Myofascial Dry Needling Practical: Lower Extremity

Overview Neurovascular Anatomy of the Lower Limb Adductor Longus Adductor Magnus Gracilis Gastrocnemius Soleus & Plantaris Tibialis Anterior Extensor Digitorum & Hallucis Longus Peroneus Longus and Brevis Tibialis Posterior Flexor Digitorum & Hallucis Longus Neurovascular Anatomy of the Lower Limb MDN of muscles in the Lower Limb: Rectus Femoris Vastus Lateralis Vastus Medialis Vastus Intermedius Biceps Femoris Semimembranosus & Semitendinosus Adductor Brevis Sartorius

Nerves: Lower Limb Basmajian, J. V. (1982)

Arteries: Lower Limb Basmajian, J. V. (1982)

Veins Basmajian, J. V. (1982)

Rectus Femoris Travell, J. G., Simons, D. G., & Cummings, B. D. (1983)

Rectus Femoris MDN Patient in a supine position with the hip slightly abducted and extended The knee is slightly flexed with the leg off the table resting on a stool The TrP is needled perpendicularly

Vastus Lateralis Travell, J. G., Simons, D. G., & Cummings, B. D. (1983)

Vastus Lateralis MDN Patient side lying on the unaffected side with the affected hip flexed and the unaffected hip extended TrP 1 is needled with a slight oblique angle directed inferiorly towards the patella. The patella must be pushed distally in order to access the TrP TrPs 2, 4 and 5 are deeply needled perpendicularly or on a slight oblique angle directed anteriorly Biceps femoris may have to be pushed out of the way to needle TrP 3, which is needled perpendicularly

Vastus Medialis Travell, J. G., Simons, D. G., & Cummings, B. D. (1983)

Vastus Medialis MDN The patient is in a supine position with the hip flexed and abducted and the knee resting on the practitioners lap or pillow The upper TrP is needled obliquely on a slight anterior angle away from sartorius to avoid puncturing the femoral artery The distal TrP may be needled in a perpendicular or oblique angle

Vastus Intermedius Travell, J. G., Simons, D. G., & Cummings, B. D. (1983)

Vastus Intermedius MDN The patient is in a supine position with a bolster or pillow under the knees The upper TrP is needled perpendicularly through the rectus femoris muscle The TrP very deep (around 3mm from the bone) and hence requires a little persistence as it may be difficult to locate and needle

Sartorius Travell, J. G., Simons, D. G., & Cummings, B. D. (1983)

Sartorius MDN The patient is in a supine position with a bolster or pillow under the knees and the hip externally rotated The TrPs are needled transversely in a superior or inferior direction

Biceps Femoris Travell, J. G., Simons, D. G., & Cummings, B. D. (1983)

Biceps Femoris MDN Patient in a side lying position on the unaffected side with the hips and knees slightly flexed The TrPs are needled on a slight oblique angle in a lateral direction to avoid the sciatic nerve

Semimembranosus Travell, J. G., Simons, D. G., & Cummings, B. D. (1983)

Semitendinosus

Semimembranosus & Semitendinosus MDN Patient side lying on the affected side with the affected hip flexed and the unaffected hip extended The muscle is pincer gripped and pulled away from the femur as to avoid the sciatic nerve which lies close to the bone The TrPs are needled perpendicularly towards the lateral aspect of the thigh Travell, J. G., Simons, D. G., & Cummings, B. D. (1983)

Adductor Brevis Travell, J. G., Simons, D. G., & Cummings, B. D. (1983)

Adductor Brevis MDN The patient is in a supine position with the hip abducted and externally rotated The femoral artery must be identified before needling Both adductor brevis and adductor longus are grasped in pincer grip to avoid puncturing the femoral artery A posterior approach is taken and the TrP is needled obliquely in an antero-lateral direction

Adductor Longus Travell, J. G., Simons, D. G., & Cummings, B. D. (1983)

Adductor Longus MDN The patient is in a supine position with the hip abducted and externally rotated The femoral artery passes anteriorly over the muscle and must be identified before needling Both adductor brevis and adductor longus are grasped in pincer grip to avoid puncturing the femoral artery An anterior approach is taken and the TrP is needled obliquely in an postero-lateral direction

Adductor Magnus Travell, J. G., Simons, D. G., & Cummings, B. D. (1983)

Adductor Magnus MDN The patient is in a supine position with the hip abducted and externally rotated The proximal TrPs are needled obliquely from the medial aspect of the thigh in a supero-medial direction The distal TrP is needled perpendicularly from the medial aspect of the thigh in a lateral direction The sciatic nerve runs along the posterior aspect of adductor magnus and care must be taken to avoid puncturing it

Gracilis Travell, J. G., Simons, D. G., & Cummings, B. D. (1983)

Gracilis MDN The patient is in a supine position with the hip abducted and externally rotated The TrPs are relatively superficial and may be needled perpendicularly or obliquely

Gastrocnemius Travell, J. G., Simons, D. G., & Cummings, B. D. (1983)

Gastrocnemius TrP 1 Patient side lying on the affected side with the knee flexed The TrP is needled perpendicularly from medial to lateral TrP 2 Patient side lying on the unaffected side with the affected knee flexed The TrP is needled perpendicularly from lateral to medial

Gastrocnemius TrP 3 TrP 4 Patient in a prone position The TrP is needled perpendicularly in an anterior direction TrP 4 Patient side lying on the unaffected side with the affected knee flexed

Soleus Travell, J. G., Simons, D. G., & Cummings, B. D. (1983)

Soleus MDN For TrP 1 the patient is side lying on the affected side with the hip and knee slightly flexed and the hip of the unaffected side flexed and resting in front of the leg to be needled The muscle is held in a pincer grip and the needle is inserted perpendicularly from medial to lateral For TrP 2 the patient is lying on the opposite side TrP 2 is needled on an oblique angle towards the fibula to avoid the tibial nerve and vessels which lie anterior to the soleus For TrP 3 The muscle is held in a pincer grip and the needle is inserted perpendicularly from lateral to medial

Tibialis Anterior Travell, J. G., Simons, D. G., & Cummings, B. D. (1983)

Tibialis Anterior MDN Patient in a supine position with the knee slightly flexed resting on a support The TrP is needled obliquely towards the tibia at an angle of 450 as to avoid the anterior tibial artery and vein and the deep peroneal nerve which lie deep to the muscle

Extensor Digitorum & Hallucis Longus Travell, J. G., Simons, D. G., & Cummings, B. D. (1983)

Extensor Digitorum & Hallucis Longus MDN For extensor digitorum longus, the patient lies supine with a pillow beneath the knees The needle is inserted close to the lateral border of the tibialis anterior on an oblique angle directed posteriorly to avoid the deep peroneal nerve and anterior tibial vessels For extensor hallucis longus the patient assumes the same position Dry needling of this TrP is not recommended because of it’s proximity to the deep peroneal nerve and anterior tibial vessels, but may be done if necessary The needle is inserted obliquely through tibialis anterior and angled towards the fibula

Peroneus Longus and Brevis Travell, J. G., Simons, D. G., & Cummings, B. D. (1983)

Peroneus Longus and Brevis MDN Patient side lying with the knees flexed and a pillow between the knees The TrPs are needled perpendicularly The common peroneal nerve lies between the peroneus longus and the fibula and may be about 1 cm above the proximal TrP

Tibialis Posterior Travell, J. G., Simons, D. G., & Cummings, B. D. (1983)

Tibialis Posterior Needling of the tibialis posterior TrP is not recommended due to its proximity to the neuromuscular bundle The needle must pass through (or very close to the neuromuscular bundle An anterior approach must be taken but the needle will have to pass through the interosseous membrane Other measures are therefore recommended to deactivate the TrP

Flexor Digitorum & Hallucis Longus Travell, J. G., Simons, D. G., & Cummings, B. D. (1983)

Flexor Digitorum & Hallucis Longus MDN For flexor digitorum longus, the patient is side lying on the affected side with the hip and knee slightly flexed and the hip of the unaffected side flexed and resting in front of the leg to be needled The needle is inserted close to the medial border of the tibia on an oblique angle close to the bone’s posterior surface to avoid the tibial nerve and posterior tibial vessels For flexor hallucis longus the patient is supine lying Dry needling of this TrP is not recommended because of it’s proximity to the peroneal vessels, but may be done if necessary The needle is inserted obliquely through gastrocnemius and soleus, and angled laterally towards the fibula

Bibliography Travell, J. G., Simons, D. G., & Cummings, B. D. (1983). Myofascial pain and dysfunction : the trigger point manual (Vol. 2). Baltimore: Williams and Wilkins Simons, D. G., Travell, J. G., Simons, L. S., & Travell, J. G. (1999). Travell & Simons' myofascial pain and dysfunction : the trigger point manual (2nd ed. Vol. 1). Baltimore: Williams & Wilkins Basmajian, J. V. (1982). Primary anatomy (8th ed.). Baltimore: Williams & Wilkins