance during MMT testing for elbow flexion, elbow extension, elbow pronation,

elbow supination, shoulder internal rotation, and shoulder external rotation.


This case report involved only one patient and the duration of treatment reported was for

the initial five weeks. The patient continued to receive individualized treatment following the

initial five weeks of treatment, and reported being able to complete his return to throwing

program and resumed high level competitive pitching. Objective data beyond the initial five

weeks of treatment is unavailable, and whether or not the patient was able to remain pain free

beyond completion of the return to throwing program is unknown as the author does not have

access to that information. Future research is necessary to determine the short term effects of

MDT on latent MTrPs in isolation from confounding treatment variables in order to develop a

better understanding the overall effect and treatment effect size for this intervention. Due to a lack

of standardized application techniques in applying MDT to MTrP, future studies should trial

different cupping parameters and frequencies of treatment. Evidence investigating the effect of

MDT in treating latent MTrPs with associated range of motion impairments, strength deficits,

decreased neuromuscular control, and referred pain, will help guide physical therapists in best

practice when treating MTrPs.


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Appendices Appendix A. Myofascial Trigger Point Diagnostic Cluster

Essential Criteria Non-Essential Criteria

Taut band within skeletal muscle Local twitch response

Hypersensitive spot Jump sign

Referred pain Restricted range of motion

*Minimum two out of the three essential criteria must be present in order to diagnose as MTrP

*Presence of multiple non-essential criteria may increase likelihood of true MTrP presence


Appendix B. Systems Review Summary

Cardiovascular/Pulmonary Mild (1+), non-pitting edema around right elbow.

Integumentary Mild yellow and purple ecchymosis, five (5) portal hole incisions with single figure-8 sutures used for approximation.

Musculoskeletal Impaired Gross Symmetry: Seated and standing posture wearing over the shoulder elbow sling on right upper extremity. Patient presents with elevated right shoulder with mild upper trapezius guarding.

Impaired Range of Motion: left elbow extension. Right elbow flexion, extension, supination. Right shoulder flexion, abduction, external rotation, internal rotation.

Impaired Gross Strength: right elbow flexion, extension, pronation, supination. Right shoulder flexion, abduction, internal rotation, external rotation.

Height: 6’2”

Weight: 198 lbs

BMI: 25.4 (overweight)

Neuromuscular Not impaired


Appendix C. Tests & Measures

Tests & Measures Initial Evaluation Reassessment #1 (Day 7) Reassessment #2 (Day 21) Reassessment #3 (Day 35) Numeric Pain Rating Scale

5/10 at rest 8/10 worst (past 24-hours) 2/10 best (past 24-hours)



0/10 rest 2/10 worst (past 24-hours) 0/10 best (past 24-hours)

Gross PROM and AROM Elbow Flexion Elbow Extension Elbow Pronation Elbow Supination Sh Flexion Sh Extension Sh Abduction Sh Internal Rotation Sh External Rotation Wrist Flexion Wrist Extension

Left Right 144 102 -6 -36 80 68 80 66

184 164 50 50

184 164 66 48

100 112 88 86 80 82

Left Right NT 118 NT -10 NT 74 NT 70 NT 172 NT NT NT 172 NT 54 NT NT NT NT NT NT



Gross Upper Extremity MMT Elbow Flexion Elbow Extension Elbow Pronation Elbow Supination Sh Flexion Sh Abduction Sh Internal Rotation Sh External Rotation Wrist Flexion Wrist Extension

Left Right 5/5 3-/5 5/5 3-/5 5/5 3-/5 5/5 3-/5 5/5 3-/5 5/5 3-/5 5/5 3-/5 5/5 3/5 5/5 5/5 5/5 5/5

Left Right NT NT NT NT NT NT NT NT NT NT NT NT NT NT NT NT NT NT NT NT

Left Right NT NT NT NT NT NT NT NT NT NT NT NT NT NT NT NT NT NT NT NT

Left Right 5/5 5/5 (pain) 5/5 5/5 (pain) 5/5 5/5 (pain) 5/5 5/5 (pain) 5/5 5/5 5/5 5/5 5/5 5/5 (pain) 5/5 5/5 (pain) NT NT NT NT


Appendix C. Tests & Measures (Continued)

Tests & Measures Initial Evaluation Reassessment #1 Reassessment #2 Reassessment #3 Special Tests

Special Test Result Painful Arc Negative Neer’s Test Negative

Empty Can/Full Can Test Positive Cross Body Adduction Test Negative

Special Test Result Painful Arc NT Neer’s Test NT

Empty Can/Full Can Test NT Cross Body Adduction Test NT

Palpation for Provocation

Latent MTrPs: right levator scapulae, right infraspinatus Pain with Compression: 5/10





Appendix D. Myofascial Interventions

Application

Interventions

Treatment Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Manual

Myofascial Dry Cupping

x

x

Self-Myofascial

Manipulation

Trigger Point Shoulder

x x x

Shoulder External Rotators

x x

x

x

x

Triceps Surae

x x x x x

Latissimus Dorsi

x x x x x

Hamstring Muscle Group

x x x x x

Quadriceps Muscle Group

x x

x

x x

Pectoralis Major/Minor

x x x x x

Gluteus Muscle Group

x x x x x

“x” = interventions completed


Appendix D. Myofascial Interventions (Continued)

Application

Interventions

Treatment Day 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

Manual

Myofascial Dry Cupping

x x x

Self-Myofascial

Manipulation

Trigger Point to Shoulder

x x x x x

Shoulder External Rotators

x x x x x

Triceps Surae

x x x x x

Latissimus Dorsi

x x x x x

Hamstring Muscle Group

x x x x x

Quadriceps Muscle Group

x x x x x

Pectoralis Major/Minor

x x x x x

Gluteus Muscle Group

x x x x x



Appendix E. Manual Therapy Interventions

Interventions

Treatment Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Manual Therapy

Upper Thoracic Manipulation

x x x x x x

PROM Elbow Flexion

with Overpressure

x x x x x x x x x x x x x

PROM Elbow Extension

with Overpressure

x x x x x x x x x x

x

x x

Scapulothoracic Joint

Mobilizations

x x x x x x

Humeroulnar Joint

Distraction - Grade III/IV

x x x

RUE Long Axis Overhead

Distraction



Appendix E. Manual Therapy Interventions (Continued)

Interventions

Treatment Day 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

Manual Therapy

Upper Thoracic Manipulation

x x x x x

PROM Elbow Flexion

with Overpressure

x x x x x

PROM Elbow Extension

with Overpressure

x x x x x

Scapulothoracic Joint

Mobilizations

x x x x x

Humeroulnar Joint

Distraction - Grade III/IV

x x x x x

RUE Long Axis Overhead

Distraction

x x x x



Appendix F. Therapeutic Exercise Interventions

Interventions

Treatment Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18


Upper Body Ergometer

x x x x x x

x x x x x x x x

Elbow Hangs Over Towel

x x x x x x x

x x x x x x x x

AROM Wrist

x x x

AROM Elbow

x x x

AROM Shoulder

x x x

AROM Scapula

x x x

Ball Squeezes

x

HEP

HEP

HEP

HEP

HEP

HEP

RUE Shoulder Horizontal

Adduction Stretch

x x x x

“x” = interventions completed; HEP = prescribed to home exercise program


Appendix F. Therapeutic Exercise Interventions (Continued)

Interventions

Treatment Day 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

Therapeutic

Exercise

Upper Body Ergometer

x x x x x x x x x x x x x x x

Elbow Hangs Over Towel

x x x x x x x x x x

AROM Wrist

AROM Elbow

AROM Shoulder

AROM Scapula

Ball Squeezes

RUE Shoulder Horizontal

Adduction Stretch




Interventions

Treatment Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18


Wrist Flexion Stretch

x x

x x x

Wrist Extension Stretch

x x

x x x

Doorway Stretch

x x x x x

Elbow Flexion Isometrics

x x x x x

Elbow Extension Isometrics

x x x x x

Sidelying Dumbbell

Shoulder External Rotation

x x x x x

BUE Tubing Circuit –

Scapular Retractions, ER + IR at 0o Sh Abduction

x x x x x




Interventions

Treatment Day 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

Therapeutic

Exercise

Wrist Flexion Stretch

x x x x x

Wrist Extension Stretch

x x x x x

Doorway Stretch

x

Elbow Flexion Isometrics

x

Elbow Extension

Isometrics

x

Sidelying Dumbbell

Shoulder External Rotation

x

BUE Tubing Circuit –

Scapular Retractions, ER + IR at 0o Sh Abduction

x




Interventions

Treatment Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18


Triceps Overhead Stretch

x x

x x

Thoracic Extension Over

Foam Roller

x x x x

Sidelying Thoracic

Windmill

Quadruped Thoracic Rotation with Reach

Manual Shoulder Rhythmic

Stabilizations – 90o Shoulder Flexion

x x x x

Rice Bucket – Wrist – All Osteokinematic Motions

x x x x

Wall Ball Dribbles x x x x x




Interventions

Treatment Day 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

Therapeutic

Exercise

Triceps Overhead Stretch

x x x x x

Thoracic Extension Over

Foam Roller x x x x x

Sidelying Thoracic

Windmill

x x x x x

Quadruped Thoracic Rotation with Reach

x x x x x

Manual Shoulder

Rhythmic Stabilizations – 90o Shoulder Flexion

x x x x x

Rice Bucket – Wrist – All Osteokinematic Motions

x x x x x

Wall Ball Dribbles x x x x x x x x x x




Interventions

Treatment Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18


BUE Trampoline Toss – Chest Pass, 2-Hand Side

Chop, Soccer Pass

x

RUE Trampoline Toss – IR

at 0o Sh Abduction, Overhead Throw

Prone 6-Back Series

x x x

RUE Tubing – Elbow

Flexion

x x x x

RUE Tubing – ER + IR at

0o Shoulder Abduction

x x

RUE Tubing – ER at 90o

Shoulder Abduction

x x




Interventions

Treatment Day 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

Therapeutic

Exercise

BUE Trampoline Toss – Chest Pass, 2-Hand Side

Chop, Soccer Pass

x x x x x

RUE Trampoline Toss – IR at 0o Sh Abduction,

Overhead Throw

x x x x x x x

Prone 6-Back Series

x x x x x

RUE Tubing – Elbow

Flexion

x x x x x

RUE Tubing – ER + IR at

0o Shoulder Abduction

x x x x x

RUE Tubing – ER at 90o

Shoulder Abduction

x x x x x




Interventions

Treatment Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18


Elbow Flexion - Self Over Pressure with Towel Roll

x x

Dumbbell Pronation +

Supination

x

Scapular Wall Angels

x

Body Blade – ER + IR at 0o

Shoulder Elevation

x

Banded Elbow Extension

Weighted Ball Catch – Half

Kneel - D2 Pattern

Weighted Ball Catch –

Supine – Horizontal Abduction




Interventions

Treatment Day 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

Therapeutic

Exercise

Elbow Flexion - Self Over Pressure with Towel Roll

x x x x x x x x x x

Dumbbell Pronation +

Supination

x x x x x

Scapular Wall Angels x x x x x

Body Blade – ER + IR at 90o Shoulder Abduction

x x x x

Body Blade – Flexion +

Extension at 180o Shoulder Elevation

x x x x

Banded Elbow Extension x x x x x

Weighted Ball Catch – Half Kneel - D2 Pattern

x x x x



Appendix G. Myofascial Decompression Cups & Suctioning Device

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