By David Kent, LMT, NCTMB Keeping It Simple Series
KentHealth.com | 888.574.5600
Back Pain Caused by
Rectus Abdominis Trigger Points
KentHealth.com | 888.574.5600
When clients schedule a treatment
session, they expect results and regardless
of which massage modality or technique
you’ve mastered, you want to deliver.
Back pain is a common complaint among
massage clients, and symptoms such as
pain across the mid back or low-back pain
over the sacrum below the iliac crest in
the gluteal region could be the result of
myofascial trigger points in the rectus
abdominis. (Photo 1) According to Simons
& Travell, “An active trigger point high in
the rectus abdominis muscle on either
side can refer to the mid-back bilaterally,
which is described by the patient as
running horizontally across the back on
both sides at the thoracolumbar level”1.
The authors also state that “In the lowest
part of the rectus abdominis, trigger points
may refer pain bilaterally to the sacroiliac
and low back regions”1 (Photos 1).
Although many trigger points have been
identified in the rectus abdominis muscle,
this article will cover two primary trigger-
point patterns that cause back pain in
these regions, as well as tips about how
to treat them and how to educate your
clients about the nature of their pain.
Clues:
Trigger points can form in the rectus
abdominis muscle due to visceral disease,
direct trauma, emotional stress, poor
posture and over-exercise, to name a few.
Examples of trauma include surgery in
the area or injury to the muscle during a
motor vehicle accident. These muscles can
also become overstressed by everyday
activities, including certain exercises or
rigorous housework.
Before treating the rectus abdominis,
however, it is important to rule out
other muscular possibilities. Referred
pain from myofascial trigger points into
the lower thoracic region can also be
produced by muscles in the back, such
as the latissimus dorsi, serratus posterior
inferior, illiostalis thoracis, multifidi,
intercoastals and insterspinales.
Lower lumbar, sacral and gluteal pain
often includes trigger points from the
quadratus lumborum, gluteul muscles,
piriformis and the hamstrings. In addition
to the rectus abdominis, the iliopsoas is
another muscle that refers pain into both
of these regions.
Encourage clients to reveal important
clues about their pain by having them
complete a thorough health history and
intake form. This useful tool also enables
you to ask intelligent questions relevant
to the possible causes of the client’s pain.
In addition to the health history and intake
forms, have your clients complete a visual-
pain chart to specify and document the
regions of their discomfort; this tool will help
you easily spot the trigger-point patterns and
treat them accordingly. (Photo 2)
Photo 1: “X” indicates the location of trigger points and red indicates the common referral zones.
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And before getting started, remember
to communicate with the client to rule
out potential contraindications, such
as recent surgery, abdominal aortic
aneurysms, or pregnancy, for example.
This information should also be
documented on the intake form.
Analogies:
Using analogies can help your client
understand the cause and effect of trigger
points and their pain. For example, some
trigger points are similar to a gun and
bullet. When pressure is applied to the
“trigger” of a gun, it shoots a bullet,
which produces an effect at the point of
impact. Likewise, when a therapist applies
pressure to a “trigger point” in myofascial
tissue, it produces referred phenomena
(shoots a bullet) to another area of the
body; that effect is usually described as
pain, numbness, tingling, weakness or
other like complaints.
Communication:
Therapists and clients must communicate
with each other to determine the presence
of trigger points. Instruct your client to let
you know if you reproduce the pain when
you palpate a myofascial trigger point.
Only the client can tell you if the region
being palpated is tender and referring
pain elsewhere. Once you have identified
the culprit, you can treat the appropriate
muscle.
Treatment:
Place the client in the supine position with
support under the knees and the arms
at the side to avoid tightening the skin
over the abdomen. (Note: these same
techniques can also be used with the
client in a side-lying position).
Determine the borders of the rectus
abdominis by asking the client to tense
the muscle; he can do this by moving
into a semi sit-up position as you palpate
the region. Make sure that the client
relaxes the muscle before you start
treatment. Check for muscle sensitivity by
palpating with your fingers using static
compression.
Release the attachments around the
xyphoid process (Photo 3) and costal
margin (Photo 4) with your fingers or
thumbs. The pubic attachments can be
easily located by asking the client to place
their thumb over their belly button and
extend their middle finger down until they
palpate the pubic symphysis. Use static
pressure initially. If the area is not too
sensitive, add a combination of friction
movements in the direction of the muscle
fiber (superior and inferior) and across
the muscle fiber (medial and lateral). It
will be more comfortable for the client
if the intention of your pressure is more
dominant in one direction.
Lubricate the muscle belly; then stabilize the
skin with the non-treating hand. With the
other hand, treat with the muscle fiber using
a scooping movement with the fingers (Photo
5), followed by cross fiber (Photo 6).
Photo 3: Release attachments
on the xyphoid process.
Photo 4: Release attachments
on the xyphoid process.
Photo 2: Identify possible trigger point patterns quickly by having your client mark the
areas of their pain on a form that can be utilized as a reference in the treatment room
and helps to document subject progress over a series of treatments.
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Photo 5: With Fiber
Photo 6: Cross fiber
Pressure:
Make sure to check in with the client
frequently about the level of pressure.
The body is reflexive, and it responds
automatically to stimulation. For example,
when you touch a hot surface with your
hand, you automatically, or “reflexively,”
pull away to avoid burning the skin.
This concept is also true in massage
therapy. If the client is reflexively
protecting him or herself by pulling away,
tightening the muscle, holding his breath,
squinting his eyes or clinching his teeth,
then you are applying too much pressure.
Additionally, if the tenderness in the area
and/or the intensity of the referred pain
does not ease up within 8 to 12 seconds
of holding static pressure on the trigger
point, again too much palpation pressure
is being applied, leave the area and return
later; and then use considerably less
pressure.
Other Concerns:
• Emotions and Sensitivity – The
abdominal region can be a sensitive
area for clients. Use good judgment
and educate your clients to ensure
that they are comfortable with having
the abdomen treated.
• Positioning and Draping – The client
must be positioned comfortably on
the treatment table in order for the
muscle to fully relax. Additionally,
your client’s privacy must always be
protected and respected. There are
a host of factors that determine the
draping technique that you use. If the
client is not comfortable with his/her
abdomen exposed during treatment,
you can still effectively treat the area
through the draping itself.
• Ice or Heat – If the injury or trauma
is acute and/or swelling is present,
avoid the injured area, and use ice
when appropriate. Otherwise, a moist
heat pack can be placed over the
muscle prior to therapy.
• Topicals – Topicals can help
relieve the client’s pain between
treatment sessions. You can earn
additional income without being
in the treatment room. One topical
company offers free samples and will
even print your contact information
on the accompanying promotional
materials.
Staying informed by reading articles,
textbooks, watching DVDs and taking
hands-on seminars to keep your
knowledge and skills sharp while helping
you perform at your best in the treatment
room to meet your personal goals and
your clients’ expectations. A percentage
of the back pain you treat will be from
myofascial trigger points in the rectus
abdominis. Watch for the clues and
patterns, educate your clients, and use all
of the tools at your disposal. Wishing you
much success.
David Kent, LMT, NCTMB, is an international
presenter, product innovator and writer. His clinic,
Muscular Pain Relief Center, is in Deltona, Florida,
where he receives referrals from various healthcare
providers. David is President and Founder of
Kent Health Systems which teaches Human
Dissection, Deep Tissue Medical Massage and
Practice Building seminars, and has developed a
line of products, including the Postural Analysis
Grid Chart™, Trigger Point Charts, Personalized
Essential Office Forms™, and DVD programs. Visit
www.KentHealth.com or call (888) 574-5600 for
more information.
1 Simons DG, Travell JG. Myofascial Pain
and Dysfunction, The Trigger Point Manual,
Volume 1, Upper Half of Body, Second Edition,
Lippincott, Williams and Wilkins: 1999 Page 943