Common Musculoskeletal Injuries and Trigger Points
Each of us who has participated in a sport or physical art understands how readily injuries can occur, particularly as we move through our teens and twenties into our middle years. Up until quite recently, most of the information that has been disseminated regarding injuries has been with respect to those very serious injuries that occur to the musculoskeletal system and that have a way of preventing us from practicing our sport for an extended period of time. These injuries affect the bones, the ligaments (which attach bones to bones), the tendons (which attach muscles to bones), and the muscles themselves. What these injuries have in common is their effect on the musculature.
When a bone, joint, or ligament is injured the muscles that surround the area undergo changes that often lead to trigger point development. This can result from the trauma that caused the injury, from immobilization that healing of the injury required, or from weakness that resulted from lack of use during healing. Once the bone or joint is healed, it is essential for the restrictions within the musculature to be addressed through trigger point release.
Physical therapy for muscle strengthening is often prescribed subsequent to the healing of an injury. Why is it insufficient or ineffective so much of the time? Because the muscle cannot be strengthened before any taut bands and trigger points within the muscle have been released, returning the muscle to its normal resting length. That’s where you come in. Understand that when you have a skeletal injury the bones need to heal properly. Once they are healed, the muscles acting on those bones need to be worked on for complete release in order for true healing to take place.
Let’s look at the characteristics of the various types of injuries.
A crack or break in a bone is a fracture. Fractures are generally accompanied by swelling, extreme pain, and tenderness in the injured area. There is generally a change in appearance of the injured part that may include protruding bone or blood under the skin. The extremity—the arm, leg, or finger—may be bent out of shape. A fracture can occur to any bone. Some fractures require surgical intervention in order to stabilize the bone; others require splinting or casting in order to maintain the proper position of the bones until healing begins. It is recommended that medical care be obtained as quickly as possible in the event of a fracture.
The muscles that act on the region of the fracture will be affected by a fracture as well. Both the trauma to the body part and the subsequent immobilization necessary for healing will impact the muscles. Trigger points develop from both trauma and immobilization. Therefore, after the bone has healed you should work on the musculature to identify and reduce areas of restriction within the muscles. This will have the dual effect of contributing to the complete recovery of the area and precluding the potential of muscular difficulties.
A stress fracture or fatigue fracture is a fracture that occurs at a microscopic level. A stress fracture often occurs as a result of repetitive overuse or with an increase in activity. This kind of fracture may signal the presence of osteoporosis. Pain resulting from a stress fracture may develop slowly, over time. It may begin with a diffuse, dull ache and progress to a localized area of concentrated pain, intensified by impact. A stress fracture may not show up on x-ray or other studies until one to two weeks after its occurrence, when bone healing has begun. Because the fracture is generally stable and does not require splinting or casting, treatment is often limited to the restriction of activity. Stress fractures commonly occur at the hip, at either of the long bones of the lower leg (the tibia and the fibula), and at the metatarsal bones of the foot.
Repeated stresses, such as prolonged standing, running, jogging, jumping, dancing, or walking, are often the source of stress fractures. Symptoms usually include mild swelling, discoloration of the area, tenderness to the touch, warmth at the site of the fracture, and pain that is alleviated by rest. Treatment of a stress fracture can include rest, ice, and elevation of the affected body part.
The activities that cause a stress fracture also cause trigger points in the musculature, and complete healing requires care of that musculature. During the time required for healing the stress fracture, work on the muscles that act on that body part in order to reduce taut bands and trigger points. Those muscles include the muscles of the low back, buttocks, thighs, and lower legs. The increased circulation that results from the release of the musculature will have the added benefit of decreasing healing time and allowing you to return to your activities sooner rather than later.
A joint dislocation is a disruption of the normal relationship between the bones that form a joint. The dislocation may be momentary and self-correcting; however, depending on its severity the injury might require medical attention in order to return the bones to their normal positions. Common sites of dislocations are the shoulder, wrist, hand, finger, hip, knee, ankle, and jaw. Dislocations affect the ligaments that hold the bones in place and also affects the surrounding muscles, tendons, nerves, and blood vessels. Symptoms accompanying a dislocation may include severe pain at the time of the occurrence, visible deformity of the body part, loss of function of the joint, tenderness, swelling, bruising, and possibly numbness. Immediate first aid includes the application of RICE—rest, ice, compression, and elevation—particularly within the first twenty-four hours and then as prescribed by your physician.
It’s important to remember that, with a dislocation, the muscles that act on the affected joint will also be affected by the dislocation and will require treatment in order to heal completely. They will have suffered an acute strain and will likely develop taut bands and trigger points. Once the swelling and tenderness of the area immediately surrounding the joint has healed, work on the muscles that act on the joint. They are each likely to have developed restrictions, taut bands, and trigger points. This will have the dual effect of contributing to the complete recovery of the area and precluding potential muscular difficulties.
A sprain is the violent overstretching of one or more ligaments surrounding a joint; when the ligament is overstretched it may give way at its weakest point, either where it attaches to the bone or within the ligament itself. Sprain is accompanied by severe pain at the time of injury, a feeling of popping or tearing at the joint site, tenderness at the injury site, swelling, and bruising. Ligaments have an extremely limited blood supply; their healing time may therefore be as long as the healing of a fracture. With a sprain it is extremely important to allow adequate time for rest and healing prior to the return of activity. Doing so will avert the possibility of joint instability and repeated, increasingly severe, sprains. The ankle and the knee are common sites for ligament tearing.
Sprains are graded as mild, moderate, and severe.
Immediate first aid for a sprain is the application of RICE—rest, ice, compression, and elevation—particularly within the first twenty-four hours. Medical evaluation will determine the extent of the sprain and appropriate follow-up therapy.
It’s important to remember that the muscles that act on the affected joint will also be impacted by the sprain and will require treatment in order to heal completely. It is likely that they will develop taut bands and trigger points in response to the injury. While the joint is healing from the sprain, identify the muscles that act on the joint and work on their taut bands and trigger points. This will contribute to the complete recovery of the area, and it may preclude the possibility of future muscular difficulties.
Bursitis is an inflammation of a bursa, the fluid-filled sac that lies between adjacent structures, providing cushioning and reducing friction between them. The purpose of a bursa is to allow one structure to glide freely over another. Bursae lie between the skin and bony protrusions such as the elbow or the kneecap; between tendons and ligaments; and between tendons, ligaments, and bones. Bursitis develops slowly over time; it is associated with chronic overuse of an area and with trauma, arthritis, or infection. Without appropriate treatment bursitis may develop into a recurring problem.
Symptoms associated with bursitis include pain that is worse during the night and in the morning upon rising. Pain may be severe until the area is moved, at which point pain recedes. Pain may return after a period of moderate movement or exercise. Pain is generally located over the site of the bursa. It is accompanied by tenderness, swelling, limitation of motion of the affected region, and (if the inflammation is severe) redness and fever. Commonly affected sites include the shoulder, elbow, knee, and hip. Treatment of bursitis includes the use of RICE—rest, ice, compression, and elevation. However, your physician can make a precise diagnosis and prescribe treatment appropriate to your needs.
Bursitis can be differentiated from pain caused by trigger points in that bursitis is accompanied by swelling in the region of pain, whereas pain caused by trigger points is not. However, because chronic overuse is associated with the onset of bursitis, it is possible that the musculature that acts on the affected joint may contain taut bands and trigger points. Identifying taut bands and reducing trigger points will contribute to the healing process by increasing circulation to the area and reducing muscular restrictions that may contribute to friction in and around the joint.
Tendinitis is an inflammation of a tendon, the structure that attaches muscle to bone. Tendinitis will often develop as a result of chronic overuse, repetitive action, engaging in activity without stretching and warming up sufficiently, or stretching the tendon beyond its normal capabilities; or, in the case of occasional sports participants (so-called weekend warriors), overdoing activity with insufficient muscular conditioning. Symptoms associated with tendinitis include pain and tenderness along the tendon—usually close to the affected joint—a generalized ache in the region, and swelling. Pain is worse with movement and may be worse at night. Heat and redness may be present over the site of the tendon. Common sites for tendinitis are the elbow, shoulder, knee, and ankle. Elbow tendinitis, known in the medical lexicon as epicondylitis, is referred to as “tennis elbow.” When it occurs on the inside of the elbow it is called medial epicondylitis, and when it occurs at the outside of the elbow it is lateral epicondylitis. Tendinitis of the knee, known as patellar/quadriceps tendinitis or “jumper’s knee,” is an inflammation of the tendon that attaches the quadriceps femoris muscle to the lower leg. Achilles tendinitis is tendinitis of the Achilles tendon, the tendon that attaches the calf muscle to the back of the heel. Self-care includes the application of ice, particularly after engaging in a sports activity.
The referred pain from trigger points is often misdiagnosed as tendinitis. The difference between the two is that, with tendinitis, swelling and possibly heat and /or redness are present in addition to tenderness at the site. When trigger points are the source of pain there is no swelling, heat, or redness. However, in both cases there may be taut bands in the musculature that act on the involved joint. That being the case, it is essential to work on the muscles that act on the joint: on the forearm muscles in the case of tennis elbow, the quadriceps femoris in the case of jumper’s knee, the gastrocnemius and soleus in the case Achilles tendinitis, and the biceps brachii and rotator cuff muscles in the case of tendinitis of the shoulder.
A strain is an injury to the muscles or to the tendons (which attach muscle to bone). A strain is often caused by chronic overuse of a muscle or prolonged or repetitive action. Overloading a muscle or sustaining trauma to an area causes acute strains. Strains are generally accompanied by pain while moving or stretching the body part, muscle spasm in surrounding areas, swelling over the site, loss of strength, and—in a severe strain—crepitus, a grating or crackling sound when the area is compressed.
Strains are graded as mild, moderate, or severe.
Immediate first aid for a strain is the application of RICE—rest, ice, compression, and elevation—particularly within the first twenty-four hours. Medical evaluation will determine the extent of the strain and appropriate follow-up therapy.
It’s important to remember that muscle strains are one of the primary causes of the development of taut bands and trigger points in muscles. Eliminating taut bands and reducing trigger points precludes the possibility of future muscular difficulties. Identify the muscles that are involved and locate their taut bands and trigger points; their release will increase circulation and will contribute to the complete recovery of the area. Treatment, allowing adequate healing time before returning to your normal sports activities, warming up prior to exercise, and conditioning the musculature will help to prevent further muscle strains.
A spasm, or cramp, is a sudden and involuntary contraction of a muscle. This frequently painful contraction produces a hard, bulging muscle. The causes of muscle spasms are varied: muscle fatigue brought on by overworking the muscle or staying in one position for too long; dehydration; insufficient stretching and warming up prior to engaging in an activity; imbalances of calcium, magnesium, or potassium; pregnancy; poor circulation; diabetes; alcoholism; kidney disease; and side effects of medications. “Splinting spasms” may occur as a mechanism that serves to inhibit movement in order to protect an injured or unstable region of the body. Calf cramps often occur at night; they are referred to as “nocturnal calf cramps.” A cramp is usually temporary and can be relieved with slow stretching, the application of moist heat or ice, and gentle massage to the area. Medical evaluation is advised if cramps are severe, prolonged, or recurrent.
Muscular pain and soreness due to muscle spasm usually diminishes with the release of the spasm. Some residual soreness may remain for a brief period of time. Taut bands and trigger points generally do not develop as a result of a spasm or cramp.
Delayed onset muscle soreness (DOMS) is familiar to many of us. It commonly occurs after a workout or exercise, particularly if you aren’t used to working out, if you are using different muscles than you are accustomed to, or if you are using your muscles differently than usual. Muscle stiffness, weakness, or soreness starts between eight and twenty-four hours following exercise; it peaks between twenty-four and seventy-two hours and it usually dissipates within three to seven days. Delayed onset muscle soreness occurs with overloading the muscle through stretch, resistance, or excessive activity. Activities that require a muscle to contract while lengthening seem to cause the greatest soreness. The standard biceps curl is an example of such a movement. The exertion that is made while flexing the muscle isn’t the source of the soreness; it’s the exertion while slowly straightening the arm that produces the overload. When you’re straightening the arm the biceps muscle is exerting force while lengthening. It is generally thought that microscopic muscle tearing and associated tissue swelling within the muscle is the source of the soreness. The degree of muscle damage is related to the intensity of soreness present and the speed with which the soreness is initially felt.
Delayed onset muscle soreness is unaffected by the application of heat and ice and anti-inflammatory medications. Sometimes light activity, stretching, and gentle massage help to reduce the pain, probably due to the increased circulation to the musculature.
Taut bands and trigger points do not generally develop subsequent to delayed onset muscle soreness.
Musculoskeletal injury is an all-too-common occurrence for athletes and dancers. Self-treatment is useful and has its place within the context of general care. However, it is important to seek professional help in these circumstances:
It has become increasingly clear that we have to take personal responsibility for our health and well-being. We have to be clear about when it is important to seek medical attention. We have to be equally clear when conventional medical treatment stops short of providing us with the means with which to completely heal. Understanding the nature of physical injury and what is required for the healing of that injury is part of taking on that responsibility. This book will help you in that endeavor.