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Repetitive micro-traumata (injuries), unresolved single
injury, inflammation, poor posture or maladaptive movement habits at play or at work,
stress, lack of sleep, or any combination of the above will produce tightness or abnormal
contraction of skeletal muscles. The investing fascia becomes taut and bound down.
Circulation to and from the muscles is decreased, resulting in the accumulation of the
end-products of muscle metabolism, particularly lactic acid and potassium ions. Localized
areas of muscle tenderness called TRIGGER POINTS are formed. These are extremely
sensitive and will fire impulses (under the slightest provocation such as pressure and
stretching), to distant tissues, producing pain and consequent loss of motion at remote
locations. This causes the further accumulation of muscle toxins, more muscle and fascial
tightness, more pain, etc., perpetuating the MYOFASCIAL PAIN cycle.
This is an extremely common cause of
pain anywhere in the body: head, face, neck, shoulders, chest, arms, low back, buttocks,
legs, feet, etc. To understand more about this ubiquitous problem, a few
definitions and explanations are in order:
Fascia is a tough connective
tissue lining, covering and investing muscles, and, indeed, all cells, tissues and organs.
Fascia is three-dimensional and is continuous throughout the body. Anything affecting
fascia in one area is manifested to some extent in all body regions.
Pain is an abnormal,
unpleasant EMOTIONAL and sensory experience caused by actual or perceived injury. This
results in the stimulation of nerve endings called nociceptors. These impulses are
transmitted to the spinal cord and then to the brain where they register as pain.
Trigger points (TrP) are foci
of hyperirritability in muscle, fascia or ligaments (connecting bone to bone as in
joints). They are characterized by taut fibrous bands, a twitch response when stimulated,
and constant areas of referred pain. The pain patterns thus produced are called myofascial
pain syndromes. There are several types and locations of trigger points:
Active TrPs are always tender.
They prevent full lengthening of the muscle and weaken it. Direct compression, stretching,
or other sources of irritation such as accumulation of the toxic chemical products of
muscle metabolism or lack of oxygen will ignite the TrP. From it, localized pain is
produced in a specific area with associated autonomic changes. These may include increased
or reduced skin temperature, sweating or dryness. The area of referred pain is often
distant from the TrP.
Latent TrPs may not be painful
to pressure, but result in muscle weakness and restricted motion. There are also secondary
and satellite TrPs, the explanation of which is beyond the scope of this article.
Ligamentous TrPs are found in
lax, stretched ligaments as a result of aging, trauma and/or poor posture, particularly
those ligaments involved in the support of the axial (vertebral column and pelvis) or
appendicular skeleton.
Periosteal TrPs are found on
the surface of bone usually at the site of ligament or tendon attachment and related to
tension on that area from stretched ligaments.
PERPETUATING FACTORS
Alignment Or Postural Factors:
Gravity in combination with aging, long term poor posture, and/or repeated injury causes
laxity of the axial (trunk and pelvis) and appendicular skeletal ligaments. This is most
relevant in the spine and pelvis. Tightness of the psoas major muscle combined with
weakness of the abdominal muscles, particularly the pelvic attachment of the obliques and
recti, combine to perpetuate a downward tilting of the pelvis and an increase in the
lumbar lordosis. Thus, the ligaments connecting the pelvis to the vertebral column and to
the lower extremities are stretched and their nociceptors depolarized, initiating the pain
cycle. The same applies to the pelvic and low back muscles which now are tightened and
ischemic.
Other Perpetuating Factors:
include leg length disparity or pelvic tilt; hyperpronation (inward rolling of the foot);
nutritional, metabolic, endocrine, postural and emotional factors as well as bacterial or
viral infections or parasitic infestations.
Major Myofascial Pain Syndromes:
The trigger points I have found most frequently related to pain complaints in our practice
are located in the following muscles: iliopsoas, quadratus lumborum, gluteus medius,
gluteus minimus, piriformis, hamstrings, trapezius, levator scapula, scalenus anticus.
TREATMENT
Passive stretching can be dangerous:
"no pain no gain" is a rule with strict limitations. The inadequately trained
person stretching you has no conception of your pain or tolerance. Stretch yourself or let
a trained therapist help.
The presence of a TrP in a muscle can
be suspected when stretching or attempting to strengthen a muscle group is either
fruitless or results in aggravation of pain with the pattern being repetitive. Don’t
attempt to stretch or strengthen a muscle with TrPs.
Any discomfort while stretching
should be experienced in the belly of the muscle, NOT at the point of attachment to bone
or in the tendon.
Remember: not everybody needs to
stretch and not every muscle needs to be stretched. Older people with extremely lax
ligaments may depend on hypertonic muscles to support unstable skeletal structures and may
react poorly to attempts to stretch.
Treatment of myofascial pain
syndromes consists principally of the following measures and is part of the program
available at the Center for Sports and Osteopathic Medicine:
Identify and correct all possible
perpetuating factors. Of particular importance are: correction of postural imbalances with
short leg lifts; correction of faulty foot mechanics with orthotics.
Identify and treat all trigger points
with ultra sound and low volt electrical stimulation, dry needling, injection with a local
anaesthetic, acupuncture, spray and stretch with a topical local anaesthetic or any
combination of the above.
Osteopathic manipulation, massage,
soft tissue mobilization.
Re-establish normal, restorative
sleep using muscle relaxants, L-tryptophan (if available), acupuncture or a combination of
these.
Pain relief with medication ranging
from acetominophen through non-steroid anti-inflammatories and aspirin to short term
narcotics, if necessary.
Careful, appropriate stretching and
strengthening are essential components of any successful treatment and rehabilitation
program. Your physical therapist and I will be your guides in such a program.
Aerobic exercise, instituted
carefully and progressed gradually to tolerance is vital to recovery and prevention of
recurrence.
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