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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
MYOFASCIAL DECOMPRESSION THERAPY
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.
MYOFASCIAL DECOMPRESSION THERAPY
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
MYOFASCIAL DECOMPRESSION THERAPY 2
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.
MYOFASCIAL DECOMPRESSION THERAPY 3
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,
MYOFASCIAL DECOMPRESSION THERAPY 4
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).
MYOFASCIAL DECOMPRESSION THERAPY 5
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
MYOFASCIAL DECOMPRESSION THERAPY 6
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
MYOFASCIAL DECOMPRESSION THERAPY 7
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
MYOFASCIAL DECOMPRESSION THERAPY 8
(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).
MYOFASCIAL DECOMPRESSION THERAPY 9
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
MYOFASCIAL DECOMPRESSION THERAPY 10
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.
MYOFASCIAL DECOMPRESSION THERAPY 11
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
MYOFASCIAL DECOMPRESSION THERAPY 12
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
MYOFASCIAL DECOMPRESSION THERAPY 13
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.
MYOFASCIAL DECOMPRESSION THERAPY 14
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
MYOFASCIAL DECOMPRESSION THERAPY 15
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
MYOFASCIAL DECOMPRESSION THERAPY 16
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
MYOFASCIAL DECOMPRESSION THERAPY 17
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
MYOFASCIAL DECOMPRESSION THERAPY 18
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.
MYOFASCIAL DECOMPRESSION THERAPY 19
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.
MYOFASCIAL DECOMPRESSION THERAPY 20
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MYOFASCIAL DECOMPRESSION THERAPY 23
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
MYOFASCIAL DECOMPRESSION THERAPY 24
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
MYOFASCIAL DECOMPRESSION THERAPY 25
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)
2/10 at rest 5/10 worst (past 24-hours) 0/10 best (past 24-hours)
0/10 at rest 2/10 worst (past 24-hours) 0/10 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
Left Right NT 132 NT -8 NT 80 NT 78 NT 178 NT NT NT 180 NT 54 NT NT NT NT NT NT
Left Right NT 144 NT -8 NT 80 NT 80 NT 184 NT NT NT 184 NT 56 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
MYOFASCIAL DECOMPRESSION THERAPY 26
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
Latent MTrPs: right levator scapulae, right infraspinatus Pain with Compression: 4/10
Latent MTrPs: right levator scapulae, right infraspinatus Pain with Compression: 1/10
Latent MTrPs: right levator scapulae, right infraspinatus Pain with Compression: 1/10
MYOFASCIAL DECOMPRESSION THERAPY 27
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
MYOFASCIAL DECOMPRESSION THERAPY 28
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
“x” = interventions completed
MYOFASCIAL DECOMPRESSION THERAPY 29
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
“x” = interventions completed
MYOFASCIAL DECOMPRESSION THERAPY 30
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
“x” = interventions completed
MYOFASCIAL DECOMPRESSION THERAPY 31
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
Therapeutic Exercise
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
MYOFASCIAL DECOMPRESSION THERAPY 32
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
“x” = interventions completed
MYOFASCIAL DECOMPRESSION THERAPY 33
Appendix F. Therapeutic Exercise Interventions (Continued)
Interventions
Treatment Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Therapeutic Exercise
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
“x” = interventions completed
MYOFASCIAL DECOMPRESSION THERAPY 34
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
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
“x” = interventions completed
MYOFASCIAL DECOMPRESSION THERAPY 35
Appendix F. Therapeutic Exercise Interventions (Continued)
Interventions
Treatment Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Therapeutic Exercise
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
“x” = interventions completed
MYOFASCIAL DECOMPRESSION THERAPY 36
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
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
“x” = interventions completed
MYOFASCIAL DECOMPRESSION THERAPY 37
Appendix F. Therapeutic Exercise Interventions (Continued)
Interventions
Treatment Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Therapeutic Exercise
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
“x” = interventions completed
MYOFASCIAL DECOMPRESSION THERAPY 38
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
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
“x” = interventions completed
MYOFASCIAL DECOMPRESSION THERAPY 39
Appendix F. Therapeutic Exercise Interventions (Continued)
Interventions
Treatment Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Therapeutic Exercise
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
“x” = interventions completed
MYOFASCIAL DECOMPRESSION THERAPY 40
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
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
“x” = interventions completed
MYOFASCIAL DECOMPRESSION THERAPY 41
Appendix G. Myofascial Decompression Cups & Suctioning Device