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Trigger Point Book
Trigger Point Book
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emotional stress (such as anger). Recovery from such stimulation is slow. Even with mild exacerbations, it may take the patient many
minutes or hours to return to the baseline pain level. Severe exacerbation of pain may require days, weeks, or longer to return to baseline.
These patients almost always give a history of having coped well in life prior to their injury, having paid no more attention to pain than
did their friends and family. They were no more sensitive to these stimuli than other persons. From the moment of the initial trauma,
however, pain suddenly became the focus of life. They must pay close attention to the avoidance of strong sensory stimuli; they must limit
activity because even mild to moderate muscular stress or fatigue intensifies the pain. Efforts to increase exercise tolerance may be self-
defeating. Such patients, who suffer greatly, are poorly understood and, through no fault of their own, are difficult to help.
In these patients, the sensory nervous system behaves much as the motor system does when the spinal cord has lost supraspinal
inhibition. In the latter, a strong sensory input of almost any kind can activate non-specific motor activity for an extended period of time.
Similarly, in these patients, a strong sensory input can increase the excitability of the nociceptive system for long periods. In addition,
these patients may show lability of the autonomic nervous system with skin temperature changes and swelling that resolve with
inactivation of regional TrPs. Since routine medical examination of these suffering patients fails to show any organic cause for their
symptoms, they are often relegated to "crock" status.
Any additional fall or motor vehicle accident that would ordinarily be considered minor can severely exacerbate the hyperirritability
syndrome for years. Unfortunately, with successive traumas, the individual may become increasingly vulnerable to subsequent trauma. A
frequent finding is a series of motor vehicle accidents over a period of several years.
Fibromyalgia
Patients with fibromyalgia are predominantly female (73-88%). Men and women are nearly equally likely to have myofascial pain
syndromes. The patient with an acute myofascial pain syndrome typically can identify the onset precisely as to time and place. Usually the
muscle was subjected to momentary overload, e.g. an automobile accident, a near fall, a sudden and vigorous movement (sports activity),
moving a heavy box, reaching over to pick something up from the floor, or getting into an automobile, although there may be a lag of
several hours to a day after the initiating event before pain appears. Patients with chronic myofascial pain may have difficulty identifying
the onset so clearly. These patients are likely to have more than a single myofascial pain syndrome. In contrast, the symptoms of
fibromyalgia typically develop insidiously; these patients usually can identify no specific moment in time when their symptoms began.
Thus, the onset of myofascial pain characteristically relates much more strongly to muscular activity and specific movements than does
fibromyalgia.
The orientation of the patient examination is quite different for the two conditions. For the diagnosis of myofascial pain, the clinician
painstakingly identifies precisely the distribution of each pain complaint, looks for dysfunctional postures and asymmetries, and examines
the muscles to determine which ones show a restricted stretch range of motion. Restriction of motion is not a part of the diagnosis of
fibromyalgia.
The myofascial examination includes palpation of the suspected muscles for tender spots in taut bands, which, when compressed, refer
pain to the area of the patient's pain complaint and, when snapped transversely, produce a local twitch response. To examine for
fibromyalgia, the prescribed tender point locations are examined only for tenderness; a relationship between the location of the tender
points and the distribution of the patient's pain is not an issue.
On palpation, the diffusely tender muscles of patients with fibromyalgia feel soft and doughy (except in specific areas, if they ateo have
TrPs in taut bands), whereas the muscles of patients with myofascial pain feel tense and are non-tender except at TrPs and in reference
zones.
Muscles that exhibit TrPs also exhibit some weakness without atrophy, but they are not particularly fatigable. Generalized severe fatigue,
rather than weakness, is characteristic of fibromyalgia.
The chronicity of myofascial pain syndromes is caused by perpetuating factors that usually are correctable; the chronicity of fibromyalgia
is inherent to the disease. This distinction is not evident at initial evaluation.
Some features are confusingly common to both conditions. Disturbed, non-restful sleep may occur in either, but is not required for
diagnosis. Over half of the designated tender point locations are also common muscle TrP sites. By definition, a latent or an active TrP at
one of those tender point sites would be counted as a tender point. Recent studies indicate that taut bands may be found not only in patients
with myofascial pain and in patients with fibromyalgia, but also in "normal" subjects. This finding may have unexplored implications as to
the relationship between the taut band and its TrP. Many patients with fibromyalgia also have active myofascial TrPs.
At this time, no specific cause of either fibromyalgia or myofascial TrPs has been established. However, clinically, myofascial pain caused
by TrPs is primarily a focal dysfunction of muscle, whereas fibromyalgia is a systemic disease that also affects the muscles.
Articular Dysfunction
We think of articular dysfunction either as joint hypomobility (including loss of joint play) that requires manual. movement,
mobilization, or manipulation to restore normal function, or as hypermobility that requires stabilization. The term somatic dysfunction is
now commonly used and includes skeletal dysfunctions that are often treated by mobilization and manipulation, as well as myofascial
dysfunctions that are frequently treated with myofascial release techniques.
An understanding of the interface between myofascial pain syndrome and articular dysfunction is one of the great voids in our current
knowledge of manual medicine.
TREATMENT
A chronic myofascial pain syndrome became chronic because of perpetuating factors that were unrecognized or were inadequately
managed. An identifying characteristic of a chronic myofascial pain syndrome is the initially unsatisfactory response to specific
myofascial therapy. Relief is usually only temporary, lasting a few hours or days. However, with correction of the perpetuating factors, the
involved muscles become increasingly responsive to therapy. Occasionally, severe perpetuating factors render the TrPs so irritable that
even the most gentle attempts at therapy cause more distress than relief. As progress is made in resolving the perpetuating factors, the
involved muscles become increasingly treatable.
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If one starts by correcting obvious mechanical perpetuating factors, myofascial TrP therapies that were previously ineffective are then
likely to provide significant relief and to encourage the patient. Each component myofascial pain syndrome should be analyzed and
managed as a single-muscle syndrome in the context of other TrPs in the same region. For patients with chronic pain, a home program of
stretch exercises is extremely important, probably even more so than for patients with a myofascial pain syndrome of only one or two
muscles.
Setting specific goals as described by Materson34 is critical for patients with chronic myofascial pain. The primary goal is to teach
patients how to recognize specific TrP syndromes, how to employ appropriate body positioning, and which stretch techniques to use for
relief. This puts the patients in control. If they want more relief, they know how to obtain it. If they prefer to trade a given level of pain for
the time and effort required to relieve it, that is their decision. They learn that control of the pain is in their hands. They come to
understand what constitutes abuse of their muscles (that will aggravate the pain) and what measures will reduce unnecessary overload of
the muscles. They learn to converse with and listen to their muscles.
Mechanical Perpetuating Factors
If the clinician selects for initial treatment a myofascial pain syndrome that is a major source of pain, is likely to respond to TrP therapy,
and has a mechanical perpetuating factor that is readily correctable (such as sitting posture or lower limb-length inequality), the patient
will see immediate benefits and will develop confidence in the treatment. Additional mechanical perpetuating factors relevant to the
patient's pain should also be corrected promptly.
Faulty posture is a mechanical perpetuating factor that is becoming increasingly common and serious with the proliferation of computer
terminals and computerized work stations.
Postural training should be one of the first parts, if not the first part, of the treatment program.
Faulty posture can aggravate TrPs in many regions of the body and can also increase the tenderness of fibromyalgia tender points.
In the seated individual, the "slumped posture," or fatigue posture, is characterized by a flattened lumbar spine (loss of normal lordosis),
sometimes by an increased dorsal kyphosis, by protracted scapulae, and usually by a flattened cervical spine with the head forward. This
posture leads to multiple muscle and joint problems in the trunk, upper limbs, neck, and head, as well as limited respiratory function.
For the seated slumped position, the patient can improve postural alignment by consciously raising the top of the head upward, keeping it
slightly forward. This simple maneuver lifts the chest to an optimum position for respiratory function. A comparable alignment can be
accomplished by "putting a hollow" in the low back. Since this erect posture (sitting "tall") cannot be actively held for long periods, the
individual can achieve this without effort by positioning the buttocks against the back of the chair and then placing a small roll behind the
lumbar spine (waist level). "Reaching" upward with the top of the head can be done several times a day as an exercise. The principle of
raising the top of the head away from the shoulders should also be applied when leaning forward to bathe or eat, thereby avoiding rolling
the shoulder up and forward and dropping the head.
For good seated posture, one's feet must reach the floor; when a person's legs are short or a seat is too high, a flexible footrest (small firm
pillow, bean bag, or sand bag] may be used to support the feet. A hard telephone book is less desirable, but can be temporarily useful. The
arms should be supported on armrests that are high enough to allow the individual to sit erect with the elbows supported. Forearm support
extensions can be adapted for desk work when typing. When one sits on a sofa or at a desk, arm support can be provided by using a lap
board placed on a pillow.
An alternate sitting position is one of sitting toward the front edge of a chair seat, placing one foot back under the chair and the other foot
forward. This balanced position promotes an erect posture with a natural, but not excessive, lumbar curve. Another way to promote good
sitting alignment with little effort is to place a pad at the back of the chair seat, directly under the ischial tuberosities (not under the thighs).
The padding tilts the pelvis forward slightly to induce normal lumbar lordosis, which, in turn, facilitates good upper body alignment.
Having two ways of sitting with good posture can be particularly useful for someone working at a desk. Frequent changes of position are
needed to promote health of the muscles and intervertebral discs.
Most important is patient awareness of the problem, understanding of its significance, and willingness to practice sitting and standing
erect. Following appropriate postural training (both "static" and dynamic), the patient can take responsibility for the management of the
pain that results from chronic postural strain and many activities of daily living. As patients exercise increasing control, they improve both
physically and emotionally.
Description of the myofascial syndromes
• trapezius
• sternocleidomastoideus
• masseter
• temporalis
• pterygoideus medialis
• pterygoideus lateralis
• digasticus
• orbicularis oculi
• zygomaticus major
• platisma
• scalp
• splenius
• deep muscles of the neck
o semispinalis capitis
o semispinalis cervicis
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o multifundi
• upper muscles of the neck
o rectus capitis p. et a.
o obliquus capitis
• levator scapule
• scalenus
• supraspinatus
• infraspinatus
• teres minor
• latissimus dorsi
• teres major
• subscapularis
• rhomboideus
• deltoideus
• coracobrachialis
• biceps brachii
• brachialis
• triceps brachii
• anconeus
• extensores carpi
o carpi radialis longus
o extensor carpi radialis brevis
o extensor carpi ulnaris
o brachioradialis
• extensor digitorum
• supinator
• palmaris longus
• flexores carpi-digitorum
o flexor carpi radialis
o flexor carpi ulnaris
o flexor digitorum superficialis
o flexor digitorum profundus
o flexor policis longus
o pronator teres
• opponens-adductor policis
• interossei
o interossei
o adductor digiti minimi
• pectoralis major and subclavicularis
• sternalis
• serratus superior posterior
• serratus anterior
• serratus inferior posterior
• paravertebralis
o iliocostalis
o semispinalis
o multifundi
o rotatores
• regio abdominalis
o obliquus abdominis
o transversus abdominis
o rectus abdominis
o pyramidalis
• Quadratus Lumborum
• Iliopsoas
• Pelvic Floor Muscles
o Bulbospongiosus
o Ischiocavernosus
o Transversus Perinei
o Sphincter Ani
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o Levator Ani
o Coccygeus
o Obturator Internus
• Gluteus Maximus
• Gluteus Medius
• Gluteus Minimus
• Short Lateral Rotators
o Gemelli
o Quadratus Femoris
o Obturator Internus
o Obturator Externus
• Tensor Fasciae Latae Sartorius
• Pectineus
• Quadriceps Femoris Group
o Rectus Femoris
o Vastus Medialis
o Vastus Intermedius
o Vastus Lateralis
• Adductor
o Adductor Longus
o Adductor Brevis
o Adductor Magnus
o Gracilis
• Hamstring Muscles
o Biceps Femoris
o Semitendinosus
o Semimembranosus
• Popliteus
• Tibialis Anterior
• Peroneal Muscles
o Peroneus Longus
o Peroneus Brevis
o Peroneus Tertius
• Gastrocnemius
• Soleus Plantaris
• Tibialis Posterior
• Long Extensors of Toes
o Extensor Digitorum Longus
o Extensor Hallucis Longus
• Long Flexor Muscles of Toes
o Flexor Digitorum Longus
o Flexor Hallucis Longus
• Superficial Intrinsic Foot Muscles
o Extensor Digitorum Brevis
o Extensor Hallucis Brevis
o Abductor Hallucis
o Flexor Digitorum Brevis
o Abductor Digiti Minimi
• Deep Intrinsic Foot Muscles
o Quadratus Plantae
o Lumbricals
o Flexor Hallucis Brevis
o Adductor Hallucis
o Flexor Digiti Minimi Brevis
o Interossei
http://www.geocities.com/alexandr_semikin/muscles/myofasci.htm
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DIGASTRICUS
Anatomy Reflected pain
6
SPLENIUS
Anatomy
Reflected pain
Home therapy
7
SEMISPINALIS; MULTIFUNDI; ROTATORES
Anatomy
Reflected pain
Home therapy
8
RECTUS CAPITIS POSTERIOR MAJOR & MINOR; OBLIQUUS CAPITIS SUPERIOR & INFERIOR
Anatomy Reflected pain
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LEVATOR SCAPULE
Anatomy Reflected pain
Home therapy
10
SCALENUS
Anatomy
Reflected pain
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SUPRASPINATUS
Anatomy
Reflected pain
Home therapy
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INFRASPINATUS
Anatomy
Reflected pain
Home therapy
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TERES MINOR
Anatomy Reflected pain
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LATISSIMUS DORSI
Anatomy
Reflected pain
Home therapy
15
TERES MAJOR
Anatomy Reflected pain
Home therapy
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SUBSCAPULARIS
Anatomy Reflected pain
Home therapy
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RHOMBOIDEUS MAJOR & MINOR
Anatomy Reflected pain
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DELTOIDEUS
Anatomy
Reflected pain
Home therapy
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CORACOBRACHIALIS
Anatomy Reflected pain
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BICEPS BRACHII
Anatomy Reflected pain
Home therapy
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BRACHIALIS
Anatomy Reflected pain
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TRICEPS BRACHII
Anatomy
Reflected pain
Home therapy
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ANCONEUS
Reflected pain
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EXTENSORES CARPI
EXTENSOR CARPI RADIALIS LONGUS, BREVIS
Anatomy Reflected pain
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EXTENSOR CARPI ULNARIS
Anatomy Reflected pain
Home therapy
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BRACHIORADIALIS
Anatomy Reflected pain
Home therapy
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EXTENSOR DIGITORUM
Anatomy
Reflected pain
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SUPINATOR
Anatomy Reflected pain
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PALMARIS LONGUS
Reflected pain
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FLEXOR CARPI RADIALIS
Anatomy Reflected pain
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FLEXOR CARPI ULNARIS
Anatomy Reflected pain
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FLEXOR DIGITORUM SUPERFICIALIS
Anatomy Reflected pain
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FLEXOR DIGITORUM PROFUNDUS
Anatomy Reflected pain
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FLEXOR POLICIS LONGUS
Anatomy Reflected pain
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PRONATOR TERES
Anatomy Reflected pain
Home therapy
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ADDUCTOR POLICIS
Anatomy Reflected pain
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OPPONENS POLICIS
Anatomy Reflected pain
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INTEROSSEI
Anatomy
Reflected pain
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PECTORALIS MAJOR
Anatomy
Reflected pain
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SUBCLAVIUS
Anatomy Reflected pain
Home therapy
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STERNALIS
Anatomy Reflected pain
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SERRATUS SUPERIOR POSTERIOR
Anatomy Reflected pain
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SERRATUS ANTERIOR
Anatomy Reflected pain
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SERRATUS INFERIOR POSTERIOR
Anatomy Reflected pain
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ILIOCOSTALIS
Anatomy
Reflected pain
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SEMISPINALIS, MULTIFUNDI, ROTATORES
Anatomy
Reflected pain
Home therapy
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OBLIQUUS ABDOMINIS
Anatomy
Reflected pain
Home therapy
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TRANSVERSUS ABDOMINIS
Anatomy Reflected pain
49
RECTUS ABDOMINIS
Anatomy
Reflected pain
Home therapy
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PYRAMIDALIS
Anatomy Reflected pain
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QUADRATUS LUMBORUM
Anatomy
Reflected pain
Home therapy
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ILIOPSOAS
Anatomy Reflected pain
Home therapy
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PELVIC FLOOR MUSCLES
Reflected pain
Home therapy
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GLUTEUS MAXIMUS
Anatomy
Reflected pain
Home therapy
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GLUTEUS MEDIUS
Anatomy
Reflected pain
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GLUTEUS MINIMUS
Anatomy
Reflected pain
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SHORT LATERAL ROTATORS
Anatomy Reflected pain
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TENSOR FASCIAE LATAE SARTORIUS
Anatomy Reflected pain
Home therapy
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PECTINEUS
Anatomy Function
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RECTUS FEMORIS
Anatomy Reflected pain
Home therapy
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VASTUS MEDIALIS
Anatomy Reflected pain
Home therapy
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VASTUS INTERMEDIUS
Anatomy Reflected pain
Home therapy
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VASTUS LATERALIS
Anatomy Reflected pain
Home therapy
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ADDUCTOR
Anatomy
Reflected pain
Longus Brevis Magnus
Home therapy
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HAMSTRING MUSCLES
Anatomy Reflected pain
Biceps femoris Semitendinosus
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POPLITEUS
Anatomy Reflected pain
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TIBIALIS ANTERIOR
Anatomy Reflected pain
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PERONEAL MUSCLES
Anatomy Reflected pain
Home therapy
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GASTROCNEMIUS
Anatomy Reflected pain
Home therapy
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SOLEUS PLANTARIS
Anatomy Reflected pain
Home therapy
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TIBIALIS POSTERIOR
Anatomy Reflected pain
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LONG EXTENSORS OF TOES
Anatomy Reflected pain
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LONG FLEXOR MUSCLES OF TOES
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SUPERFICIAL INTRINSIC FOOT MUSCLES
Reflected pain
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EXTENSOR DIGITORUM BREVIS, EXTENSOR HALLUCIS BREVIS
Anatomy
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ABDUCTOR HALLUCIS, ABDUCTOR DIGITI MINIMI
Anatomy
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FLEXOR DIGITORUM BREVIS
Anatomy Function and PIR, home therapy
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DEEP INTRINSIC FOOT MUSCLES
Reflected pain
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QUADRATUS PLANTAE
Anatomy
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LUMBRICALS
Anatomy
81
FLEXOR HALLUCIS BREVIS
Anatomy
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ADDUCTOR HALLUCIS
Anatomy
83
FLEXOR DIGITI MINIMI BREVIS, INTEROSSEI
Anatomy
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