Chronic pain, depression, fibromyalgia and chronic fatigue all seem to feed off each other but which came first? What is the root of this debilitation?

This is a difficult question to answer. The etiology of each of these chronic illnesses remains, alas, a mystery that we have yet to conclusively solve.

That being said, it is very important that we solve them. Why? Because baby-boomers (a very large portion of the American population) are headed into geriatric conditions. Among the most common of these is fibromyaligia. It is to pain management, what alzheimer’s and frontotemporal dementia are to neurology.

What we do know is that pain, fibromyalgia, depression and chronic fatigue syndrome often share common symptoms:

  • sleep disturbance (usually long-term)
  • excessive stress levels
  • psychological repercussions/detriments from sleep loss, excessive stress, and other factors
  • reduced capacity for activities of daily living (ADLs), resulting in reduced cardiovascular exercise and resultant hypofitness

All these factors result in:

Fibromyalgia domains[1]

We also know that although the above symptoms seem to correlate with inflammation, research has shown a demonstrated lack of local inflammation in these shared co-morbidities (common co-occurences). In addition, as inflammation does not occur, anti-inflammatories do not help.

Further answers to this question have filled many textbooks (and been part of ongoing debate in pain management) due to unexplained etiology: if we could figure out the biological pathways that develop the disease, we would at least be closer to a definitive understanding of the commonalities between these diseases. We could then address and treat them definitively.

To my knowledge, the closest we have come to a definitive etiology of fibromyalgia is as follows (if someone knows differently, PLEASE correct me):

  • Fibromyalgia can be considered a discrete condition, as well as a construct. This helps explain how/why individuals have multifocal pain and other somatic symptoms in spite of the lack of nociceptive input (i.e., peripheral damage/inflammation) that adequately accounts for the pain.
  • The primary abnormality, identified to date in fibromyalgia and related pain syndromes, is an increased gain (as in a volume control turned up) in central nervous system pain processing (i.e., secondary hyperalgesia/allodynia).
  • It is likely that this “turning up the volume” on pain and sensory processing is in part due to increased levels of excitatory neurotransmitters (e.g., glutamate, substance P), and/or low levels of inhibitory neurotransmitters (serotonin, norepinephrine, GABA, cannabinoids).
  • Analgesics that work well for “peripheral/nociceptive” pain syndromes (e.g., NSAIDS, opioids), are largely ineffective in fibromyalgia.
  • The most effective classes of drugs in fibromyalgia are centrally acting analgesics (e.g., triciyclics, serotonin re-uptake inhibitors, “SNRI”s, and anticonvulsants (calcium channel blockers).
  • Nonpharmacologic therapies such as education, exercise, manual therapy, and cognitive behavioral therapy are very effective in fibromyalgia and are typically underutilized in routine clinical practices. [2]

Diffuse pain (11/18 points on the body) [3]

Diffuse pain (11/18 points on the body – see diagram above) is the hallmark of fibromyalgia, and this is notably absent in depression and chronic fatigue syndrome. It is also absent, in this pattern, in myofascial pain syndrome (MPS), which tends to be more localised, and also tends to be more functionally oriented. In the fibromyalgia patient, the common complaint is that, “I hurt all over.” The tissue feels very soft and broken-down, versus taut bands and knots of MPS. However, they do sometimes coincide. (See Devin Starlanyle and Mary Ellen Copeland’s “Fibromyalgia & Chronic Myofascial Pain.”)

"Fibromyalgia & Chronic Myofascial Pain: A Survival Manual."

As to how this has been established in case studies, please see the below table:

Frequency of Comorbidity in Fibromyaliga[4]

So, what does this all mean?

  • Sleep quality/quantity is interrupted.
  • There is usually a level of sustained stress and psychological distress.
  • There is a discrepancy of diagnostic criteria: pain with fatigue and psychological distress, versus fatigue and psychological distress, versus psychological distress alone. Granted, cases may change over time (see above diagragm) but the primary characteristics of each individual’s case remain unique in these criteria.

To show this in another way, here’s a current diagram for commonalities that would produce these common symptoms:

Neural Influences on Pain and Sensory Processing[5]

This would help to explain the commonalities of:

  • sleep disturbance ~/= fatigue
  • depression
  • low pain threshold (easily triggered pain)
  • functional compromise

In addition, it may explain why:

  • Amitryptaline/Nortryptaline (SSRI) are helpful in treating many of these common symptoms, via increased levels of available serotonin and norepinephrine/noradrenaline levels in overall tissue.
  • Lyrica/Neurontin (Ca Channel blockers) are helpful to treat many of these common symptoms, via reduced central excitability in signal (especially pain signal) processing.

It is agreed, though, in interdisciplinary pain management, that effective therapy for ALL of these conditions MUST include:

  • Appropriate pharmacologic prescriptions, and
  • Cognitive Behavioral Therapy, to learn triggering deactivation and new coping mechanisms: to mediate pain perception and subsequent neuromodulation.

The following is further noted as helpful:

  • Physical therapy: Begin an appropriate “start low, go slow” low-impact cardiovascular exercise program, such as aquatic therapy or other low-impact mechanisms. This maximises tissue metabolism and ultimate tone.
  • Massage therapy: This modality maximises efficiency of circulatory return and tissue metabolism, in order to enable the tissue to respond to functional demands and short/long-term capabilities (much like physical therapy).
  • Acupuncture: This modality reduces overall CNS (central nervous system) hyperactivation and restores CNS stability. Some studies vary as to the effectiveness of this modality, but observed results are more consistent. In practice, it has shown to help with patient’s ability to comply with functional demands, perhaps due to lowering levels of CNS hyperalgesia. [6]

I wish I had more definitive information to convey. In pain management circles, this is what we’ve got so far. Know, however, that we’re working on it, ardently.

I’ll update as I’m able to.


 

  1. Essentials of Pain Medicine, 3d Edition; 2011; Benson, Raja, et al.; pg. 346
  2. Ibid., pg.350
  3. fibromyalgia points of pain diagram
  4. Weiner’s Pain Management: A Practical Guide for Clinicians (American Academy of Pain Management), 7th edition; 2007; Mark V. Boswell, B. Eliot Cole; pg. 497
  5. Essentials of Pain Medicine, pg.347
  6. What can neuroscience conclude about acupuncture? by Adriano Stephan on CogSci

What is the science behind Trigger Point deep muscle massage? Does it work? How many sessions does it take before you feel relief?

The answer to this question will include current, state-of-the-art research, as well as my and my colleagues’ clinical experience over several decades. I will address each of the three questions in sequence.

 

1) What is the science behind trigger point deep muscle massage?

There are several theories for the etiology/pathophysiology of trigger points and myofascial pain syndrome. Research continues on each, as none have yet been decisively proven.[1][2] Massage therapy (MT) has been studied extensively, and has been shown to produce objective effects most notably in those bodily systems which interact locally with the myofascial (muscle and connective tissue) systems.[3] These include the local circulatory systems, local and central nervous systems, and the lymphatic system within the immediate vicinity of the area worked on. It should be noted that the fascial structures, which encapsulate the contractile structures and tissues, exert mechanical forces upon the other associated structures, thus affecting their physiological function. MT (specifically ischemic compression and friction massage) has been shown to be effective in releasing myofascial trigger points.[5] MT also has minimal side effects, no drug interactions, is low cost, and often includes positive patient-practitioner relations (which lead to a positive and productive mentality during therapeutic treatment and rehabilitation).

 

2)  It does work. But how?

MT that successfully releases trigger points includes ischemic compression and friction massage. Ischemic compression involves holding pressure steadily on a trigger point until it softens/releases. Friction massage involves sliding the finger/hand/etc. along a (usually) venous direction of a muscle. This creates a vacuum/suction effect upon the circulation which quickly introduces freshened circulatory fluids to the area, and moves inflammatory chemicals present back into general circulation.[6] The freshened circulatory fluids include blood and lymph, which carry pain-relieving endorphins, as well as energy constituents for metabolic recovery for both the myofascial tissue and the neuromuscular junctions. Inflammatory chemicals removed include substance P, prostaglandins, bradykinin, etc.[7]

Dry Needling & Manual Trigger Point Therapy Courses and Training )

(image: Dry Needling & Manual Trigger Point Therapy Courses and Training)

If you’d like to see some of this for yourself, try this: locate the blue (venous) lines on the underside of your wrist. Press, then rub, slowly along the blue line toward the elbow. The blue line will go clear for a moment, then the blue, or venous, blood will return in a second or two. You have just performed friction massage to the veins which will drain blood and lymph from the tissues it serves. These tissues may contain nociceptive (pain inducing) and/or inflammatory biochemicals. If you flush the tissue of venous blood/lymph, creating a “quick-refresh” of arterial blood, the tissue will be flushed of painful biochemicals, while receiving pain-relieving biochemicals. This is the function of ischemic compression and friction massage for painful areas, including tissue with active trigger points.

3) How many sessions does it take before you feel relief?

If you have been properly diagnosed with MPS, and your practitioner is well-trained and experienced, you should feel immediate relief. Ischemic compression and/or friction massage releases a trigger point (and the attendant pain and tension) within a minute or two. If trigger points are extremely active, it may take several passes over an area to treat it completely.

There is a clinical understanding in our profession: the complex part of therapy is not releasing the patient’s pain (if you know what you are doing), but rather keeping them out of pain.

If your therapist is good, you will feel better, at least significantly, for a while. The task for you then is to:

  1. learn to do effective self-care to release the trigger points,
  2. stretch/strengthen the tissue, and
  3. track when the pain recurs, so that your practitioner can superimpose the timeline of recurrence with functional tasks, to possibly trace those tasks that need to be modified or eliminated (which will remove the trigger point’s perpetuating factor).

When these have been accomplished, you should be solidly on the road to recovery. Progress often follows a “two steps forward, one step back” pattern, as perpetuating factors are gradually eliminated and the tissue rehabilitates successfully. How long that will take depends on many factors: your age, general health, metabolic factors, stress levels, fitness, ergonomic factors, daily functional tasks, diet, sleep, emotional state, etc. Your doctor and therapist should help you to minimize the impact of triggers, and also to bolster those areas of overall healthy living that need help. If symptoms don’t improve noticeably within several weeks, you should seek other opinions and help.

————————————

[1] “Etiology of Myofascial Trigger Points,” article on the National Center for Biotechnology Information, U.S. National Library of Medicine website.

 

[2] “Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: an application of muscle pain concepts to myofascial pain syndrome,” article on the Science Direct website.

 

[3] “Physiological and clinical changes after therapeutic massage of the neck and shoulders,” Article on the Science Direct website.

 

[4] “The Effects of Pressure Release, Phonophoresis of Hydrocortisone, and Ultrasound on Upper Trapezius Latent Myofascial Trigger Point,” article on the Science Direct website.

 

[5] “The muscular force transmission system: Role of the intramuscular connective tissue,” article on the Science Direct website.

 

[6] Myofascial Pain and Dysfunction: the Trigger Point Manual, pg. 86.

 

[7] “Changes in Blood Flow and Cellular Metabolism at a Myofascial Trigger Point With Trigger Point Release (Ischemic Compression): A Proof-of-Principle Pilot Study,” article on the Science Direct website.

 

Why am I getting headaches when I make long phone calls?

From a reader:

Why am I getting headaches when I make long phone calls? Why do they last up to a week before the pain starts to go away? It’s hard to get to sleep with such pain, and even when I do sleep, the pain is still there when I wake up. Is this dangerous for me? Are there any health concerns?


My answer:

First, you should definitely see a physician. Make that appointment ASAP! 😉

That being said, a likely scenario is activated trigger points in the muscles of the neck and shoulder (most likely the upper trapezius, splenius capitus, splenius cervicis, and suboccipitals). These are the muscles that produce this very familiar posture:

Headaches from long phone calls

How often do we see and DO this on any given day? This action strains the muscles and the connective tissue (myofascia) mentioned above because they are probably not used to, and are definitely not “designed for,” the sustained contraction shown above.

Let’s go through the pain patterns that emerge when these various muscles undergo repetitive strain (which leads to active trigger point referral patterns):

1) Upper trapezius:

Pain in the upper trapezius muscle

2) Splenius capitus:

Splenius capitis

3) Splenius cervicis:

Splenius cervicis

4) Suboccipitals:

Suboccipitals

(Credit for all of these medical illustrations belongs to Barbara D. Cummings, the illustrator for Travell and Simons’ “Trigger Point Manual.” She had an extraordinary gift for giving the viewer an accurate, literal view of subjective pain.)

ALL of these muscles are engaged in the posture in the first picture, where someone is holding a phone between their head/ear and their shoulder. You have to hold it there somehow, right? Well, these are the muscles that do it for you, and they are most probably strained and activated through prolonged, static holding of this posture.

The most obvious way to help prevent this from happening again is by correcting the problematic posture that strains these muscles:

  1. Keep your head upright and your neck straight on prolonged conversations.

  2. Switch which hand holds the phone, so that you are not constantly loading the same muscles on the same side (thereby straining them). Give them a rest by using the similar muscles on the opposite side, then switch again when they get tired.

  3. Give yourself a few moments to slowly take your head and shoulders through their comfortable range-of-motion, in order to restore circulation and re-establish normal resting length for the muscles. This involves making SLOW circles, or moving the head in opposing directions (i.e., up/down & right/left).

Also, if the calls tend to be especially stressful, give yourself “breaks” every 5-10 minutes to disengage for at least 60 seconds. If needed, perhaps mention that you must take a moment to attend to something personal (letting the cat in, a call on the other line, etc.), then take that moment to:

  1. Consciously relax any tension you feel. For example, try tensing your muscles for 5 seconds while holding your breath, then exhale while relaxing those muscles (2-3 times in a row). This is a simple biofeedback technique.

  2. Imagine the tension as something physical (smoke, dirty water, etc.) draining out of your feet into the floor/ground. This is a simple meditative/visualisation technique.

  3. Give yourself permission to drop as much tension as you can, and to breathe as slowly, deeply, and as relaxed as you can manage. This is a simple cognitive behavioral therapy technique.

When ready, resume conversation. 🙂

If you would like to know some relatively easy ways to relax your muscles and stop the pain, and your physician has cleared you to do such exercises as the above (no contraindications), see my blog post How can I reduce knots in my shoulders (trapezius muscles)?

Good luck, truly. I think a great deal of people are struggling with this right now.

How can I reduce knots in my shoulders (trapezius muscles)?

From a reader:

How can I reduce knots in my shoulders (trapezius muscles)? I work at a computer most of the day, and have tight knots in my shoulders; specifically, in my trapezius muscles. How can I reduce the tension in these muscles, without having someone else massage them? Are there self-massage techniques I can use? What are appropriate stretches?

Trazpezius


My answer:

EVERYBODY gets tension (and sometimes, pain) in the neck and shoulders as well as in between the shoulder blades. This has, of course, increased in these times when we’re all looking down and hunching up at our phones and laptops. Here’s how to get rid of it. Based on the reader’s questions, I’ve broken up my answer into 3 sections below.

 

How do I reduce tension in these muscles?

This is the most important question. You could have the best therapist to resolve the tension for a time, but if you continue to do the actions that result in the tension and pain, they will just keep coming back and probably keep getting worse.

The most common problem that exacerbates tension and pain in the neck and shoulders is holding the neck in an unnatural position. The two most common are looking down for extended periods and craning the neck and head forward (most probably to focus on miniscule print on a device such as a smartphone or laptop). The answer is to figure out how to keep the head as upright and without rotation as possible, while you relax your shoulders and arms at your sides.

The trapezius itself is, ironically, not the most common cause of neck/shoulder pain in the curve of the shoulder (the levator scapula is). However, TrP1 (Trigger Point 1) at the curve of the neck/shoulder is one of the myofascial TrPs observed the most often [1]:

Trigger Point 1

There are about seven common trigger points located in the upper, middle and lower portions of the trapezius muscle:

Trigger points located in the trapezius muscle

Point 7 (x) produces pilomtor activity or “gooseflesh” to the upper extremity [2]

Trapezius trigger point 7

“In study of static loading, Bearns (1961) discovered that the upper fibers of trapezius, contrary to universal teaching, ‘play no active part in the support of the shoulder girdle in the relaxed upright posture.” [3]

 

Are there self-massage techniques I can use?

ABSOLUTELY.

FIRST, you must have been assured by a proper diagnostician (MD/DO) that there are no problems (such as a herniated disc, bone spurs, etc.) that will constantly madden the nerves that feed the musculature of the neck and shoulder. If there is such an inflammatory component, anything I write here will be transitory because the true cause has not been addressed. My suggestions below can temporarily interrupt the pain signal, which has benefit, but ALL pieces of the problem must be addressed to have lasting comfort.

First, it is very helpful to heat the area first. This will dilate blood and lymph vessels, bringing an influx of fresh blood into the area. It will also soften the connective tissue (fascia) that surrounds and binds the muscle fibers and heads, which will make the whole area more amenable to stretching. This step also prepares the tissue for massage (flushing) of the inflammatory chemicals that are making it hurt.

You can use a couple Swedish massage techniques to soften and relax the tissue. These are friction (rubbing along the fiber) and kneading (like with bread dough). For more information, see my blog entry What is the difference between kneading, rolling, percussion, and vibration?

For trigger point deactivation, you can use point-compression with fingertip(s) or a pressure tool (such as a backnobber or theracane):

Using a backnobber

You can also use a tennis or pinky ball against a wall, but they are notoriously difficult to use on the curve of the shoulder. I’ve found the backnobber to be the most useful. It’s only $30, and the product and subsequent comfort can last the rest of your life (no affiliation, just a big, big fan of one of the coolest designs EVER!) [4]

Here’s what you do:

  1. Find the trigger point (any “x” in the above diagrams) that produces the pain pattern that you have, or alternately find a knot in a band of muscle in the curve of the neck/shoulder.

  2. Heat first!

  3. Apply pressure with a fingertip or tool, just enough to “feel it,” and HOLD for 15-60 seconds, until it feels like it is “dissolving/softening,” or until it feels “done.”

  4. Apply the same technique to adjacent and associated trigger points

  5. At this point, you MUST take the muscles released through their normal resting range of motion!

 

What are appropriate stretches?

This is a tricky one for the neck and shoulder, which have an astonishing array of motion capabilities.

PLEASE NOTE: The exercises below will NOT help and will probably be painful and/or harmful if the tissue is not softened first. Before doing any of the below stretches, follow steps 1 and 2 above. Take it slow and EASY, and remember to breathe. Do NOT make it hurt, just stop at the first point of stretch and relax into it.

Stretches that are most helpful for neck/shoulder pain are as follows:

Stretches helpful for neck and shoulder pain (points 4-7)

(points 4-7)

Stretches helpful for neck and shoulder pain (points 5-7)

(points 5-7)

Stretches helpful for neck and shoulder pain

If you follow the steps above, you should get immediate, long-lasting relief from neck/shoulder pain from computer use. If you do not, it’s time to see a pain-management doctor. Don’t wait. The longer these muscles go on in an inflamed, irritated, shortened state, the longer it takes to deactivate and rehabilitate them.

Ultimately, the triggers must be eliminated, the tissue must be softened/relaxed/deactivated, and then it must be strengthened within its current capability.


[1] Myofascial Pain and Dysfunction; the Trigger Point Manual, Travell and Simons, pg.184

[2] Ibid., pg.186

[3] Muscles Alive; Their Functions Revealed by Electromyography, John V. Basmajian, Carlo J. DeLuca, pg.266

[4] The Pressure Positive Company

How long does the pain last once you start walking again after foot surgery?

From a reader:

“I fractured my fifth metatarsal and, after attempting to heal naturally for a couple weeks, I ended up getting it fixed surgically, with a titanium plate. Ten weeks after the injury occurred, I finally was able to walk again, using a cam boot and cane. I have no balance issues, but the pain was pretty severe.  I’d say it ranged from 7 or 8/10 at first, and now, a week later, it’s around 5-6.

I’m wondering if you have a sense of when my foot will feel normal again? As in being able to maybe take a jog, or chase my cat?”


My answer:

How long the pain lasts can differ from case to case, but from these descriptions, several ideas come to mind. However, anything I say here is obviously trumped by your podiatrist, who has seen you and directed your care.

You say that you are now at 11 weeks post-op, and you only began mobilizing the foot/ankle last week. My guess is that the area of the heel, where the achilles tendon anchors, has become tight and somewhat adhesed. This creates inflammation in the area. Also, I would bet that the soleus muscle has an active trigger point which needs to be deactivated, and that the muscle needs to be mobilized and rehabilitated.

The reason that I say the soleus muscle, in particular, is that the referral zone for the soleus is nearly unique to that muscle. It looks like this (see TrP1 in the diagram):

Soleus muscle

Keep in mind, 10 weeks (2.5 months, roughly) is a LONG time for your foot to be immobilized. Muscle / connective tissue that has been damaged begins to heal, literally, overnight. Unfortunately, when there is bony tissue fracture or damage that requires immobilization, the soft-tissue takes a backseat to healing the bones completely, which results in the soft-tissue being pretty darned stiff and sore when you begin to re-mobilize.

Here’s what I recommend to those who present with this type of complaint:

  1. Heat the foot and calf with a hot water/epsom salt soak for 10-15 minutes to dilate the blood/lymph vessels and reduce swelling in the joints.
  2. Use a rolling pin (yes, that’s right, like for pastry) to roll across the soleus muscle and compress the trigger point (“X”, above, for TrP1). You can also use the Tiger Tail, a cool new tool I learned about:

Tiger Tail

  1. Use a tennis ball or other compression ball (not too small or hard!) to roll the foot and heel on, to massage it.
  2. Take the foot, ankle and calf through a more challenging series of motions, such as “drawing the alphabet, A-Z” with the foot.
  3. If still sore, either use an ice pack or a lidocaine cream on the heel (only, not the ankle or calf, and please clear with your podiatrist first):

Lidocaine

The ice or 4% lidocaine will temporarily deaden the superficial sensory nerves, and hopefully lessen the soreness.

I also recommend walking on a soft surface (such as sand or with your body supported in water) very slowly and barefoot to maximize mobility and minimize impact and weight-bearing to the heel.

Good luck!

What does scapular retraction do?

Scapular retraction is movement of the scapula (shoulder blade) backwards and inwards towards the spine. It is mainly produced by the rhomboids (M/m) and medial / lower trapezius in this isolated movement:

Movements of the upper limbMovements of the Upper Limb

Keeping these muscles toned is important in order to support functionally healthy placement of the scapula in static postures and to have good shoulder girdle strength. This strength is balanced with those muscles that pull the scapula forward, which can be overly tight and weak with extended slouching.

A simple isolation exercise to strengthen these muscles of scapular retraction involves squeezing the muscles backwards against resistance. Such resistance can be accomplished by using simple arm weights, or by using an added weight or resistance device, such as free weights (or even a soup can), strengthening bands, pulleys, etc.

"Such resistance can be accomplished by using simple arm weights, or by using an added weight or resistance device, such as free weights (or even a soup can), strengthening bands, pulleys, etc."

Any of these variations of this exercise will be more effective in isolating these muscles if you bend your torso forward 90′, which prevents primary loading of supporting muscles.

Here’s a video which shows such an exercise (credit: WellCor):

CAUTION

If you have ANY neck problems or discomfort, support the head with a towel and relax it (do NOT lift up head or tuck the neck). Remember to breathe in a relaxed manner during the exercise: breathe IN through the nose during the contraction, then EXHALE through the mouth when you relax the contraction.

If you experience any discomfort during or following the exercise, alert your therapist or doctor immediately.  Good luck!

 

Are dental guards and occlusal splints really effective to treat Bruxism (teeth grinding)?

As long as the guards / splints are well designed and worn consistently, they can be effective for those people who grind so badly that they damage their teeth. Ill-fitting splints, however, can create more problems than they solve (besides which, they are rarely worn because they are uncomfortable).

In my practice, the most common problems I’ve seen with splints is that they are too big. This throws off the placement of the temporomandibular joint (TMJ) which then makes the muscles of the jaw (most notably the masseter and pterygoid muscles) painful and tight. Very often, the tension in these muscles feeds into the grinding through muscle tension and heightened activation.

In the below diagrams, the red areas indicate the primary patterns of pain associated with bruxism. In the first diagram, the muscle drawn at the back of the jaw is the masseter, which is the main chewing muscle. You can easily feel this muscle when clenching your jaw:

Masseter muscle

Bruxism also affects the medial and lateral pterygoid muscles:

The medial and lateral pterygoid muscles

which are very difficult to reach, but important to treat for TMJ pain and bruxism.

There is a good product out now for self-treatment of the muscles of the jaw, called The MyoFree Solution:

The MyoFree Solution

Very often, if you deactivate trigger points in the jaw and restore normal tone and resting length, the bruxism reduces or is eliminated entirely.

In the meantime, though, let your dentist know that the splint is uncomfortable, and ask them to reexamine the fitting. Good luck!

Why do we get knots in our back muscles, but not in other areas (e.g. arms or legs)?

Why do we get knots in our back muscles, but not in other areas (e.g. arms or legs)?

“Muscle knots,” otherwise known as trigger points, can occur in any muscle of the body when that muscle is used improperly or damaged. With repeated misuse or damage, the affected sarcomeres (contracting fibers) can “lock” into immobility and inflammation of varying levels. Online research of any skeletal muscle of the body reveals images of trigger point pain patterns for that muscle. (Various muscles associated with locations of pain throughout the body are shown here too: National Association of Myofascial Trigger Point Therapists | Symptom Checker)

Current wisdom on this subject is as follows: “The presence of CGRP (calcitonin gene-related peptide) drives the system to become chronic, potentiating the motor endplate response and potentiating, with SubstanceP, activation of muscle nociceptors. The combination of acidic myofascial pH and proinflammatory mediators at the active trigger point contributes to segmental spread of nociceptive input into the dorsal horn of the spinal cord and leads to the activation of multiple receptive fields. Neuroplastic changes in dorsal horn neurons occur in response to constant nociceptive barrage, causing further activation of neighboring and regional dorsal horn neurons that now have lowered thresholds. This results in the observed phenomena of hypersensitivity, allodynia, and referred pain that is characteristic of the active myofascial trigger point.” 1

To put it in simpler clinical terms, an active trigger point that is referring pain will activate (as a result of tissue metabolism and biochemistry altering the nociceptive threshold) associated soft tissue and neural regions through neuroplasticity.


1. An expansion of Simons’ integrated hypothesis of trigger point formation (pg. 474, 1st P.)

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 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.