1. Myofascial Dry Needling Practical: Lower Extremity

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

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

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

5. Veins
Basmajian, J. V. (1982)

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

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

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

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

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

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

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

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

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

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

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

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

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

19. Semitendinosus

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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