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Myofascial Meridian Stimulation Therapy
Myofascial Meridian Stimulation Therapy (MMST)
經筋動穴針法
Dr. Seonghyung Cho, M.D.
Korean Integrative Medicine Institute
Korean Integrative Medicine Institute
Myofascial Meridian Stimulation Therapy
MMST( 筋經動穴針法 ) History통증 치료에 있어 “ HOW” 가 아니라 “ WHY” 라는 하나의 접근 법으로서 MMST( 經筋動穴針法 ) 를 저의 스승이신 김일환 M.D. 선생님의 도움아래 고안하게 되었습니다 .
MMST( 經筋動穴針法 ) 는 근골격계와 자율신경병에 기인한 만성 통증에 있어 Acupuncture 가 왜 동양의학에서만 받아들여지고 서양의학에서는 쉽게 받아들여지지 않는가에 대한 의문점에서부터 출발하게 되었습니다 .
그 이유는 Acupuncture 의 과학적 기전이 완전히 밝혀지지 않았기 때문이며 실제 임상에서 Acupuncture 를 사용하는 시술자들에게도 그 효과 자체가 수수께끼로 남아있기 때문입니다 .
하지만 서양의학적 시각에서 Acupuncture 자체가 동양 철학과 밀접하게 연결되있다는 것을 분명 간과해서는 안될 것으로 보입니다 .
Korean Integrative Medicine Institute
Myofascial Meridian Stimulation Therapy
ICMART 2004, 호주 시드니 Main Session 논문 발표
Korean Integrative Medicine Institute
Myofascial Meridian Stimulation Therapy
ICMART 2005, 체코 프라하 좌장 및 Full Time Workshop
Korean Integrative Medicine Institute
Myofascial Meridian Stimulation Therapy
MMST( 經筋動穴針法 ) Introduction
Western medicine: Myofascial
Oriental medicine: Meridian
Integrative approach: Stimulation Therapy
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Myofascial Meridian Stimulation Therapy
Western medicine: Myofascial
Myofascia 라는 개념은 근막통증증후군 (MPS) 의 발통점 (Trigger Point) 과 연관된 근막 (Myofascia) 을 의미하는 것이 아니라 우리 몸 전체에 두루 퍼져있는 해부학적 근막선들 (Myofascial lines) 의 연결을 뜻하는 것입니다 .
이러한 근막선들의 네트워크를 통해 인체의 긴장통합체 (Bio-tensegrity) 와 분절성 신경 체계 (Segmental Nervous System) 를 유지할 수 있는 것입니다 .
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Oriental medicine: Meridian
Meridian 이라는 개념은 움직임이나 자세를 통해서 근육을 따라 인체에 퍼져있는 경락 (Meridian lines) 의 변화를 통해 유지되는 네트워크 체계를 의미하는 것입니다 .
동양의학에서 사용되는 주관적이거나 비객관적인 진단 방법을 지양하고 이러한 움직임을 통한 경락의 네트워크 체계를 이용하여 보다 객관적으로 진단하는 것입니다 .
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Myofascial Meridian Stimulation Therapy
Integrative approach: Stimulation Therapy
Stimulation Therapy 라는 개념은 근막선 (Myofascial line) 의 해부학적 구조와 경락의 경로 (Meridian pathway) 간에 상호 연관성과 분절성 신경 체계를 통해 선택된 경혈점 (Meridian point)을 다음과 같은 방법으로 자극을 하는 것입니다 .
Acupuncture, Dry needling, Injection, Magnetic therapy, Subcutaneous taped acupuncture, Myofascial release.
MMST( 經筋動穴針法 ) 는 이와 같이 임상의의 치료범위나 선호도에 따라 치료방법을 결정할 수 있습니다 .
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T.P(Trigger Point or Treatment Point) on the MMST
Segmental facilitation 에 의해 야기된 stress 는 muscle imbalance 를 통해 인체의 tensegrity 를 무너뜨리게 된다 .
그리고 이러한 유해성 자극 부위와 연속적으로 연결된 kinetic chain (myofascial line) 에 가장 취약한 부위가 발생된다 .
이러한 부위에서 referred pain 이나 hypertonic muscle 그리고 sympathetic dysfunction 등과 같은 비정상적인 증상이 일어나는데 이를 T.P.(Trigger Point or Treatment Point) 이라 한다 .
MMST( 筋經動穴針法 ) 에서는 이러한 T.P. 를 서양 의학적인 concept 을 기초로 하여 선택된 meridian point 를 이용하여 치료를 한다 .
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MMST( 經筋動穴針法 ) Introduction
“ 古爲今用”을 통해 MMST( 經筋動穴針法 ) 는 동양의학과 서양의학에 있어 장점을 포용하고 단점을 보완하여 진단과 치료를 할 수 있는 동서양 의학의 통합적 접근법 (Integrative approach) 으로 이루어졌습니다 .
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A prospective view of the western medicine
Stephen M. Levin : Bio-tensegrity(tension + integrity) model
Thomas W. Myers : Anatomy of myofascial connections
Autonomic nervous system and its relation to voluntary nervous system
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Tensegrity(Tension +Integrity) model
Bicycle wheels and similar structures with compression elements floating in a continuous tension network have been termed “tensegrity”s
tructures by Buckminster Fuller.
Compression
element Continuous
tension
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Bio-tensegrity (Tensegrity Biomechanics) proposed by Stephen M. Levin
He asserted the bio-tensegrity model that the human body structure is maintained by bony frame embedded in myofascial tension strut just as a bicycle wheel structure is maintained by reciprocal tension of strut
Myofascial tension strut
CT
LS
Compression
element
Continuous
tension
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Similarity of Tensegrity model between human and other structures
All human structures are similar to a tension icosahedron model because of they are formed of triang
ular truss type.
Tension Icosahedron
model
Tension Icosahedron
model
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The kinetic chain concept of biomechanics
Weakest link in The same kinetic chain
Tissue lesion or dysfunctionin tensegrity structure
Symptoms:local inflammation
and pain
Strain orLimitation
Owing to ceaseless connection of the whole myofascia, a disorder in one region may be expressed in the form of pain and limitation on certain movement in other part of
body mainly in the same kinetic chain(myofascial tension line)
Primary: tissue lesion
Secondary:The weakest
link on remote area
As a result, Pain or Limitation on movement
Same kinetic chain or myofascial tension line
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Definition of Kinetic Chain
Three system: Myofascial, Articular, Neural system
Work as an integrated functional unit to provide structural and functional efficiency during integrated activities.
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Why Kinetic Chain is so important in MMST?
Efficiency of Movement and Posture: tensegrity and alignment of kinetic chain
Dysfunction of tensegrity and alignment in any kinetic chain: compensatory reaction for maintaining the balance of kinetic chain -> serial distorsion pattern of kinetic chain
Compensatory reaction(excess adaptive potency (flexibility, force, neuromuscular control) on tissue): tissue failure and overload -> cumulative injury cycle -> symptom and sign
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Cause of kinetic chain dysfunction
Postural dysfunction
Joint dysfunction
Muscle imbalance
Decreased neuromuscular control
Myofascial adhesion and shortness
Decreased core strength
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Dysfunction mechanismAltered length-tension relationship (Reciprocal Inhibition) Altered force couple relationship (Synergistic Dominance)Altered arthrokinematic relationship (Joint Dysfunction)
Result of these relationship:
->Altered neuromuscular control
->Decreased neuromuscular efficiency
->Tissue fatigue and failure
->Cumulative Injury Cycle
->Pain and other signs and symptoms
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Importance of optimum posture and alignment on the MMST
Help to prevent serial distorsion pattern
Help to provide optimal shock absorption
Help to provide weight acceptance and transfer of force during functional movement
Help to prevent the initiation of the cumulative injury cycle
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Ideal alignment and Optimum movement
Ideal alignment -> facilitate optimum movement
Malalignment due to repeated movement and sustained posture -> joint or surrounding support system 에 micro-trauma 유발 가능성이 증가 (ex:spinal segment-> degenerative change)
자동차의 wheel movement -> wheel balance and good alignment for optimum rotation -> 자동차와 지지면 사이에 있는 타이어가 균일하게 마모
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Good postural alignment
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Hypothetical concepts of Connective tissue injury
Piezo(pressure)-electric charge
Interference field
Electromagnetic field
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Piezo(Pressure)-Electric chargeAll the tissue of the body generate electrical fields when they are compressed or stretched
Mechanical force -> structural deformation -> piezo-electric effect
Muscles are under a constant strain. And also the strain creates a piezo-electric charge that runs through the fascia within and around the muscle
On the body surface, the electrical resistance of strained point(acupuncture point) is lower than in its surrounding area.
Low resistance point: meridian point, strained point, myofascial trigger point
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Segmental superficial dry needling’s MTrP(strained point) pain-relieving mechanism
Insertion of needle into tissue immediately overlying active pain-producing MTrP
Stimulation of A-delta sensory afferents
Direct arousal of activity in dorsal horn-situated enkephalinergic inhibitory interneuron
Indirect stimulation of these as a result of creation of activity in a serotonergic descending inhibitory system
The creation of activity in the descending nonadrenergic system
Blockade of intra-dorsal horn passage of MTrP’s nociceptive information
Alleviation of MTrP pain
PLUS
AND
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Interference Field on tissue strain
Interference field of nerves, cells, muscles,
vessels & othersCell,nerves,mus
cles,vessels,others
+ +++++ ++++ +++ ++- +
-- -----
- --- -
Normal membrane
Bio-electrical Potential
Disruption of membrane reverses normal Bio-electrical Potential – Dysfunction, Pain and Energy loss result
Damage
During an injury or other imbalance, the membrane is broken or disrupted. The electrolytes pass freely into or out of the membrane and walls
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Electromagnetic FieldExtra-cellular matrix synthesis and repair are subject to regulation both by chemical agent(cytokines and GF) and physical agents,principally mechanical and electrical stimuli.
In soft tissue, alternating current electrical fields induce redistribution of integral cell membrane proteins which could initiate signal transduction cascades and cause a reorganization of cytoskeletal structures.
All physical and mental functions are controlled by electromagnetic fields produced by movement of electro-chemicals within the body.
When an injury occurs and tissue is damaged, positively charged ion move to affected area, causing pain and swelling.
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Characteristics of Connective tissue
As a result, Piezo-electric charges, Interference fields and Ele
ctromagntic fields in connective tissue resulting from constant strains can occur pain and dysfunction in the body.
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fascial considerationSurrounding, supporting, separating, wrapping of the body
Be surrounded from sole to skull as one soft tissue structure
Function: ~innervated by many nerve ending ~elastically contraction & relaxation ~muscle attachment ~support & fix for balance ~all exercise ~blood & lymphatic circulation ~change earlier than chronic degenerative disease ~chronic passive tissue congestion ~tissue congestion(formation of fibrotic tissue) d/t H ion increase in the joint area ~stress band in overloading area ~burning nature pain d/t stress injury ~inflammatory action ~mediator:transport of the body fluid & inflammatory substance ~surround the CNS
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Myofascial line :
Superficial back lineSuperficial front lineLateral lineSpiral lineDeep front arm lineSuperficial front arm lineDeep back arm lineSuperficial back arm lineFunctional lineDeep front line
Recently, a model suggested by Thomas W. Myers in his book Anatomy Trains try to explain this concept of the myofascial tension line anatomically and to integrate with meridian co
ncept of TCM
network system in the body that controls structure of posture and movement.
Bio-TensegrityMyofascial tension strut
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Relation between myofascial connections and the kinetic chain concept on tensegrity
Dysfunction due to total myofascial connections-> limitation of movement
Sensitive tender point -> pain on remote area ( 압통점을 못 움직이도록 고정시키기 때문에 오히려 그 긴장도가 멀리 말초까지 뻗치게 됨 )
주된 장해부위로부터 사지를 움직이려 할 때에 조직의 tensegrity 구조물들은 어떤 강도의 감소 없이 그대로 힘을 전달 받아 우리 신체는 외부의 역학적 영향상태에 놓이게 되는 것이다 . 또한 한쪽이 고정된 상태에서 완전 가동운동을 일으키려 시도하면 인체는 보상작용을 하게 마련이다 .
As a result, dysfunction in excess movement -> repeated stress (local inflammation and pain) -> 발통 물질 and biomechanical failure
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Dysfunction according to Muscle imbalance on movement
Nociceptive stimuli -> postural muscles (tight:facilitated) & phasic muscles(weak:inhibited)
chain reaction -> imbalanced pattern and movement dysfunction
hypoxia -> ischemic state -> pain -> continue feed-back cycyle -> hyperactivty on neural stimulation -> imbalance and dysfunction
신체의 한 부위가 반복적이고 만성적인 스트레스를 받을 때 , 그 부위에 신경 구조들은 overexcitable 되어져 아주 쉽게 활성화되고 hyperirritable해지는 경향이 있다 . -> “facilitation”
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Segmental facilitation by I.Korr
Spinal segment: not independently
Principal of reciprocity -when the threshold of the segment is reached, all neurons will fire.
The segment in lesion has a lower threshold and is hyper-reflexive.
“lens” for afferent input collecting facilitatory or inhibitory afferents from segment above and below.
occur at areas of focus for postural stress(muscle imbalance), trigger point, visceral problem
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In sequence of Segmental facilitation in disturbed lesioned segment
Facilitation of the sensory pathways -> easier access to the nervous system including the higher centers
Facilitation of motor pathways -> sustained muscular tensions, exaggerated responses, postural asymmetries and limited & painful motion.
Since the muscles have rich sensory as well as motor innervation, under these condition, they and related tendons, ligaments, joint capsules may become the source of relative intense and unbalanced streams of impulses.
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The characteristics of the facilitated segment
Roots are overly sensitive or hair-triggered :hyperactive ventral motor root -> intervertebral foramen -> join the symp
athetic nerve chain -> in a state of chronic overactivity, result in damage to target organ
Produce a palpable change in tissue texture :local paravertebral muscle & connective tissues develop a shoddy feel :joints in the area are less mobile :the tissues are tender to touch :often painfully irritable
Sympathetic system dysfunction :changes in skin texture, sweat gland activity & capillary blood supply to t
he skin
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Pathway of Sensory information:Transmit information to spinal cord through dorsal horn
via ascending fibers to higher centers
via intrasegmental fibers to the anterior horn(somatic nervous system)
via intrasegmental fibers to the lateral horn(autonomic nervous system)
Transmission of sensory information through dorsal horn is modulated by descending stimuli of high level and intersegmental reflex.
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Gray matter of Spinal cordAnterior(Ventral) Horn:
cell bodies of somatic efferent nerve fibers
Posterior(Dorsal) Horn: cell bodies of interneurons upon which afferent(sensory) neurons termi
nate
Intermediated gray(Lateral Horn in the thoracic segments): cell bodies of autonomic(sympathetic) efferent nerve fibers
Gray commissure ---- connection of left and right
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Anatomy of Autonomic nervous system
Parasympathetic nervous system is divided into cranial outflow and sacral outflow
In sympathetic nervous system, the axon of the sympathetic preganglionic neurons leave the spinal cord with the ventral roots of the eighth cer
vical to the second lumbar spinal nerves.
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Division of Autonomic lateral horn
Medial column is comprised in cell bodies of preganglionic fibers toward internal organs
Middle column is comprised in cell bodies of preganglionic fibers toward trunk
Lateral column is comprised in cell bodies of preganglionic fibers toward head and extremities
Three columns are related to secondary segmental modulations through various and numerous interneurons.
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Secondary segmental relation
Segmental innervation: lateral horn 에 sympathetic nervous system 의 anatomy
Interconnection to lateral column of lateral horn: lateral horn 의 preganglionic cell body 가 efferent outflow 를 따라 머리와 사지로 가는 effector 의 segment
C8/T1/T2 C1/C2T2/T3/T4 C3/C4
T5/T6 C5/C6T7/T8/T9 C7/C8T10/T11 L3/L4
T12/L1/L2 L5/S1/S2
The MMST uses lateral column of lateral horn toward head and extremities related to secondary segmental modulation
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Somato-Visceral Point
Secondary segmental relation
For example, In C5/6 dermatome area pain, T5/T6 – C5/C6 : secondary segmental relation
We can explain that SomatoVisceral Points (SVP) for treating abnormal somatovisceral reflex use the anatomy of autonomic nervous system through extremities and head and the secondary segmental relation.
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SomatoVisceral Points (SVP) consisted of .
Segmental innervation
Interconnection to lateral column of
lateral horn
C8/T1/T2 C1/C2
T2/T3/T4 C3/C4
T5/T6 C5/C6
T7/T8/T9 C7/C8
T10/T11 L3/L4T12/L1/L2 L5/S1/S2
Sympathetic nervous system:
C8~L2
SomatoVisceral Points (SVP) consisted of UB meridian points on surrounding C8-L2 dermatome area.according to secondary segmental relation
Secondary segmental relation
Magnetic therapy on UB line
(paraspinal dermatome area)
UB line
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T5T6
Magnetic therapy on UB line
(paraspinal dermatome area) onT5-6
Somato-Visceral Point
C5/6
vasodilation (decrease sympathetic tone )
Secondary segmental relation
In the selection of points for treating abnormal somatovisceral reflex on common C5 segment area, we used magnetic therapy on UB meridian line of trunk related to anatomy of sympathetic nervous system and secondary segmental relation (C5/6-T5/6) instead of using acupuncture needle. SomatoVisceral Points (SVP) consisted of UB meridian points on surrounding T5-6 dermatome area. In using acupuncture needle on T5-6 segment of UB meridian line, the blood vessel tone was increased on C5-6segment area. But in using magnetic therapy, we found the blood vessel tone was not inc
reased in our clinical observation.
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Magnetic Therapy
The application of magnetic field to injured area helps to restore the normal electromagnetic balance.
The magnetic field relaxes capillary walls, as well as surrounding muscle and connective tissues, allowing for increased blood flow.
More oxygen and nutrients are transferred to the injury site, while pain and inflammatory-related electro-chemicals are more efficiently removed.
The overall process restores the normal electromagnetic balance of the area, relieving pain and inflammation and promoting accelerated healing.
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Segmental innervation
Dermatome, myotome and sclerotome derived from the same somite embryologically have the same nervous pathway and a referral common afferent pathway.
Relation with sclerotome and dermatome:
Anterior and posterior surface of plevis attached to iliolumbar ligament accord with L2 sclerotome. Also, Area of referred pains in iliolumbar ligament accords with L2 dermatome.
Referred pain pattern by ligament laxity follows the pattern of segmental dysfunction.
If nociceptive stimuli occur in a certain segment, these stimuli will influence same innervated segment (dermatome, myotome, sclerotome and viscerotome). As a result, referred pains, hypertonic muscles, activated trigger points, trophic changes and autonomic symptoms such as vasomot
or symptoms can occur.
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Somato-Somatic Point
Area in accordance with dermatome, myotome and sclerotome
For example, In C5/6 dermatome area pain C5/6 segment
Treatment points in the MMST for abnormal somatosomaic reflex use common segment area in accordance with dermatome, myotome and scler
otome.
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LU2
LI15
TE14
Somato-Somatic Point
Deep dry needling
Stimulate meridian points (combined area of dermatome,myotome and sclerotome on C5/6) by deep dry nee
dling
Stimulate skin, muscle and periosteum in order
Combined area of dermatome,myotome and
sclerotome on C5/6
In the selection of points for treating abnormal somatosomaic reflex on left shoulder pain, we applied SSP to common C5 segment area (dermatome,myotome and sclerotome). These points consisted of LU2, LI15 and TE14. Also, we stimulated these points by deep dr
y needling
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SomatoSomatic Point (SSP)LU2,LI15,TE14
ST36,GB34,BL53
LI11,LU5,TE9
LR8,KI10
GB30,BL60
Common Back pain
Common Knee pain
Common Shoulder pain
Deep dry needling
(combined area of dermatome, myotome, sclerotome)
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Primary: TL junction
syndrome
Secondary: Pain on LS junction by ligament laxity
Compensatory reaction
Common Back pain:Lumbar pain with/without gluteal pain
1.Acute problem: occur suddemly
2.Iliac crest 의 허리볼기 지 역에 pain: neurotrophic change of cellulalgia
3.Typical facet locking
1.Chronic problem: TL problem이후에 occur
2.LS junction 부위에 pain:
-compensatory movement
-gluteus muscle 에 T.P.
-hypersensitivity of greater trochanter (sometimes)
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Tenoperiosteal hypersensitivity
Cellulalgic zone
Common Knee painASIS
Q
ROM is not limited: Knee pain originated from the spine (L3-4)1.cellulalgic zone: L3-4 dermatome around the knee2.T.P.: Quadriceps femoris (Vastus medialis oblique)3.Tenoperiosteal hypersensitivity: pes anserinus area
Q increase: external
torsion of the proximal tibia
VMO 와 Medial retinaculum 의 작용에 의해 alignment 유지
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Relationship between biomechanical overload and painful joints associated with MPS and muscle imbalance
Painful joint
Trigger point
Shortened muscle
Inhibited muscle
Faulty posture
Faulty movement
patternCervico-cran
ialSCM Suboccipitalis DNFs Head
forwardNeck
flexion
Gleno-humeral
Upper Trapezius
Levator scapulae or subscapula
ris
Lower trapezius
Rounded shoulder
Scapulo-humeral rhythm
Upper ribs
Scalenes Pectoralis Diaphragm
Slumped posture
Respiration
TMJ Lateral pterygoids
Masseter Digastrics
Chin poke Mouth opening
Common Shoulder pain
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Injection Site: Facet joint & ligament
TL junction problem
transitional zone
Knee pain originated from the spine(L3-4)
LS junction problem:
ligament laxity
Posterior primary ramus 의 medial br
anch
UB line
GV line