More On Myofascial Trigger Points (TrP’s)

Back in May of this year, I posted an article titled Trigger Points (TrP’s) In Detail and thought I would take it a step further by describing additional TrP’s that I learned about via the Precision Neural Mobilization seminar I attended. Before I list them however, please allow me to give you some other details.

1) TrP’s may be caused by several factors, including acute or chronic muscle overload, activation by other TrP’s, disease, psychological distress, homeostatic imbalances, direct trauma to the region, accident trauma, radiculopathy, and infections/health issues.

2) TrP’s form only in muscles—as a local contraction in a small number of muscle fibers located within in a larger muscle or muscle bundle. They can pull on tendons and ligaments associated with the muscle, which in turn, can cause pain deep within a joint where there are no muscles. They can also cause muscle weakness.

3) TrP referral patterns follow specific nerve pathways and have been readily mapped—thanks to Travell & Simons—to aid in the identification of pain. Many TrP’s have pain patterns that overlap, and some create reciprocal cyclic relationships.

4) A taut band in muscles containing TrP’s can feel like hard nodules. Upon palpation, a twitch response can often be felt; activateing the “all or nothing” response in a muscle that causes it to contract. Pressing on an affected muscle can often refer pain, and clusters of TrP’s are not uncommon in some in larger muscles (i.e. the gluteus group).

As promised, here is a list of TrP’s above and beyond what I gave you the last time; the first three being what was listed in my previous post…

  • Active – A TrP that causes a clinical pain complaint. It is always tender; prevents full lengthening of a muscle; weakens a muscle; activates a local twitch response when stimulated; direct compression refers patient-recognized pain that is generally in it’s pain reference zone. (Click here for a website that lists reference zones and pain referral patterns.)
  • Latent – A TrP that is clinically inactive with respect to spontaneous pain; painful only when palpated. It may have all other characteristics of an active TrP and always has a taut band that increases muscle tension and restricts range of motion (ROM).
  • Satellite – A TrP that is influenced neurogenically or mechanically by the activity of a key TrP.
  • Associated – A TrP in one muscle that develops in response to compensatory overload, a shortened position, or referred phenomena cause by TrP activity in another muscle. Satellite and secondary TrP’s are types of associated TrP’s.
  • Attachement – A TrP at the musculotendinous junction and/or at the osseous attachment of a muscle that identifies the enthesopathy caused by unrelieved tension, characteristic of the taut band that is produced by a central TrP.
  • Central – A TrP that is closely associated with dysfunctional end-plates and is located near the center of muscle fibers.
  • Key – A TrP responsible for activating one or more TrP’s.
  • Primary – A central TrP that is activated by acute or chronic overload, or repetitive overuse of a muscle in which it occurs, and was not activated as a result of TrP activity in another muscle.

The misdiagnosis of pain is the most important issue taken up by Travell and Simons. Referred pain from trigger points mimics the symptoms of a very long list of common maladies, but physicians, in weighing all the possible causes for a given condition, rarely consider a myofascial source. The study of trigger points has not historically been part of medical education. Travell and Simons hold that most of the common everyday pain is caused by myofascial trigger points and that ignorance of that basic concept could inevitably lead to false diagnoses and the ultimate failure to deal effectively with pain.

The above quote comes from a workbook titled The Trigger Point Therapy Workbook. With this book, you will learn about TrP’s and how to treat them; however, it is important for you to keep in mind that if your muscular-skeletal system is misaligned, other muscles are affected, which in my opinion, makes it hard to self-treat in a way that is more than just temporary. Every little bit helps though!

As always, I hope you find this information informative!

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“Neutral balance alignment is key to becoming pain free!”™ ~ Me

The QL: Another Player In Back Pain

In a previous post, I went over the psoas major and how it is a major player in back pain, so today I thought I would go over the QL—the quadratus lumborum, which is a common source of low back pain. Before I go on though, let’s go over the anatomy…

THE ANATOMY (per Tortora & Derrickson, 11th edition)
Origin: Iliac crest and iliolumbar ligament.
Insertion: Inferior border of 12th rib and first four lumbar vertebrae.
Action: Acting together, pull 12th ribs inferiorly during forced exhalation, fix 12th ribs to prevent their elevation during deep inhalation, and help extend lumbar portion of vertebral column; acting singly, laterally flex vertebral column, especially lumbar portion.
Innervation: Thoracic spinal nerve T12 and lumbar spinal nerves L1-L3 or L1-L4.

The QL is a very strong lateral flexor and lateral stabilizer of the trunk; working synergistically with the psoas—on the same side—in lateral stabilization. It also assists the multifidi, erector spinae, and serratus posterior inferior in extension.

So, how do you know when the QL could be influencing back pain? Well, here are a few indicators for treatment…

  • Persistent pain, even at rest
  • Back pain after a violent sneeze or cough
  • Great pain when turning from one side of the body to the other while in bed
  • Excruciating pain when laterally bending or during forward flexion
  • Pain when standing; however, putting bilateral pressure above both iliac crests lessens the pain
  • Hyperlordosis is present.

If you experience one or more of the aforementioned, there is a good chance the QL is a player in your back pain—low back, specifically.

As always, I hope you find this information to be informative!

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“Neutral balance alignment is key to becoming pain free!”™ ~ Me

Muscle Contractions

In this rather lengthy post, I’d like to go over muscle contractions and their types; isotonic (concentric and eccentric) and isometric. However, before I delve into each contraction specifically, I’m going to start off by providing a very watered-down version of an anatomy and physiology lesson in regards to our muscular system from a cellular level. For the record, I am not an A&P professional… Just thought I would use this opportunity to brush-up on some facts that I learned back in ’06. In fact, I probably learned this sometime between ’90 and ’93, but who remembers such detail from almost 20-years ago and while in high school. Hahaha! 🙂

Skeletal muscle tissue—which produce body movements, stabilize body positions, store and move substances within the body, and generate heat—is made up of hundreds to thousands of cells, also called muscle fibers. Muscle fibers consist of sarcomeres, which are made up of thick filaments, thin filaments, and Z discs; among other things. In order for muscle fibers to contract, certain proteins must be present; two of those being actin and myosin. Check out this link for visual aids and here is where you can read more about this in detail.

Okay, enough A&P for now! I’m a layman so onward with layman terms regarding the functions of skeletal muscles, that being muscle contractions. While the muscle is under tension, it may shorten, lengthen, or remain the same…

Muscle contractions are classified as being either isotonic or isometric. An isotonic contraction (iso- = equal; -tonic = tension) happens when tension developed by the muscle remains almost constant while the muscle changes its length. These contractions are used for body movements and for moving objects. The two types are known as concentric and eccentric.

Concentric isotonic contractions happen when two ends of a muscle are brought closer together during the contraction. The muscle shortens and pulls on another structure, such as a tendon, to produce movement and to reduce the angle at the joint. An example of a concentric isotonic contraction is when one does a bicep curl. As the dumbbell is lifted up, visualize how the two ends of the bicep move closer together during the contraction. This is the simplest form of contraction and is usually the least problematic.

Now imagine one lowering the dumbbell after the bicep curl. It is with this movement that the previously shortened bicep now lengthens during the contraction, which is known as an eccentric isotonic contraction. The bicep in this example contracts so it can control the speed at which the dumbbell is lowered. Per Tortora & Derrickson, 11th edition, repeated eccentric isotonic contractions produce more muscle damage and more DOMS (delayed-onset muscle soreness) than concentric isotonic contractions.

Isometric contractions happen when a muscle contracts but the ends do not move at all, and even though they do not result in body movement, energy is still expended. Isometric contractions are vital because they stabilize some joints as others are being moved. They maintain posture and support objects in fixed positions. The perfect example would be me sitting at the computer typing this right now. I’m sitting erect trying to use good posture and my mid-back is starting to hurt… Ugh! My lower trapezius is sustaining a contraction—to hold me upright—and it is becoming too much. At no time have the ends of the muscle come closer together. Make sense? I bet all of you have experienced this at one time or another.

There is one more category that should be mentioned, that of approximation; the length-tension relationship. If two ends of a muscle are brought closer together, over time, the muscle will adjust its length to keep the same tension. While not a true contraction, it acts like one. This is the concept of Davis’ LawWhen two ends of a muscle are brought together, the pull of tonus is increased. When two ends of a muscle are separated, tonus is lessened or lost, thereby weakening the muscle.

The first part of Davis’ Law has to do with adaptive-shortening. Unless something acts upon the shortened muscle, it will remain in the shortened position and adapt that position as the new “normal”. It will then resist attempts to return to the old “normal” as it has forgotten what that position was.

The second part of Davis’ Law has to do with stretch-weakeness. Muscles are affected by either duration or magnitude. Stretch-weakness is definitely a factor of duration, not magnitude. Having a shoulder much lower than the other for a short period of time is not as powerful as having a small difference for a long period of time.

It is through this length-tension relationship that PNMT comes in handy. These discrepancies within the muscles can cause pain and dysfunction. That being said, proper measurement from a Certified Precision Neuromuscular Therapist can help verify whether your pain and/or dysfunction is caused by misalignment within the muscular-skeletal system.

I hope this information has been informative!

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“Neutral balance alignment is key to becoming pain free!”™ ~ Me