What can cause muscles to be sore for weeks to the point that they're painful when used?

What can cause muscles to be sore for weeks to the point that they’re painful when used?

Unfortunately, there are quite a few diagnoses that are relevant to muscle soreness and weakness beyond a week’s span. Be sure to have a physician examine you to at least rule out some of the more basic physiological diseases.

Once those are cleared satisfactorily, ask yourself the following questions:

  1. Was there a precipitating event? That is, did it happen all of a sudden? If so, how?

  2. Where in the body did the pain originate? What was the quality of the pain (sharp/burning/dull & aching/sore/tingling/numbness)?

  3. How long did the pain last?

If the pain began with a precipitating event (e.g. “I lifted something;” “I slept funny;” “I twisted in the shower;” “I leapt to catch a ball;” etc.), it usually indicates a sprain or strain to muscle, tendon, or ligament. If you hear a “pop” or “crack” in a joint, it is most likely a connective tissue rupture. If this is the case, you will need a good interview by a sports medicine physician (MD/DO) and probably a scan of some kind (x-ray or CAT scan for bony/cartilage tissues; MRI for muscle/tendon/ligament tissues). This will help to determine what damage, if any, has been done, and if the issue warrants surgery and/or therapeutic intervention. This needs to be your first port-of-call for pain lasting longer than 1-2 weeks.

Once you have determined that there is minimal damage, and therefore, that surgery is unwarranted, you can determine that the cause is one of the following:

  1. Not normal delayed onset muscle soreness (lasting 24-72 hours): See my answer to What causes delayed onset muscle soreness?

  2. A sprain or strain: See Sprains, Strains and Other Soft-Tissue Injuries

  3. If there are multiple areas around the initial location of pain and injury, you may have developed myofascial pain syndrome: “Myofascial pain syndrome typically occurs after a muscle has been contracted repetitively. This can be caused by repetitive motions used in jobs or hobbies or by stress-related muscle tension. While nearly everyone has experienced muscle tension pain, the discomfort associated with myofascial pain syndrome persists or worsens.”

Myofascial pain syndrome (Mayo Clinic)

As a bit of an aside, sub-acute (1-6 months) and chronic (more than 6 months) of myofascial pain are treated thus:

“A successful treatment protocol relies on identifying trigger points, resolving them and, if all trigger points have been deactivated, elongating the structures affected along their natural range of motion and length. In the case of muscles, which is where most treatment occurs, this involves stretching the muscle using combinations of passive, active, active isolated (AIS), muscle energy techniques (MET), and proprioceptive neuromuscular facilitation (PNF) stretching to be effective. Fascia surrounding muscles should also be treated, possibly with myofascial release, to elongate and resolve strain patterns, otherwise muscles will simply be returned to positions where trigger points are likely to re-develop.

The results of manual therapy are related to the skill level of the therapist. If trigger points are pressed too short a time, they may activate or remain active; if pressed too long or hard, they may be irritated or the muscle may be bruised, resulting in pain in the area treated. This bruising may last for a 1–3 days after treatment, and may feel like, but is not similar to, delayed onset muscle soreness (DOMS), the pain felt days after overexerting muscles. Pain is also common after a massage if the practitioner uses pressure on unnoticed latent or active trigger points, or is not skilled in myofascial trigger point therapy.” (Wiki: Trigger point)

(PS – I’m really proud of the Wiki on this. They nailed it, spot on.)

In a standard clinical interview, you have to go over all the aforementioned patient history, physicians’ reports, scans and anything else you can tell or show the practitioner about what may be the cause of the pain. Your practitioner can then figure out what muscles do the motion that produced the injury & other perpetuating factors, which allows the practitioner to decide what to treat first. This is the general clinical starting point for therapeutic focus.

What causes delayed onset muscle soreness?

This is a hot topic in physiotherapy, so I’m adding some research and detail to this. If you’re looking for a quick answer, see the first three points, because I agree with them. For those who want more data, I provide further detail to the symptom/diagnosis below.

The generally accepted characteristics of Delayed Onset Muscle Soreness (DOMS) are: [1] [2] [3] [5]

  1. generally due to unusual or unaccustomed muscular activity (What did you do that was new or different?)

  2. most often associated with eccentric (lengthening) contraction versus concentric (shortening) loading. For example, when your torso returns slowly to the floor after a sit-up (eccentric for rectus abdominus) versus the sit-up itself (concentric for rectus abdominus). Another example is lifting and lowering a barbell using your biceps:

Isometric contraction

  1. general period of onset is 24 hours or so after exercise-incident, peaks around 24-72 hours after exercise-incident, and then mostly subsides (versus a muscle/tendon STRAIN or ligament SPRAIN, which continues beyond this timeline).

The two major associated theories for DOMS:

  1. “The view taken here (see also Morgan & Allen, 1999) is that the damage process begins with overstretch of sarcomeres. [1]

The damage process begins with overstretch of sarcomeres

“Postulated series of events leading to muscle damage from eccentric exercise:

  1. During an active lengthening, longer, weaker sarcomeres are stretched onto the descending limb of their length-tension relation where they lengthen rapidly, uncontrollably, until they are beyond myofilament overlap and tension in passive structures has halted further lengthening. Repeated overextension of sarcomeres leads to their disruption.
  2. Muscle fibres with disrupted sarcomeres in series with still-functioning sarcomeres show a shift in optimum length for tension in the direction of longer muscle lengths. When the region of disruption is large enough it leads to membrane damage. This could be envisaged as a two-stage process, beginning with tearing of t-tubules. Any fall in tension at this point would be reversible with caffeine (see text).
  3. It would be followed by damage to the sarcoplasmic reticulum, uncontrolled Ca2+ release from its stores and triggering of a local injury contracture. That, in turn, would raise muscle passive tension. If the damage was extensive enough, parts of the fibre, or the whole fibre, would die. This fall in tension would not be recoverable with caffeine.
  4. Breakdown products of dead and dying cells would lead to a local inflammatory response associated with tissue oedema and soreness.”

(Source: The Journal of Physiology, Volume 537, Issue 2, pages 333–345, December 2001)

  1. “The alternative view is that the starting point is damage to components of the excitation-contraction (E-C) coupling process. In a recent review, Warren et al. (2001) summarised their position by declaring that 75% or more of the decline in tension after eccentric exercise was attributable to a failure of the E-C coupling process. The remaining damage seen during the first few days after the exercise was attributed by the authors to physical disruption of the tension-bearing elements within the muscle. So the suggestion is that most of the primary damage arises in the E-C coupling system and only a small component occurs at the level of the sarcomeres. Supporting evidence comes from the observation that in mouse muscle the post-exercise deficit in tension can be recovered with caffeine (Warren et al. 1993; Balnave & Allen, 1995). In the first of these studies, tension was recovered with 50 mm caffeine, which releases Ca2+ from the sarcoplasmic reticulum and leads to development of a contracture in the muscle. In the second, 10 mm caffeine was used to potentiate tension in single fibres in response to direct electrical stimulation. It was concluded that in mouse fibres changes in E-C coupling may be a major contributor to the observed fall in tension after eccentric contractions (Allen, 2001). [2] [4]

Neither of these theories will be resolved without:

  1. a way to measure pain objectively, and

  2. a way to measure the biochemical millieu of the area from “start to finish” in a controlled setting. This is a key area for fMRI studies.

What does it all mean??

Isometric contractions may not build hypertonicity (excessive tension) as quickly, but they will also produce less widespread micro-damage, with its resultant pain and inflammation lasting up to 4 days. This may allow you to resume continuing strengthening faster than if you concentrate mainly on eccentric strengthening. This does not make it less valuable, simply more dangerous to the user of new methods/exercises It also makes them more needful of longer recovery periods in order to avoid repeated and deeper strain/sprain.


[1] Delayed onset muscle soreness (Wiki)

[2] Muscle damage from eccentric exercise: mechanism, mechanical signs, adaptation and clinical applications

[3] Eccentric exercise-induced injuries to contractile and cytoskeletal muscle fibre components

[4] Mechanisms of Exercise-Induced Muscle Fibre Injury

[5] Sprains, Strains and Other Soft-Tissue Injuries

If one had a probable hernia that has gone undiagnosed by a doctor, and which is negatively impacting one’s quality of life, what should one do?

First, it’s good that one see a doctor, even if that doctor is unable diagnose the problem. If there is no diagnosis of hernia, however, below is some information concerning the muscle-strain aspect of this issue.

This presentation of symptoms is consistent with a strain of the external oblique muscle of the abdominals (shown in red, below):

Lateral abdominals

The strain can result in a trigger point, which is a hyperirritable locus, or “knot,” within a taut muscle band that refers (sends) pain to a location distant to it (pictured as circles in the above picture). The trigger point we’re concerned with is located in the bands of external oblique about 1-2″ above the inguinal ligament (groin line). This is the lower circle in the picture. If you lean forward a bit, to relax this muscle, you can feel the fibers of this muscle going in a diagonal line:

Anterior view of the abdominal muscles

You can palpate (feel) this muscle quite easily, as it is very near the surface of the body:

Abdomen: Iliocecal Junction

After you’ve found the taut, guitar-string-like band of external oblique, do the following:

  1. Apply heat to the area first. This will help relax the muscle fibers and flush pain chemicals from the tissue. This also dilates the blood/lymph vessels and brings fresh blood to the area, making it easier to “dissolve” the trigger point (#3, below).

  2. Run your fingers up and down the band (guitar-string) of the external oblique muscle to find a “knot” (trigger point) or point of “exquisite tenderness.”

  3. Push on the trigger point for up to 1-2 minutes. It should feel as if it is “dissolving,” softening, or simply becoming less sensitive. Keep the pressure on until it feels done “dissolving.”

You can also use ice packs along the lower ribs to decrease motor nerve over-activation to this muscle.

(For more information on the Abdominal external oblique muscle, please click on the highlighted text.)

Next, It is important to take the external oblique muscle through its full range of motion following trigger point release. The following stretches are helpful:

  • A full (careful, non-painful) lunge:

A full (careful, non-painful) lunge

Please be careful not to take the front knee more forward than that side’s foot (which can strain that side’s knee). Observe the upright calf angle here on the forward leg.

  • A good side-stretch:

A good side-stretch

Observe that the person reaches up and back over the side being stretched, which directly stretches external oblique

If there is pain during these stretches, fall back to a position where there is no pain, just a sensation of “pull/stretch.” Then relax/breathe until you don’t feel the pain anymore.

If there is sharp pain at any point during these exercises, STOP immediately and ice the area of sharp pain. Wait until all pain or tension in the area has passed. Then try again, going much slower and easier.  

If these techniques do not work within one week of daily practice, more interventional techniques (trigger point injection or nerve block) may be in order, which a pain management specialist can determine.

In my practice, I have found that roughly half of the cases respond quickly and well to these simple techniques. More severe strains (most often sports injuries, and minus hernia diagnoses) require the deeper interventional techniques mentioned above.

What could cause severe, unexplained tooth pain?

While there can be a myofascial (muscle/connective tissue) component to this, it will, of course, be secondary to any significant findings by dental surgeons. This answer presupposes you have already sought a diagnosis from a dental surgeon.

Most commonly, the myofascial diagnosis will be of TMJ (temporomandibular joint dysfunction). Muscles that can cause pain in the teeth (due to myofascial trigger points) include:

Temporalis – a broad, flat muscle on each side of the head, which is a key muscle in mastication:

Temporalis

The “knots”, or trigger points, in this muscle refer (or send) pain to the regions denoted in red – including the teeth. To find if this is the cause of the pain, we’re going to do a bit of trigger point decompression. Heat the temporalis muscle and press on the “x’s” above until they feel like they soften or disappear. The tooth pain should immediately lessen or disappear as well.

Masseter – a quite strong muscle running vertically along the back of the jaw. This picture also images the lateral pterygoid muscle:

Masseter

To find if the masseter muscle is the cause of the pain, we’ll treat it as we treated the temporalis muscle. First, heat the muscle. Then, hold compression on the areas indicated by the black dots. Do this until the knot feels like it is dissolving or becoming less painful.

Afterward, yawn as wide as you can, comfortably. Then take the muscle through its full range of motion by moving the lower jaw front/back/R/L/in/out/up/down. Yawn once more.

Again, if the tooth pain has reduced or has disappeared, a myofascial issue is probably your primary culprit.

If not, take yourself back to the your dental surgeon’s scans.

What is the difference between massage parallel to one's muscle fibers and massage perpendicular to them?

What is the difference between massage parallel to one’s muscle fibers and massage perpendicular to them?

The answer will, at least in part, depend on the massage technique you are using for the myofascial fibers.

The principal objective of friction, or “stripping” massage (gliding the finger(s), hand or tool parallel to the fibers), is to empty the venous and lymphatic channels, which encourages better circulation at the deepest layers of the tissue.

Cross-fiber work (Active Release Technique or ART, “deep tissue”, etc.) mainly addresses the breakup of adhesive connective tissue.

Reference: “The Muscular Force Transmission System: Role of the Intramuscular Connective Tissue”, by Andrea Turrina, PT, Miguel Antonio Martínez-González, PT, PhD, and Carla Stecco, MD. Published online on June 7, 2012

How would you go about finding an experienced RSI therapist?

How would you go about finding an experienced RSI therapist?

The most important first step in finding a well-trained and experienced RSI therapist is to find a great physician who is a specialist in occupational injuries (such as RSI). This doctor must be committed to referring to a good hand, physical, or manual (massage) therapist who has the training, experience and track record of success in treating RSI and associated dysfunctions.

I have had great success in working with occupational physicians at the major hospitals in San Francisco (where my practice is located). No one knows how hard these gentleman and ladies work; they are a credit to their profession. My current favorites are Jules Steimnitz, MD (at St. Luke’s), and Elliott Krames, MD, and Robert Markison, MD (UCSF). They have been exemplary physicians to their patients over several decades, and I am proud to work with them. They don’t monkey about in deciding the best and most comprehensive course of action for RSI cases, and they are willing to go to bat with insurance companies that drag their feet or are blatantly obstructive.

I believe the very best Hand Therapist in SF is Pam Silverman, LHT at Hand Therapy of San Francisco. If I had RSI, and I didn’t know which doctor to choose, or even with whom to consult, Pam would be my first stop. She has worked with, and on, the best.

Yelp is a good resource for finding good therapists, but the quality of the reviews are spotty sometimes, as they are written by patients. Use with caution when vetting medical talent.

The last resource (or perhaps the first) is your gut. Check out a therapist’s website. Talk to them. Check out their CV/resume. Check out their reviews. If you give them a “try-out” session, be ruthless: do you feel relief or not?  Have they helped you with tension reduction and helpful advice, or not?

In the end, medicine is a service, one that serves the patient. The US is a free market, and each patient is beholden only to themselves and their recovery. Find your best medical “servant” who will help you recover the fastest. Settle for nothing; life is too short.

 

How do I know whether or not a stretching exercise could actually hurt my body?

Very simply. The best way to ascertain if a stretching exercise is hurting you is … wait for it … if it hurts to do it.

Your body is actually quite adept at letting you know if it is being hurt. It is “wired” with sensors that send your brain pain signals if damage is occurring. If a stretch you are doing results in a sharp twinge or an “uh-oh” kind of sensation, it is best to STOP that stretch, and to also leave off similar stretches to that muscle and its myotatic group (associated muscles).

Rest is to follow, as well as ice applied to those muscles (to reduce swelling and inflammation). An anti-inflammatory medication such as ibuprofen (Tylenol) may also be called for. If symptoms are severe, naproxen (Alleve) can be especially helpful in the short-term. Please consult a physician if you are not sure what to take or are concerned about drug interactions or side effects, or if you have other significant health issues.

What is the difference between kneading, rolling, percussion, and vibration?

All the different useful procedures of massage can be classified under eight main categories.


Passive Touch is passive (still). It consists of lightly touching the body with one or more fingers, the whole hand or both hands. This technique is used in Swedish massage, Myofascial Release and Craniosacral therapy, to name a few. Physiological effects include elevation of temperature via heat from the hand, and sensory influence on the cutaneous nerves, often associated with comfort.

Simple touch can be remarkably effective in relieving hypersensitivities, especially in the head and joints. Nervous irritability can be quieted sometimes by simple touch of the hand on the head.

Compression consists of making light or heavy pressure with the whole hand or one or more fingers. This is used in manual deactivation of a myofascial trigger point or to temporarily numb an irritated nerve such as in trigeminal neuralgia or sciatica. When administered correctly, the effect of compression is to diminish swelling and circulatory congestion, and to slightly numb the nerves pressed upon.

Stroking is simply light touch combined with motion. The tips of two to five fingers or the entire palmar surface of one or both hands are moved slowly and gently over the skin with minimal contact at a rate of 1-2 inches per second in the direction of arterial (heart-outward) flow only.

There are many different techniques and reasons for stroking, both direct and reflex. The main effect of stroking is a decided sedative effect. However, very light stroking may produce a very powerful reflex effect, like a tickle or stimulant to spinal nerve roots. This can be very useful to alleviate sleeplessness or hypersensitivity such as a nervous headache (very useful with upset babies and children). Neuralgic pain and numbness may also be somewhat abated with this technique. It can be used abdominally to reflexively stimulate digestion: think of how you gently rub your stomach when you have overeaten or have indigestion.

Friction is where the whole or part of the hand is moved steadily over the surface of the skin following venous flow (toward the heart) with a varying but significant degree of pressure according to the “thickness” of the area being worked on. There are many different techniques for friction depending on the influence you want on the tissue. As a rule, some lubricant such as oil, lotion or powder should be utilized to avoid overstimulation, abrasion and irritation of the skin.

The principal objective of friction is to encourage better circulation, thus emptying the veins and lymphatic spaces and channels of waste matter and painful chemicals. It is probably the most valuable of the various massage procedures.

Swedish massage, Cross-Fiber massage and Active Release Technique use deep friction to break up scar tissue in different structures such as skin, muscle, tendon or ligament. Manual Lymphatic Drainage uses very light friction to clear swelling and congestion from joints and lymphatic outlets.

Friction and kneading are probably the most widely used massage techniques worldwide.

Kneading is probably the best known massage procedure, as familiar as kneading dough. It essentially consists of alternating and intermittent compression and squeezing of the tissue, either by grasping it or compressing it against underlying bony surfaces. Kneading differs from friction in that the skin is held in firm contact with the surface of the hand.

Kneading techniques can either be superficial or deep, and can be further delineated by specific techniques. These include superficial/deep kneading (like a baker kneads dough), skin rolling, wringing, and palm/fist/finger kneading, to name a few. Swedish massage and Deep Tissue Massage utilize these heavily. The main goal of kneading is to stimulate all the vital activities of the body part being worked on, including the nerves, blood vessels, glands and cellular exchanges of the tissue. Deep kneading assists muscles to increase in size and function through better circulatory exchange, and assists in the removal of painful chemicals and connective tissue adhesion. Superficial kneading is especially indicated for swelling and any other condition where the skin and superficial circulatory channels need to be more active.

Vibration consists of fine vibratory or shaking movements from the therapist’s hands to the area worked on. This can be subdivided into lateral, knuckle, superficial, deep, shaking and digital vibration, depending on how the therapist uses his or her hands to address the patient’s needs.

Vibration primarily stimulates. It can cause muscle contraction, a pleasant tingling sensation due to stimulation of sensory nerves, and increased blood flow and subsequent temperature rise of the region. It is valuable in cases of paralysis, neuralgia or neurological weakness or fatigue, where stimulation of the area’s function is needed. I have found it to be especially helpful in cases where the patient is unable to relax a muscle or has trouble with neurologic dysfunction and spasm (such as with Cerebral Palsy).

Percussion consists of blows to the tissue using the hands or fingers with varying degrees of technique and force. The movement is always elastic and from the wrist, which penetrates deeply without bruising superficial structures. As a rule, the hand should strike the body transversely across the muscle’s fibers. Different techniques include tapping strike w/ finger’s ends, spatting (strike w/ fingertips), clapping (strike w/ whole palm), hacking (strike w/ pinky side of hand) and beating (strike with palmar side of a closed fist).

Percussion is a powerful stimulant for both the skin and underlying structures. A short, light application produces a momentary spasm, and thus blanching, of the superficial vessels. Strong percussion dilates the vessels a great deal, as evidenced by the reddening which follows. If very strong, percussion can produce nerve paralysis, as any martial artist knows. Other effects include stimulation of the organs through reflex centers and the spinal cord, and assisting with dislodging mucus congestion in the lungs.

Joint Movement obviously consists of the therapist moving the patient’s joint through a range of motion. This can be combined with other techniques such as deep friction (as in Active Release technique) or touch (as in Myofascial Release and Unwinding). It may be either passive (no effort from the patient) or resistive (as in Proprioceptive Neuromuscular Facilitation, Lewit technique, etc.). Joint Movement strongly affects fluid flow through both the joint and the joint’s connective and adjacent structures. It is useful in cases where there is stiffness, pain, swelling and hyperstimulation. Think of how you shake your hand when it feels tired or stiff.


All this being said, reading this or any other blog does not make one a massage therapist. If you want to truly learn these techniques, whether to give a better backrub or to become a licensed therapist, check out good schools nearby and take an appropriate class.  The internet and certifying massage school associations, such as AMTA (American Massage Therapy Association), can help with this. The skills gained will benefit you and your loved ones throughout your lives.

There are many wonderful books about massage, but my favorite one on basic technique is “Art of Massage” (John Harvey Kellogg, MD, reprint 1975 by Health Research, CA), which was our main textbook in 1988. Most of the information on our Medical Board exam for licensure was taken from this text.

What is the best handheld deep tissue massager?

The best “brand” is the tool that does the best job for your needs. I wouldn’t spend a lot of money on a handheld massage device; there are some everyday tools that serve perfectly.

What you need depends on what you are trying to do:

  1. Increase Blood Flow.

    1. Use a heating pad of any kind. I prefer moist electric heating pads because they remain at a constant temperature for longer and don’t over- or under-heat.

    2. Use Swedish massage techniques of centripetal friction. Slide with the hand or other tool (like the Knobble, pictured below) toward the heart. This flushes older blood out, and increases the supply of more freshly oxygenated blood.

The Knobble

  1. Decrease Tension in Tissues.

    1. Use Swedish massage techniques of kneading. That is, rub or grip the tissue with the fingers or other tool (such as the knobble) to loosen constricted connective tissue or tissue bound into an adhesion. However, DO NOT try to “rub out” knots with deep pressure. This can result in bad bruises, or even permanent damage.

  1. Promote Relaxation.

    1. Use percussion (tapping lightly with the fingertips) or shake the arms loosely.

    2. Use heating pads (see 1.1 above).

  1. Increase Range of Motion:

    1. Do gentle, static (single-position, held) stretches.

    2. Do gentle, circular motions of the shoulder, elbow, wrist and fingers.

If any of these actions cause excessive pain, burning, tingling or numbness, discontinue immediately and consult a physician.

What is the best self-treatment for a myofascial trigger point?

First, be certain that you actually have a trigger point. There are other, more serious problems that can mimic the referral zones of myofascial trigger points. (A referral zone is an area of pain that is caused by the trigger point, but is not necessarily in the same area as the trigger point.) See a competent doctor who can rule these factors out.

Once you have a firm diagnosis, the texts mentioned here are useful in finding the trigger points and understanding what factors cause them. Included in the books is useful, everyday advice on what actions or positions to avoid so you don’t re-activate the trigger point and thus the pain cycle. Clair Davies’ books are particularly good. For example:

The Trigger Point Therapy Workbook on Amazon.com

I also recommend Sharon Sauer and Mary Biancalana’s book on self-treatment for lower back pain:

Trigger Point Therapy for Low Back Pain on Amazon.com

In addition, the website of the NAMTPT (National Association of Myofascial Trigger Point Therapists) has a great *free* feature called the “symptom checker.” This allows you to see common areas of pain and the trigger points (and their locations) which are most likely the cause.

To release a trigger point yourself, you will need to use your fingers or some sort of compression tool. Such tools include a Backnobber or Theracane:

The Backnobber at the Backnobber Store

You can also use a simple tennis ball or racquetball.  No expensive tool is needed; some just reach “difficult” spots better.  You can also put a tennis ball in a sock to use as a compression tool against a wall.

The trigger point is suffused with muscle-fatigue chemicals and pain chemicals, which lock the affected fibers into a state where they can’t contract or expand properly. With tools such as your hands or the Backnobber, you are trying to direct blood to the trigger point. What you are not trying to do is “break it up” by rubbing across it. This can, in fact, bruise and/or irritate it.  A myofascial trigger point is not the same thing as an adhesion or scar tissue, although sometimes they coincide.

Presuming the trigger point does not include much inflammation, swelling or an entrapped nerve, here is what I’ve found works best:

  1. Heat the tissue. The connective tissue softens and the muscle relaxes more. Blood is redirected to the area through vasodilation. Sometimes, this alone is effective enough to reduce the pain.

  2. Perform compression to the trigger point. Use only enough pressure to “just feel it,” not as much pain as you can stand. If you press too hard and you tense against it, you will not gain a release. A muscle cannot tense and relax at the same time. By holding the compression steady for a minute or two, you are “showing the blood where to go.” Wait until you feel a softening or dissolving feeling in the knot (trigger point), and hold it until it feels “done.”

  3. Stretch the muscle slowly though its comfortable range. If you force the end of the stretch, you could reactivate the trigger point.

  4. Apply a non-heating, anti-inflammatory cream. I use Myoflex cream.

  5. Avoid whatever actions seem to make it worse. For help with that, see the books above.