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You attempt to teach a client a stretch and it simply results in more pain, less flexibility, every time. You try to pump up your butt, no matter how often, hard and how many ways you try, all you get is pain and flab. What gives? One of the possible explanations is the presence of trigger points in the muscles, tendons or ligaments being stretched or exercised.

1. Pain is an abnormal, unpleasant EMOTIONAL and sensory experience caused by actual or perceived injury. Nerve endings called nociceptors are stimulated. Their impulses are transmitted to the spinal cord, and then to the brain where they register as pain.

2. Trigger points (TrPs) are areas of increased irritability in muscle, fascia (the lining of muscles) or ligaments (connecting bone to bone as in joints). Taut fibrous bands, a twitch response when stimulated, and constant areas of referred pain characterize them. The pain patterns thus produced are called myofascial pain syndromes.

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 changes involving the autonomic nervous system. These include increased or reduced skin temperature, sweating or dryness. The area of referred pain is often distant from the TrP, but is almost always identical region.

Latent TrPs may not be painful to pressure, but result in muscle weakness and restricted motion.

Secondary TrPs are the result of muscle overload in a muscle substituting for another, stronger muscle or in an antagonist to the muscle containing the primary TrP. For example, a secondary TrP may develop in the piriformis as a result of that muscle substituting for the gluteus maximus in external rotation of the hip. A secondary TrP may form in the triceps brachii when the primary TrP is in the biceps.

A Satellite TrP is located within the zone of reference of the primary TrP. For example, a TrP in the piriformis may produce a satellite TrP in the hamstrings. Irritation of this may refer pain to more distal site, such as the calf.

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 (upper or lower extremities) skeleton. These TrPs are extremely sensitive to further stretching and may be fired by prolonged maintaining of a stressful position or sudden movements to an extreme range. They are usually associated with weak, tight muscles.

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 a stretched ligament or tendon.3. Myofascial Pain Generation: Movement in the presence of tissue ischemia (lack of oxygen due to impaired blood flow) results in inflammatory changes with the accumulation of nocigenic(pain generating) substances (prostaglandins, bradykinin, histamine, etc). Referred pain from TrPs produces autonomic reflex changes with uncontrolled muscle contraction. In turn, there is narrowing of the blood vessels (vasoconstriction) and ischemia. Muscles, tendons and fascia are shortened. Joint motion is restricted and myofascial pain syndromes are perpetuated.

4. Postural Factors: Gravity in combination with aging, long- term poor posture, and/or repeated injury causes laxity of the axial and appendicular skeletal ligaments. This is most pertinent 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 downward tilting of the pelvis and 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.

5. Perpetuating Factors must be identified and treated by a physician or physical therapist, but trainer input is extremely valuable.

A disparity in leg length may result in a pelvic tilt to one side with chronic over-stretching of some muscle groups and shortening of others and consequent Trps

Excessive foot pronation (inward rolling) may cause chronic muscular and ligamentous stresses involving the foot, ankle, knee, hip, lower back and neck with the formation of Trps.

If one half of the pelvis is significantly smaller than the other, trigger points may form in muscles of the back and neck while sitting. The same may result if the upper arms are shorter than normal, forcing awkward sitting positions.

Habitual awkward, inefficient or dysfunctional movement patterns may produce chronic muscle or ligamentous injury.

Chronic muscle tightness related to emotional factors such as over-reaction to stress, depression, repressed anger, fatigue, etc. as well as to poor nutrition, certain metabolic diseases and endocrine factors may contribute to the generation of Trps.

Chronic bacterial or viral infections or parasitic infestations may contribute to the development of Trps.

Trigger points related to disease or systemic conditions will not respond to physical methods of treatment as long as the underlying conditions are untreated.

The trigger points I have found most frequently related to fitness and weight training are located at the iliopsoas, quadratus lumborum, gluteus medius, gluteus minimus, piriformis, pelvic ligaments, hamstrings, trapezius, levator scapula and scalenus anticus. There are many other TPs, practically one for each skeletal muscle, but these are the ones occurring most commonly and interfering with training.

The following are suggestions designed to minimize the frequency and severity of fitness training injury:

Don't attempt to stretch a muscle with trigger points.

Passive stretching can be dangerous: your client wants to please you and him/herself: "No pain no gain" can be a dangerous concept for both the trainer and client.

Carefully identify appropriate body areas & indications. Stretch tight muscles without TrPs, strengthen weak muscles without TrPs. Normally flexible muscles should be maintained at their optimal level of pliancy, and excessive stretching is contraindicated, lest shifting excessive stress to ligamentous structures destabilize joint structure.

Remember: not everybody needs to stretch with the same intensity. Older people with extremely lax ligaments may depend on hypertonic muscles to support unstable skeletal structures and may react adversely to excessive stretching.

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. At this point, referral to a qualified sports medicine facility, such as The Center for Sports and Osteopathic Medicine would be appropriate. The specific problem needs definition.


Image: Netter
The psoas major muscle and its relationship to the iliacus,
vertebral column, quadratus lumborum, and respiratory diaphragm.

Psoas Dysfunction/insufficiency Alignment

This alignment is characterized by an increase in the lumbar lordosis, shortening of the thoraco-lumbar fascia and erector spinae muscles, stretching and consequent weakness of the abdominal muscles and forward projection of the head. The hamstring and gluteal muscles are tightened and often hypertonic.

The information contained in this website is for educational and informational purposes only and should not be regarded or interpreted as anything else. Diagnosis and treatment of disease, injury, pain or disability is the province of your health professional who should be consulted in regard to any medical symptoms or conditions before adopting any course suggested in this website. By proceeding to the table of contents page, you agree to accept the provisions of this disclaimer.

Copyright © 1996-2006 Dr. Richard M. Bachrach
317 Madison Avenue, NY 10017 - 212-685-8113

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