Male patient aged 44 with pain on the medial side of the right elbow and on the ulnar side of the forearm. The problem has been present for a couple of years, but it always gets worse during the summer. Last winter was also painful, but symptoms were not constant, more following the activity level. Loss of strength in the forearm and grasping followed the pain. Symptoms started to present on the left side this year. Very active person who competes on high level endurance races cross country.
During examination we quickly found out that the ulnar nerve was very tight and that the nerve itself bounced anteriorly and posteriorly during extension and flexion of the elbow. Increased tightness of the ulnar nerve was palpated by the medial elbow/forearm when shoulder external rotation and abduction were introduced (more stretching of the nerve). Patient reported increased symptoms when ulnar nerve was tested. Patient presents restrictions in shoulder external rotation and abduction (more active than passive).
Her knees always get painful first and then the hips will start to hurt. This typically happens after 45 to 60 min. of playing tennis. She feels that it is a bit less painful and that it takes longer time to trigger the symptoms when playing on softer ground.
Examination indicated a compensatory pattern from the toes to the spine. Reproduced knee pain by testing and palpating the knee capsule, lateral meniscus and the insertion of the iliotibial band. Both feet were pronating. Stretching the external rotators of the hip showed restrictions and increase in pain. Adductors were sensitive and shortened. Decreased dorsal flexion of the ankle both side and decreased inversion of ankle joint. Squatting was difficult to perform. Poor activation of peroneus longus and brevis.
Male patient aged 60 with pain in the left groin and testicle. GP referred the patient after relevant examinations had been carried out to exclude pathology. Patient has complained about intense and almost constant pain for several years. Symptoms get slightly better after 15 to 20 min of exercises. Symptoms get worse and intense as he stands up from a seated position. The longer he sits the more intense the pain during standing up.
Male golfer aged 44 was told he had «Tennis elbow» and tendinitis by his GP. He was given NSAIDs. His symptoms were intense pain on the lateral side of the right elbow with some radiation distally on the extensor side of the forearm and superiorly along the lateral aspect of the arm. Pain starts as he starts to grasp, and gets worse after activity. Symptoms might be milder during the activity itself. He was a bit surprised with the definition of the problem. He has played golf for almost 30 years and he has previously had the same problem at more occasions. He knew that the tendinitis diagnose was wrong and he took contact with our clinic. He never started on the NSAID’s.
Female patient aged 46 with symptoms indicating Thoracic Outlet Syndrome and/or Carpal Tunnel Syndrome on both sides. Symptoms have been severe to mild and vice versa for more than 2 years. She has tried most forms of treatment without any results. Specialists were considering surgical intervention of the Transverse Carpal ligaments both sides for her problems. She works as an accountant and trains at the gym 2 to 3 times a week. She keeps busy with 3 kids and more…
Our initial examination indicated secondary compression on the plexus between her middle and anterior scalene, secondary tension/pressure/friction from the coracopectoral gate and along the neurovascular sleeve in the upper arm. Palpation and neurovascular tension tests for these structures reproduces/elevated the patient’s symptoms in the arms and hands. Median nerve tests by the flexors of the forearm did slightly reproduce symptoms, but not as distinct as for the earlier mentioned higher up the tracts. Test of breathing pattern indicating secondary breathing activation at rest, and slightly lesser activation of Diaphragm.
Active Release Treatment was performed 4 times over a period of 4 weeks, including specific gliding/flossing exercises for the particular tract involved. At the 5th visit, the patient explains that she has not experienced any of the symptoms since the last treatment.
Patient was given correcting breathing exercises and specific gliding exercises for maintenance after 5th visit. At the evaluation 3 months later patient had no complaints and she had not experience any setbacks during the period.
Saved from the knife. ART – When results matter!
This paper is written simply to try and stimulate you as a practitioner to think about what you are doing when addressing Myofascial Pain and Dysfunction disorders, especially when addressing such problems from a Trigger Point of view. I hope that practitioners and others interested in Myofascial Trigger Points and soft tissue disorders in general, will find the paper useful. I am not trying to disrespect any practitioner or others concerning their approach, work or belief. I am just trying to share my clinical experiences and present the findings made as a clinician. I know many practitioners acknowledge the findings and the reasoning being presented in this paper. Let us see where it goes…
Hypoxia (lack of oxygen) and accumulation of waste products (due to lack of circulation/exchange deficiency) can cause pain symptoms of various degrees in the tissue involved. Hypoxia happens either by overworked structures (Cumulative Injury Disorder – CID) and/or after an injury. Hypoxia over time results in adhesions and “hardening” in, or between fibers in soft tissue structure (1, 2, 3, 4).
When investigated closer, we find that all of our soft tissue is connected and blends together where they meet, cross, penetrates and/or inserts. When movement is made, our soft tissue “melts” and slides together or from each other (depending on movement and function of structures) (5, 6).
When the tissue is in the healing phase after an injury or when overworked for too long too many times, the body lays down new tissue to replace the original damaged fibers. This type of new tissue will be formed by much less elastic and passive fibers (adhesions or “Fuzz”). These newly laid down fibers will eventually connect and “grow” into the surrounding layers. The Cumulative Injury Cycle demonstrates the cycle of an injured tissue and points out the importance of breaking out of the ongoing cycle (2, 3, 4, 5, 6, 7, 8).
We can compare an injury inside the body (beneath the skin) and what happens in the healing phase, to a cut to our skin. The injured area becomes hard and less stretchable after some months. At some point, the tissue thickens and blends in with the surrounding layers from other soft tissues such as; muscles, fascia, tendons, ligament, nerves, capsules. If you have a scar from an operation, try to pick up the skin and feel what happens underneath. Compare to the other healthy side on your body. What did you discover? (3, 4).
It makes NO sense at all that these local “muscle spots” by themselves should radiate/refers neurological symptoms in the distribution area of a specific peripheral nerve. It is obvious that the peripheral nerve itself plays an important role in the total symptom pattern. The changes in the soft tissue surrounding the nerve after an injury or when overworked, causes the nerve to respond locally and in the distribution area (pressure, friction lack of blood supply etc.) (3, 4, 5, 6, 9).
For some reason, Trigger Point is one of the most accepted terminologies among practitioners dealing with soft tissue treatment, when it comes to describing/treating pain spots that preferably radiate to other specific areas. And, it has become some sort of acceptance how to address such problems. Many tools and many possibilities, all based on vague theories. Well, is it not about time we work on a theory that makes sense, and explains the referred symptoms without concluding, quote; “With certain muscles, the reality of referred pain can often be demonstrated by simply pressing on a trigger point that is bad enough to reproduce part of its referred pain pattern. It’s a little harder to explain why pain is referred at all”(10, 11).
Tissue layers and structural tunnels in our body
As mentioned earlier, our soft tissue is interconnected, but its structures are also “separated” by fascia. These “separations” makes it possible for the different structures to glide, stretch and contract respectively to, from and for each other when movement is made (lifting your arm or walking). If we follow the neurovascular structures from where they leave the center of the body and enters the limbs throughout to our fingers and toes (Peripheral nerves from the Spinal cord through a bony tunnel made out of two vertebras, and the arteries and vein where they branch out), we will find that our soft tissue structures such as muscles, tendons, ligaments and fascia, creates natural pathways (tunnels) throughout our musculoskeletal system. These tunnels are found between our layers of soft tissue structures, and they are easily accessible to palpation and certainly compression (5, 11, 12).
Tunnels are not fixed, and will move and adapt as we move our bodies. As we move our limbs, our nerves and vascular structures glides back and forward in each tunnel respectively to which movement is made. When you extend your wrist the Median nerve will glide distally in the Carpal Tunnel, and when you flex the wrist the nerve glides superiorly (5, 6, 13).
Sensitive structures like nerves, veins and arteries should not be met by force or violence. Personally, I would never in my mind find it reasonable to compress and/or twitch a nerve with direct force (risk of damaging the myelin sheet/nerve). Practitioners “tend” to have an idea that the more it hurt, the better it is. In cases, where we are talking about sensitive structures like nerves and vascular structures, it is definitively not the case. Nerves they branch, penetrates structures and glides among the tissues through our entire musculoskeletal systems (5, 6, 9, 12).
Examples of some natural nerve tunnels (often also vascular) in the body:
Soft tissue palpation and Hands On work
To palpate and differentiate soft tissue as they move and/or in passive position is an ART. It is as simple as playing the piano and just as difficult. It takes a practitioner a great deal of training and experience to be able to actually feel different structures, and to differentiate them from one and the other. The deeper the structures are, the more difficult it is to palpate and differentiate.
It is particularly difficult to feel a nerve. The deeper the nerve the more difficult it is to palpate and differentiate it from the other surrounding structures. Peripheral nerves vary in size and length. Some nerves are thick and easy to palpate for a trained hand, while others are thin and more difficult to feel (13).
It takes a great deal of training and experience for a practitioner to develop good palpation skills. A trained practitioner will be able to feel the body’s different structures and layers. He or she can feel the different depths of tissues and if abnormalities are present in, or between the tissues involved.
When treating a tender “spot” in the soft tissue, the practitioner must be sure not to compress any neurovascular structures. It is not the nerve tissue itself you want to influence, but the surrounding structures causing the nerve to respond (13).
If the practitioner uses force to create compression with the thumb or wrist, he or she will not be able to feel or differentiate the tissues underneath the contact point. The Trapezius muscle is quite thin. Think about how you treat the Trigger Point just superior to the medial boarder of the Spina Scapulae (preferably radiates/refers neurological symptoms either distally along the medial boarder of the Scapulae, and/or up the medial/lateral side of the neck all the way to the head). How deep and how hard do you go with your contact or tool? (14, 15).
Wikipedia 2014 (10):
“Practitioners claim to have identified reliable referred pain patterns which associate pain in one location with trigger points elsewhere. There is variation in the methodology for diagnosis of trigger points and a dearth of theory to explain how they arise and why they produce specific patterns of referred pain.
Compression of a trigger point may elicit local tenderness, referred pain, or local twitch response. The local twitch response is not the same as a muscle spasm. This is because a muscle spasm refers to the entire muscle contracting whereas the local twitch response also refers to the entire muscle but only involves a small twitch, no contraction.
Among physicians, many specialists are well versed in trigger point diagnosis and therapy. These include physiatrists (physicians specializing in physical medicine and rehabilitation), family medicine, and orthopedics. Osteopathic as well as chiropractic schools also include trigger points in their training. Other health professionals, such as athletic trainers, occupational therapists, physiotherapists, acupuncturists, massage therapists and structural integrators are also aware of these ideas and many of them make use of trigger points in their clinical work as well.“
Are you a soft tissue practitioner?
If you are a practitioner and you work with soft tissue diagnosis and treatment, you probably have treated such tender “spots” that radiates/refers neurological symptoms many times. A lot of our treatment modalities these days are focused on some sort of high direct compressive force, with or without twitching (tools, machines or fingers, hands, elbows etc.). Sometimes we penetrate the skin with a needle and twitch it around deep in to the tissues where it hurts and also “preferably” radiates/refers to other parts of the body. We might even use machines which produces waves of direct blows to the actual area.
More tissue injury = better recovery?
Say you are a pretty much up to date practitioner dealing with these issues on a regular basis. You have a good anatomical, physiological and neurological base knowledge, and many “treatment tools” available. You have worked for a long time and built up lot of experience in dealing with such complaints. You know where to find and palpate muscles, nerves, tendons, blood vessels, ligaments etc. And, you know how the nervous system functions and how the peripheral nervous system is built up. What would your initiative reasoning be for solving these “Trigger Points”?
What is your choice of approach? Are you thinking of compressing the nerve and/or surrounding tissue? Or, are you thinking of reducing/releasing compression on the nerve from its surrounding tissues? These two examples of starting points addressing soft tissue symptoms such as “Trigger Points”, will definitely determine the approach of the practitioner.
Some common misunderstandings amongst practitioners when it comes to treating “Trigger Points” (and other Myofascial Pain and Dysfunctions):
Example: Median nerve entrapment at the m. Pronator Teres
The Median nerve penetrates through one of the heads or between both of the muscle Pronator Teres in the forearm, just below the elbow. The depth (from the skin and to the nerve) may vary due to the size of the muscles and other structures or tissues.
- Pain in the forearm and in the distribution area is present. Symptoms can be loss of strength, tingling sensations, electrical firings, numbness etc. all the way to the palm of the hand and fingers.
The patient’s symptom dscriptions and history together with your tests (palpation) will indicate how the nerve is involved and for how long the problem has been present/developed. Symptom onset and the description of symptoms will tell you something about how the nerve is involved and at what stage. If the problem has been present for a long time, with gradually increase of symptoms, you should ask yourself why those structures in that particular area behaves the way they do? Has it something to do with how that particular patient is using his/her body and/or is it because of adhesions and other alternations in the tissue (tonus, size, hardness, displacements etc.).
Conclusion: The trigger point chart shows the same distribution area for the muscle Pronator Teres trigger point as the peripheral nerve chart does for the Median nerve (13, 17, 18).
You should suspect a certain degree of damage to the myelin sheath of the nerve if the surrounding tissues have been allowed to compress and damage it for a long time (friction and pressure). This will probably affect the prognosis (longer recovery). You should also suspect that the nerve structure itself also has lost some of its gliding capacities due to biomechanical soft tissue compensation and/or if the nerve is entrapped (19).
Please do the following:
1. Compare the Peripheral nerve chart with the Trigger Point chart. Check also the referred pain/distribution areas. What do you find?
2. Ask yourself, would you like someone to compress and twist, or needle your ex. median nerve where it penetrates the Pronator Teres muscle?
3. Now, let us say we are pretty much sure that a nerve is involved in the picture. How can we determine the cause of the nerve symptoms? Entrapment by adhesions? Entrapment by muscle tonus? Friction? Loss of gliding capacity? Lack of blood supply? Damage to myelin? Tumor? etc.
YES! YES! YES! Most “real” tender spots you find that radiates/refers neurological symptoms actually are nerves firing (Patient complains about radiating pain or other neurological symptoms in the respective distribution area. These symptoms are often reproduced or increased when the spot is compressed).
In basic terms, we know (don’t we?) that friction, compression and pressure (given by fingers/hands/tools or internally by adhesions or other structural alternations) on soft tissue structures can, and most probably will cause local tissue damage. As we know, tissue injury causes more rigid fibers to lie down in the area. Why do we choose approaches that are meant to do the same kind of damage to the tissue as an injury?
The “reasoning” for these treatments are always; “I have to cause more tissue damage so that the repair process (healing) kicks in”. Think about the football player when he gets a knee into his quadriceps causing a crushing injury in the tissue. That is actually what we are doing when using compressive modalities with direct force. It just does not make any sense to try and cause more injury to the tissue, whatever the original problem is.
There is a more reasonable approach to our treatments
We need to turn our thoughts around dear fellow practitioners. Instead of approaching a “Trigger Point” on the basis that it is a muscle knot that needs to be compressed/crushed with some sort of direct force, think about what can be done to create relative motion in, and between the structures involved without a vertical direct force into the tissue. The reason for this approach is simple. If you are able to eliminate the cause of the nerve compression/entrapment by reintroducing gliding potentials of the local surrounding structures, you will be able to eliminate the “pressure” on the nerve itself.
NO pressure/friction on the nerve = NO pain or other neurological symptoms in the distribution area + NO hypersensitivity of the nerve locally (excluding a damage to the myelin sheet). Typical example is Carpal Tunnel Syndrome.
Most of our tender spots or pain areas in soft tissue are developed over a period of time. These soft tissue changes happen due to compensatory patterns, when over-trained, after an injury and/or in combination with underlying diseases and lifestyle. I always ask myself the question “WHY” until I stop from lack of knowledge, or because the reasoning of my findings suggested I am on the right track. There is a reason why the soft tissue changes its working load and/or function (secondly developing into a soft tissue symptom or syndrome, thirdly to functional impairment etc.).
Examples of some natural nerve tunnels (often also vascular) in the body:
A. Between the muscles Psoas and Iliacus (Femoral nerve)
B. Coracopectoral tunnel (Chord)
C. Between the Median and Anterior Scalene muscles (Plexus)
D. Arch of the Soleus (Tibial nerve)
E. Through the muscle Pronator Teres (Median nerve)
F. Between the muscles Trapezius and Levator scapulae (Spinal accessory nerve)
G. Between the muscles Extensor carpi radialis longus and brevis (Superficial radial nerve)
H. Trough and/or by the hip rotators in the hip like the muscle Piriformis (Sciatic nerve)
I. Between the two heads of the muscle Flexor Carpi Ulnaris (Ulnaris nerve)
J. By the muscle Superior Oblique (Suboccipital nerve)
Note 1. Tender spots that radiates are NOT inflammatory problems. Therefore NO usage of NSAID’s is necessary.
Note 2. Using Trigger Points as references to determine vague and misguiding diagnosis such as Fibromyalgia (general hypersensitivity – CNS – neuroplasticity) is way off target and causes more problems than it helps. A person with the alarm center switched on (over a long period of time), will most likely be hypersensitive in one or more of the Peripheral nerve pathways (20).
If you work with soft tissue you have to take the Peripheral nervous system into consideration in your examination and treatment. The Peripheral nervous system should not be neglected when approaching soft tissue problems. When doing so the practitioner risks causing more damage than good, especially when approaching the problem as discussed earlier.
When your findings suggest multiple triggering “spots” on both sides of the body (often with varied intensity, onset time and variations in symptoms), please be aware of the involvement of the Central Nervous System. It might not be a local problem at all.
If we accept that it does not make any sense to reinforce the ongoing Cumulative Injury Cycle (adhesions/scar formation) in the tissues involved, then we have to reconsider many of the treatment tools and modalities being used today. A more functional approach should be accepted at all levels of treatments, from the soft tissue treatment itself to the exercises and other necessary adjustments.
Remember to be curious about your patients’ soft tissue problems. Try to find a reasonable explanation for the symptoms described by the patient and provoked through testing. Most of our clues lies in the words from the patient, listen to what they say.
I hope that the paper can contribute to future research on the subject, and that it can be used as a guide to distinguish some common soft tissue problems from one and the other.
A special thank you to my wife Katrin van der Lagen and my colleagues at the clinic in Norway for contributing with case reports on the subject and for helping out with pictures and design. I would also like to give a BIG thank you to Dr. P. Michael Leahy in Colorado Springs for introducing and teaching me how to develop and refine my palpative skills through his own soft tissue system; Active Release Techniques®.
Personal recommendation for soft tissue practitioners: Active Release Techniques®
Anatomy pictures: Visible Body®’s 3D anatomical models of the human body. I use this app for learning and teaching purposes. The app is also used to educate patients at the clinic. www.visiblebody.com
About the writer
ART® is our soft tissue “tool” of preference in our movement based treatment approach.
The whole concept is based on improving movement in a structure (muscle, tendon, fascia, capsule or ligament), and/or improving the gliding potential of a structure vs another or more (ex. median nerve at the carpal tunnel, iliotibial band on the vastus lateralis, biceps + infraspinatus + deltoid). Limited movement potential in structures and/or between structures is prone to cause many of our modern soft tissue diagnoses/conditions. If you have restrictions in your soft tissue somewhere in the body, your structures and the body compensates so you can keep on going.
A restriction in the soft tissue causes limitation and alternation of movement.
When limitation of movement is caused by adhesions in a structure, and/or “fuzzing” in the surrounding tissues, biomechanical alternations will emerge, thus making it possible to continue with your tasks (ex. computer worker with general aching in arms/shoulders – raising the shoulder and holding it in a static position while the forearm, hand and finger do they work on the keyboard/mouse). Many examples can be given, the point being, your other structures (the ones you use to compensate) will have to work harder and differently than they are suppose to, this additionally to your already overloaded structures in the forearms and wrists. This will in the long run reinforce the unfortunate pattern along the whole chain and probably cause you more changes/problems in more areas of the body. Remember that the timeline is essential. The longer the pattern has been reinforced, the more “fuzz” you will find. The more “fuzz” you find, the more the tissue shape, function and texture changes. I believe that most surgical interventions for soft tissue conditions could be avoided when correctly approached (I am obviously not talking about total or partial ruptures of structures needing reattachments etc.).
Systematically integrating ART® into your practice/work with patients, athletes or teams.
Mobility and flexibility are important elements in achieving desired strength and endurance. Strength, endurance, coordination etc. determines our functional abilities. Without the necessary glide and slide of our soft tissue, injuries are predisposed and the athlete or worker will perform at a poorer biomechanical level.
Soft tissue flexibility is important in the mid- and later stages of the healing process after an injury has occurred. At this stage, ART® plays an important role in achieving desired local flexibility in the injured area and in the surrounding tissues (fascia, connective tissue, muscles, tendons, nerves etc.). Achieving desired local flexibility in the tissue fibers and in the surrounding tissues, will give the patient or athlete huge advantage in the rehabilitation work, and later in their functional settings.
“Just think about what happens with the skin when you cut yourself. Fibers are forming from all directions and between all layers in the actual area (FUZZ), making the skin and the underlying connective tissue less flexible. The same happens to injured tissue under the skin (fascia, connective tissue, muscles, tendons, nerves etc.). It is a good idea to watch the FUZZ Speech by Gil Headly, and his 1 hour dissection video for informative purposes”.
It is important to address mobility/flexibility issues before you focus on strength etc. in rehabilitation after injury. The same applies for athletes in their training. Think about how common it is for football players with injury history of the hamstrings (semitendinosis, semimembranouses and biceps femoris long head) to get re-injured in the same area. Inhibition of movement in between structures by FUZZ, will happen after injury and/ or by your daily loading pattern. The ART® provider must give special attention to any local structures predisposed to re-injury for the individual athlete. It is also of high importance that the provider analyses the kinetic lines to address inhibitions of movements along the chain. We now talk about cause relationships! Take a look at this article: Recurrent hamstring muscle injury: applying the limited evidence in the professional football setting with a seven-point programme
How many theories do we have about Trigger points? And, how many theories do we have on solving the problem? I believe that many vague, and sometimes strange theories are served to our patients and athletes when it comes to soft tissue disorders in general. If you deal with soft tissue disorders in general, please do the following:
1. Compare the peripheral nerve chart with the trigger point chart. Check also the radiation/distribution areas. What do you find?
2. Ask yourself, would you like someone to compress (squeeze) and twist, or needle your ex. median nerve by the pronator teres muscle?
3. Now, let’s say we are pretty much sure that a nerve is involved in the picture. How can you determine the cause of the nerve symptoms?
4. Entrapment by adhesions? Entrapment by muscle tonus? Friction? Loss of gliding capacity? Blood Nutrition? Damage to myelin? etc.
Differentiate! How you solve the issue is of course up to you. I would pretty much focus on releasing the nerve and surrounding structures + introduce nerve- and tissue gliding by treating neighboring entrapment sites + nerve gliding exercises etc. I would also always make sure to address the underlying biomechanical cause to avoid “backfires”.
KNOW YOUR NERVES
Carpal Tunnel Syndrome – Median Nerve – Peripheral Nerves