Injury avoidance

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The hands-on treatments

Let's deal first with the different hands-on techniques that can work wonders in easing the pain and stiffness in muscles.



1. Ischaemic compression

TPs can be 'deactivated' by temporarily occluding their blood supply and causing a reactive increase in blood supply, effectively flushing out the muscle of inflammatory exudate and pain metabolites, breaking down scar tissue, and reducing muscle tone. The muscle is nourished by the extra flow-through of blood, nerve endings are desensitised, and scar tissue is broken down so that the muscle fibres can move better.

Essentially, this involves applying sustained pressure to the TP with sufficient force and for long enough to slow down the blood supply and force the tension out of the muscle(30). The muscle should be placed in a position of mild stretch, with little or no pain present. The patient must be comfortable and relaxed, and the compression gradually applied with the finger, thumb, or elbow. Such pressure should be relative to how much pain the patient can tolerate, since too much pain will tend to cause tension in the muscle and negate the treatment.

The pressure is gradually applied, maintained, and then gradually released. It can be held for as long as 60 seconds, but the desired effect is usually achieved in 10-20 seconds. The therapist should then pause before gradually reapplying pressure three or four more times, perhaps moving to another part of the muscle if the treated area feels 'looser' or softer to the touch. Initiating pressure on a TP must be done gradually in an effort to minimise increases in tone, and so get closer to the core of the TP. It is important to reproduce the LTR for optimum treatment result(13).

Ischaemic compression can be used as a prophylactic (preventive) measure(32) in athletes with LTPs that affect their performance, although the technique must be used carefully in pre-race massage as it can lead to soreness. In a treatment situation, it is my experience that ischaemic compression is better for dealing with acute (recently developed, inflamed) TPs than more entrenched and chronic ones, which will need a more vigorous approach.

Most TPs will need a number of treatments to deactivate them(9) and deal with related causal factors. As the TP settles, there will be an accompanying decrease in referred pain and an improvement in other related issues such as weakness, muscle spasm, joint impingement etc. The TP itself should become less sensitive, and it will become harder to find a painful spot.



2. Specific soft tissue mobilisations (SSTM)

SSTM is another manual technique used by physiotherapists to restore a tissue's ability to cope with the loading placed upon it. It uses graded and progressive applications of force, matched as closely as possible to the stage of the healing process, to return the tissue to its previous tensile strength.

This approach has been designed by Glen Hunter(33) to facilitate healing in tissues that have broken down; however, it is my experience that SSTMs can also be effectively used in later stage and chronic TP treatment because of the large stiffness component that characterises the late stage of TP development.

Following a thorough assessment, an oscillatory force is applied to the site of the lesion or TP, in a direction perpendicular to and on the same plane as the line of its fibres. As with ischaemic compressions, the force of the pressure used is dependent on the stage of healing.



3. Frictions

These can be used in the same context as SSTMs - ie for later stage treatment when multiple cross-linkages between collagen fibres results in considerable stiffness or scar tissue(7,19,28). Frictions 'free up' scar tissue within a TP, allowing muscle fibres to move more normally, increasing blood flow through the tissue and decreasing nerve sensitivity.

Frictions are performed transversely across the top of the tissue, with some compressive force, for some minutes at a time. Initially pain levels will be quite high, but as the friction progresses it eases off.



4. Massage

The overall treatment of a tight or sore muscle and its TPs can include any or all of the above treatments, as well as more standard massage techniques, such as deep tissue massage (strong longitudinal strokes designed to promote length of tissue) or effleurage (wide sweeping movements that clear the tissue of excess lymphatic fluid). Together they have a rich variety of effects that combine first to treat TPs, then loosen muscle fibres bound by scar tissue, improve overall muscle flexibility, clear any oedema (fluid) collected and restore good nutrition to the muscle via an improved blood supply. A regular sports massage is a superb way to overhaul the muscular system and gain many of these effects, albeit in smaller doses.



Other approaches to TP treatment

1. Stretching. This is a huge topic in itself, but one that must at least be touched on here. There is no doubt that stretching helps prevent TPs from two perspectives:

Warm-up routines. After doing some muscle-warming activity, some sports-specific stretching and drills (call it 'dynamic stretching' if you like), there is no question that you will significantly minimise the formation of TPs through the increased blood flow and consequent malleability and better alignment of muscle fibres and fascia;

Flexibility. Regular 'static stretching' will mean you have that much more 'give' in the joints and soft tissues, reducing the risk of TPs. Conversely, stiff joints will frustrate the muscles operating around them - and that's when muscle or tendon breakdown occurs.

What about stretching to repair the actual TP? This is a tricky one: we know from one study(9) that ischaemic compression with stretching is more effective than just doing mobility exercises, and from another(11) that stretching is second only to ischaemic compression in its ability to treat TPs. But it can be very difficult to isolate a stretch to a specific portion of the muscle where the TP is located. The conclusion would seem to be that stretching is best used as an adjunct to ischaemic compression.



2. Spray and stretch.(30) This involves placing the muscle on stretch and applying cold spray to the length of the muscle in order to reduce the spasm, tension and inflammation that accompanies TP formation.



3.Electrotherapy. Physiotherapists may use ultrasound to improve the rate of healing of the TP(11,30), or they may use 'TENS' or other electrical machines to achieve the same effects. However, all of these therapies are best used as adjuncts to hands-on treatment.



4. Injecting / needling. Relevant literature speaks volumes about the highly effective use of TP injections to achieve the most complete level of resolution of TPs(1,3,5,6,12,20). However, this is the domain of only a few specialising musculoskeletal physicians and sports doctors. First, the point of the needle is directed into the centre of the TP, where it gently divides muscle fibres and scar tissue bound together within the TP; then various mixtures can be injected to produce added benefits - the most notable being 0.5% lidocaine to reduce post-treatment soreness(13).

In one study(15) comparing TP injections with heat, electric stimulation, stretching and relaxation exercises for sufferers of plantar fasciitis (heel pain), treatment time was reduced by a massive 83.9%, and the effects persisted for two years after the treatment.

The bottom line is that some treatments are vastly superior to others. As far as self-treatment is concerned, the most effective technique would be ischaemic compression, as it doesn't require too much movement.

While you really cannot go wrong with self treatment of TPs, always go gently at the start until you have done it a few times and know what to expect. Remember that the pain felt during treatment may be quite strong, but should never be sharp and debilitating. If there is swelling in the area, or if it is warm inside or any nerve problems are present (ie pins and needles, numbness or weakness), do not try and treat the injury yourself.

If the history of your injury suggests a muscle tear (ie strong sharp pain, swelling/bruising, that occurred suddenly with rapid movement or exertion), you will need to let the injury settle right down and have professional treatment for 2-3 weeks before you begin self-treatment.

Other precautions include making sure you are not pressing on to a major nerve (resulting in pins and needles and, later, numbness and weakness) and not moving too much when the pressure is on the muscle, which can aggravate the problem.

You may be able to obtain a specific device for self treatment, but for most sports people a tennis or golf ball will easily suffice(10). You treat yourself by lying, rolling, or leaning on the device, as described below, allowing your body weight to help put pressure on the muscle.

If there is stronger or sharper pain with any swelling, the TP is probably an acute one, and 15 minutes of ice wrapped in a damp towel will be of added benefit in helping to prevent further inflammation, numbing nerve endings and reducing muscle spasm.

Light exercise or a brief warm-up is a good prelude to self treatment with ischaemic compression, especially for the more chronic TPs. After the treatment, you can then use heat treatment (a hot water bottle, a warm moist towel or even a soak in the bath) to prevent soreness and promote blood flow(11).



Self-treatment exercises

Low Back Pain. Take an object with which to exert pressure (eg a tennis ball) and place it under your back as you lie on the floor facing the ceiling with your knees bent and feet flat on the floor. Make sure the object is in the soft muscular areas on either side of the spine and above the bony edge of the pelvis. Feel it sink into the tight and sore area. Take the same-side knee and hold it with both hands. Now use this as a lever to press your back gently down on to the object as you pull your knee up slowly towards your chest. Spend 10 minutes pressing into all the tight TPs and it should make a huge difference to how loose the area feels. You might even get closer to touching your toes immediately!



Calf pain or cramps(21). Sitting in a chair, cross the sore leg over the other knee but stop when the sore calf rests directly on the other kneecap. Hold the knee of the sore leg with both hands, and allow the sore calf to sink into the other kneecap. Now search for tender and tight bands up and down your calf, spending time putting deep pressure into those you find. Every now and then move your foot around to help pump the blood out of the lower leg.



Heel pain(15,29). I recently read of the idea of sticking a Coke can in the freezer and rolling it under the arch to relieve the pain of plantar fasciitis. Has anyone tried freezing a golf ball (or near equivalent) and using that instead? It would be worth a try because it would be much more specific to treating the TPs in the plantar fascia and intrinsic muscles of the foot.



Hamstring soreness and tightness. Sitting on the edge of a bed or chair so your knees are at the edge, place massage object under your affected hamstring near where it is sore. While not letting your pelvis roll backwards, slowly straighten out the same knee until you feel the object under your hamstring dig deep into the sore area. In this manner treat and explore for other TPs.



NB: If the pain is severe or doesn't abate after a couple of attempts, you'll need an assessment by a physiotherapist because something a little more complex is probably going on.



Summary

So there you have it - the story of trigger points and how they relate to your injuries or lagging performance. Now it is up to you to try some of the ideas for yourself. And when you find a TP and hit the pain barrier at some stage in your home treatment, remember that you are targeting the bulls-eye centre of the problem. Just relax into the 'good pain' and feel the muscle tight spot let go gradually.

Persist with it and you will have learnt the magic key to releasing your muscles to new levels of looseness and power.

Ulrik Larsen

References/ further reading
1. Baldry PE, 'Acupuncture, Trigger points and Muskuloskeletal Pain', 1989
2. Bloomfield et al Editors, 'Science and Medicine in Sport', 2nd, 1995
3. Borg S et al, 'Trigger points and tender points. One and the same? Does injection treatment help?' Rheum Dis Clinics of North America 1996 22(2)
4. Brukner & Khan, 'Clinical Sports Medicine', 1995
5. Esenyel M et al, 'Treatment of Myofascial Pain', Am Jour of Phys Med & Rehab 2000 79(1)
6. Feinberg BI, 'Persistent Pain after total knee arthroplasty: Treatment with manual therapy and trigger point injections', J of Muskuloskeletal Pain 1998 6(4)
7. Formby & Mellion, 'Identifying and Treating Myofascial Pain Syndrome', The Physician & Sports Med Vol 25 No2 1997
8. Gerwin R, 'The management Myofascial Pain Syndromes', J Muskuloskeletal Pain 1993 1(3-4)
9. Hanten WP et al, 'Effects of active head retraction with retraction/extension and occipital release on the pressure pain threshold of cervical and scapular trigger points', Physiotherapy Theory and Practice 1997 13(4)
10. Hanten WP, 'Effectiveness of a home programme of ischaemic pressure followed by sustained stretch for treatment of myofascial trigger points', Physical Therapy 2000 80(10)
11. Hong CZ et al, 'Immediate effects of various physical medicine modalities on pain threshold of an active myofascial trigger point', J of Muskuloskeletal Pain 1993 1(2)
12. Hong CZ et al, 'Referred pain elicited by palpation and by needling of myofascial trigger points: A comparison', Arch Phys Med &Rehab 1997 78(9)
13. Hong CZ, 'Lidocaine injection versus dry needling to myofascial trigger point: the importance of the local twitch response', Am J of Physical Med & Rehab 1994 73(4)
14. Hoven et al, 'Management of peroneal nerve entrapment in an elite skier: A Case Report', J of Sports Chiropractic and Rehab 2000 14(3)
15. Imamura et al, 'Treatment of myofascial pain components in plantar fasciitis speeds up recovery', J of Muskuloskeletal Pain 198 6(1)
16. Ingber RS, 'Shoulder Impingement in tennis/racquetball players treated with subscapularis myofascial treatments', Arch of Physical Med & Rehab 2000 81(5)
17. Lew et al, 'Inter-therapist reliability in locating latent myofascial trigger points using palpation', Manual Therapy 2(2)1997
18. Lewit K, 'Manipulative Therapy in rehabilitation of the motor system', 1985
19. Manheim C, 'The Myofascial Release Manual', 1994 2nd Ed
20. Perle DC, 'Clinicians Corner: Myofascial Trigger points', Chir Sports Med Vol 9 No3,1995
21. Prateepavanich P et al, 'The relationship between myofascial trigger points of gastrocnemius muscle and nocturnal calf cramps', Jour of the Med Assoc of Thailand 1999 82(2)
22. Quinter JL, 'Referred pain of peripheral nerve origin: An alternative to the 'myofascial pain' construct', Clin Jour of Pain 1994 10(3)
23. Ruscoe G, 'Trigger points and Muskuloskeletal Pain', 1996
24. Saggini R et al, 'Myofascial Pain syndrome of the peroneus longus : A biomechanical approach', Clinical Jour of Pain 1996 12(1)
25. Schneider MJ, 'Snapping hip syndrome in a marathon runner: Treatment by manual trigger point therapy. A Case study', Chiropractic Sports Med 1990 4(2)
26. Sheon, Moskowitz & Goldberg, 'Soft Tissue Rheumatic Pain', 1987
27. Sonkin LS, 'Therapeutic Trials with thyroid hormone in chemically euthyroid patients with myofascial pain and complaints suggesting mild thyroid insufficiency', J of Back & Muskuloskeletal Rehab 1997 8(2)
28. Stoddard A, 'Manual Of Osteopathic Practice', 1974
29. Tillu A, 'Effect of acupuncture treatment on heel pain due to plantar fasciitis', Acupuncture in Medicine 1998 16(2)
30. Travell & Simons, 'The Trigger Point Manual', 1983
31. Vanderween et al, 'Pressure algometry in manual therapy', Manual Therapy 1(5)1996
32. Vecchiet L et al, 'Latent myofascial trigger points: Changes in muscular and subcutaneous pain thresholds at trigger point and target level', J of Manual Medicine 5(4) 1990
33. Hunter G, 1998. 'Specific soft tissue mobilization in the management of soft tissue dysfunction.' Manual Therapy 3(1) 2-11

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