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The following articles have been written by Neil Motyer.  Click on the hyperlink to take you to the article of your choice.

Headaches, Backache and Sciatica, Muscular and Joint Pain, Muscular Injuries and Flexibility Problems Ė Relief with Soft Tissue Therapy

Tension Headaches and Trigger Point Therapy

Neck Shoulder and Upper Back Pain - Relief with Trigger Point Therapy

Lower Back Pain - Relief with Trigger Point Therapy

Upper Limb Pain and Overuse Syndromes

Stretching to Release Chronic Hip Tension 

Strengthening Exercises to Prevent Back Pain

Kyphosis Correction Exercises

The Use of Taping in Injury Management

Tennis Elbow (lateral epicondylitis) - Strapping Scientifically

A self help guide to beating tennis elbow

Headaches, Backache and Sciatica, Muscular and Joint Pain, Muscular Injuries and Flexibility Problems - Relief with Soft Tissue Therapy

 

 

HEADACHE MANAGEMENT

 

The majority of headaches can be given dramatic relief with massage treatment.  Although there are many types of headache, most headaches can be classified as either tension (muscle contraction), headaches or migraine.  They generally have different causes and symptoms, and require different treatment.

 

 

TENSION HEADACHE

 

Tension headaches are generally caused by anxiety, stress or over exertion.  These headaches can be relieved by relaxation techniques including heat, massage and relaxation and flexibility exercises.  Where appropriate stress management or work practice techniques should be used to prevent recurrences. 

 

Tension headaches are caused by muscular tension in the neck, shoulders and/or various head areas.  A vicious cycle of tension, ischemia (restricted blood supply) and pain produces a characteristic steady, non-pulsating ache.

 

Tension headaches are not usually present on waking after a good sleep, but generally appear after periods of tension or stress.  They can invariably be given dramatic relief with an appropriate combination of heat and massage.  Sometimes light stretching of the affected muscles will then be given by a masseur to produce a long-term relaxing effect.

 

For tension headaches, heat-packs or hot baths will often provide some relief for emergency self treatment.  If pain relief is still inadequate take one or two Panadol or Panadeine.  Regular headache sufferers should consult a medical doctor.

 

 

MIGRAINE

 

Most migraine headaches also have a tension component which may benefit from massage treatment.  For pure migraines, massage is inappropriate, but acupressure techniques may be helpful.

 

Migraines are characterized by a pulsating ache and the pain is often one sided.  Migraines can be accompanied by nausea and sensitivity to light or noise.

 

For initial treatment of migraine headaches follow the medical advice given to you by your local doctor.  Lie in a quiet, dark room.  Cold packs to the back of the neck may give some relief.  Anti-nausea medication (eg Maxalon or Stemetil) followed by analgesia (eg two Panadol, Panadeine or Mersyndol) taken early may abort attacks.

 

Pure migraine headaches can have a variety of causes, including anxiety, stress and certain foods; poor general health may contribute.

 

 

Migraine and Diet

 

Cheese, chocolate, red wine and sherry commonly trigger migraines.  Less common triggers may be citrus fruits, alcohol, tea, coffee, yeast, bananas, avocados, pickled herring, chicken liver, cigarette smoke, possibly low water intake and skipping meals.

 

The following is a useful procedure you can use in conjunction with your local doctor to identify dietary for migraine headaches:

 

1. Make a record of everything eaten or drunk in the twenty-four hour period prior to the headache, each time a headache occurs.

 

2. Leave out all suspicious items for a week.  Then re-introduce your suspects one at a time for one day each, eating the same food twice in the same day to be sure.  Introduce the next suspect item the next day, and so on.  If a suspect item produces a headache, wait four days before testing the next suspect item.  On completion, retest implicated items to confirm them as migraine triggers.

 

3. Remove implicated items from the diet.  Confirm that the new diet is balanced and healthy on your next visit to your local doctor.

 

 

General Health and Migraine

  

Migraine headaches may occur more often if you are not in good health.  To promote good health:

 

1. Take plenty of exercise in fresh air; practice deep breathing.

2. Get plenty of rest at night, and possibly a nap every afternoon.

3. Drink plenty of water on rising and throughout the day (for example about 8 glasses per day).

4. Adopt a high fibre diet with an emphasis on complex carbohydrates, raw foods, fruits, vegetables and sprouted seeds.

5. Take small regular meals.

 

 

WARNING

 

If you have any doubts or concerns, medical advice should be sought from your local doctor.

 

 

TRIGGER  POINTS

 

Trigger Points are tender points in characteristic locations.  Sometimes Trigger Points are referred to as fibrositis, fibrositic nodules or muscular rheumatism.  Muscular damage, chronic tension or pain almost invariably result in the development of active Trigger Points - with associated local ischemia (restricted blood supply), muscle shortening, tension and weakness.  The result is a taut band of muscle with hyper-irritable points in characteristic locations.  Any muscle with an active Trigger Point will generally have its own characteristic pain/symptom referral pattern.

 

If an active Trigger Point is untreated for some time, satellite Trigger Points may become active, producing their own pain/symptom referral patterns.  Trigger Points cannot be released unless correctly diagnosed and then properly treated by a doctor, physiotherapist or masseur with appropriate specialist training.

 

Factors leading to the development of active Trigger Points include disease, injury, surgery, bad work practices, prolonged bad posture, muscular tension or spasm, stress, overstretching and chilling.

 

 

BACKACHE AND SCIATICA

 

Backache and sciatica can have a wide variety of causes.  These can range from problems in the spinal column with ligaments, discs, inflammation, bony spur growth, and nerve root impingement; through to muscular and other soft tissue disturbances both adjacent to and further from the spine.  The appropriate use of massage can often provide dramatic relief.

 

Often muscular spasm or active Trigger Points are the direct cause of local or referred pain.  In addition, muscular tension, spasm, or active Trigger Points can lead to local flexion forces on the spinal column.  This can often aggravate existing spinal problems such as nerve root impingement.

 

The appropriate use of massage or Trigger Point therapy will often, therefore, give dramatic relief from both Trigger Point referred pain and muscle induced nerve root pain such as certain types of sciatica and similar referred pain.

 

The type of treatment will vary depending on the nature, location and degree of the problem.  Techniques will vary from advice through to heat, relaxation massage, Trigger Point therapy or stretching in appropriate combination.  Regular use of heat, stretching exercises, and strengthening exercises will often be advised to accelerate both short and long-term improvement.  A healthy lifestyle is important if rapid improvement is desired.

 

When pain is due to muscular tension, heat-packs or hot baths will often provide some relief for emergency self treatment.  If pain relief is still inadequate take one or two Panadol or Panadeine.  Regular pain sufferers should consult a medical doctor.

 

 

MUSCULAR AND JOINT PAIN

 

The causes of muscular and joint pain include disease, and damage or surgery to nerves, ligaments, other joint tissue, muscle or tendon fibres.  In traumatic injuries (eg whiplash) active Trigger Points can develop if early treatment is inadequate.  In chronic conditions (eg osteoarthritis) muscle tension generally leads to the development of active Trigger Points.  The resulting pain/symptom referral pattern can become the major source of pain.

 

In overuse syndromes (eg tennis elbow, RSI) active Trigger Points will invariably be present.  If overuse continues, satellite Trigger Points develop rapidly.  The interaction with the nervous system is a major factor in the development of chronic pain.

 

Joint pain can be due to problems within the joint, but can also be due to referred pain from an active Trigger Point.  It is not uncommon for Trigger Point pain/symptom referral patterns to closely match those of disease such as arthritis, sciatica or nerve root impingement.  A thorough assessment should be undertaken to identify the actual causes of symptoms.

 

An appropriate treatment using heat, massage, Trigger Point therapy or stretching will then be given.

 

 

SPORTS MASSAGE

 

A large number of injuries can be treated with sports massage.  The list includes muscular bruising (eg corked thigh), muscle spasm and cramp, muscle strain, joint sprain, and overuse injuries (eg tennis elbow, shin splints).  In addition, pre and post-event massage can be used to enhance performances.  These massage techniques encourage the removal of metabolic wastes such as lactic acid, and allow fresh blood containing oxygen, glucose and other nutrients to enter the muscles.  They also bring about muscle relaxation providing lower resistance from antagonistic muscle groups during activity.  The overall result is an enhanced physical performance with greater speed, power and stamina.

 

 

FLEXIBILITY ENHANCEMENT

 

The benefits of greater flexibility include improved well-being, a reduction in tension related problems and an increased range of movement during sport or other physical activities.

 

Regular hard training or physical exertion can lead to muscular tension, spasm or even active Trigger Points.  This can result in pain, and a reduction in muscle strength and flexibility (eg chronic groin stiffness).  Affected muscle groups are generally sensitive to both tension and compression, and will often inhibit the range of movement of antagonistic muscle groups.  Trigger Point therapy can often be used to provide rapid improvement in cases of chronic muscular stiffness.

 

Following assessment, a flexibility enhancement program is designed to meet individual needs.

 

 

REFERENCES

 

1. TRAVELL J, SIMONS D: Myofascial Pain and Dysfunction:   The Trigger Point Manual.  Williams and Wilkins, Baltimore USA, 1983 (pp. 1-180, 538, 576, 618)

2. BALDRY P: Acupuncture, Trigger Points and Musculoskeletal Pain.  Churchill Livingstone, Melbourne Australia, 1989 (pp. 29-54)

3. FRICTON J: Myofascial Pain Syndrome.  Neurologic Clinics 1989 May; 7(2); 413-27 (46 references)

4. FAST A: Low Back Disorders: Conservative Management.  Arch Phys Med Rehab 1988 Oct: 69(10): 880-91 (106 references)

 

ACKNOWLEDGEMENTS

 

Grateful acknowledgements for advice in preparing this pamphlet are due to James Doran, KSJ, B Sc, B App Sci (Physio), MRJPHH, Course Co-ordinator, Victorian School of Massage and Andrew Gallagher, B App Sci (Physio). Director of Post Graduate Studies, Victorian School of Massage.  Both are practising physiotherapists, expert in the use of Trigger Point therapy.

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Tension Headaches and Trigger Point Therapy

 

 

TENSION HEADACHE

 

Although there are many types of headache, most headaches can be classified as tension (muscle contraction), vascular, traction or inflammatory headaches.  They generally have different causes and symptoms, and require different treatment.  This article concentrates on tension headaches.

 

Tension headaches are generally caused by anxiety, stress or over exertion, resulting in muscular tension in the neck, shoulders and /or various head areas.  A vicious cycle of tension, ischemia (restricted blood supply) and pain produces a characteristic steady, non-pulsating ache.

 

Many chronic headaches are  tension headaches involving overwhelming pain, and often include other symptoms such as nausea, dizziness, and blurred vision.  These headaches are often described by the sufferer as "migraines".

 

 

TRIGGER POINTS

 

Trigger Points are tender points in characteristic locations.  Sometimes Trigger Points are referred to as fibrositis, fibrositic nodules or muscular rheumatism.  Muscular damage, chronic tension or pain almost invariably result in the development of active Trigger Points - with associated local ischemia (restricted blood supply), muscle shortening, tension and weakness.  The result is a taut band of muscle with hyper-irritable points in characteristic locations.  Any muscle with an active Trigger Point will generally have its own characteristic pain/symptom referral pattern.

 

If an active Trigger Point is untreated for some time, satellite Trigger Points may become active, producing their own pain/symptom referral patterns.  Trigger Points cannot be released unless correctly diagnosed and then properly treated by a therapist with appropriate specialist training.

 

Factors leading to the development of active Trigger Points include disease, injury, surgery, bad work practices, prolonged bad posture, muscular tension or spasm, P.M.T., stress, overstretching and chilling.

 

 

PAIN PATTERNS

 

Tension headaches generally exhibit characteristic pain/symptom referral patterns, such as deep pain behind the eyes, pain in the base of the skull and/or forehead, the crushing pain of a "tight band", pain at the top of the skull, pain arching over the ear and into the forehead just behind the eyes, pain in the temple, and many other identifiable patterns.  Often in more chronic cases, one or more patterns can overlap, resulting in a sometimes confusing pattern of symptoms.  Sometimes less chronic cases may show only part of a pattern.

 

Muscles always refer their headache patterns unilaterally, except for sternocleidomastoid - clavicular division which can also refer pain to both sides of the forehead.

 

Pressing and/or stretching at the suspected source will confirm whether these headaches are caused by active Trigger Points in muscles such as splenius cervicis, suboccipitals, occipitalis, frontalis, splenius capitis, upper trapezius, sternocleidomastoid, and temporalis.

 

Some examples of referred pain patterns are illustrated below.  These illustrations show only a fraction of the muscles which could be responsible for headaches involving referred pain.

 

   

 

 

 

 

 

MULTIFIDIS

Refers pain and tenderness upward to the sub occipital region, and sometimes down the neck to the vertebral border of the scapula.   

 

 

 

SUBOCCIPITALS

Refers head pain that seems to penetrate the skull, but is difficult to localise.  Likely to be described as "all over".  Distressing headaches can occur suddenly when the weight of the occiput presses against

the pillow at night. 

 

 

SEMISPINALIS CERVICIS

 

Refers pain over the occiput and towards the vertex

 

 

 

 

 

TRAPEZIUS 

Refers pain upward along the posterolateral aspect of the neck to the mastoid process, and is a major source of "tension neck ache".  The referred pain, when intense, extends to the side of the head, centring in the temple and back of the orbit, and also may include the angle of the jaw.

 

 

SPLENIUS CERVICIS

 

Refers a diffuse pain through the inside of the head, focussing severely behind the eye and blurring vision.

 

 

 

 

 

STERNOCLEIDOMASTOID - STERNAL DIVISION 

Refers pain to the eye and face and is sometimes diagnosed as "atypical facial neuralgia".  Also refers autonomic phenomena which involves the eye and sinuses.  Refers pain to the occipital ridge behind, but not close to, the ear, and to the vertex, with scalp tenderness in the pain reference zone.  Eye symptoms include excessive lacrimation, reddening of conjunctiva, blurred vision, and perceived dimming of light. 

 

 

SEMISPINALIS CAPITIS

 

Refers a pain that travels forward like a band that half encircles the head and reaches its maximum intensity in thee temple and forehead over the eye.  When present bilaterally, the headache is often described as ďa tight bandĒ.

 

 

 

STERNOCLEIDOMASTOID - CLAVICULAR DIVISION

Referred pain is usually described as frontal headache and earache.  When severe, pain in the frontal region can extend across the forehead to the other side.  Proprioceptive dizziness related to posture and disturbed equilibrium can occur.  Also the referred autonomic phenomena of localised sweating and vasoconstriction (blanching) can occur in the frontal area or referred pain. 

 

 

 

 

HEADACHE MANAGEMENT

 

Soft tissue techniques are the least frequently used, yet often the most appropriate form of treatment for most chronic muscular pain.

 

The majority of tension headaches can be given dramatic relief with an appropriate combination of heat and Trigger Point therapy.  Usually light stretching of the affected muscles will then be given to produce a long-term relaxing effect.

 

When just about all other methods of treating chronic pain have been tried unsuccessfully, Trigger Point therapy will often produce excellent results.

 

Once the Trigger Points responsible for the pain have been identified and released, advice can often be given as to how work practices or posture can be altered to prevent recurrences.

 

For tension headaches, heat packs or hot baths will often provide some relief for emergency self treatment.  If pain relief is still inadequate take one or two Panadol or Panadeine.  Regular headache sufferers should consult a medical doctor.

 

 

REFERENCES

 

1. TRAVELL J, SIMONS D: Myofascial Pain and Dysfunction:   The Trigger Point Manual.  Williams and Wilkins, Baltimore USA, 1983

2. BALDRY P: Acupuncture, Trigger Points and Musculoskeletal Pain.  Churchill Livingstone, Melbourne Australia, 1989

3. FRICTON J: Myofascial Pain Syndrome.  Neurologic Clinics 1989 May; 7(2); 413-27 (46 references)

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Neck Shoulder and Upper Back Pain - Relief with Trigger Point Therapy

 

 

CAUSES OF PAIN

 

Back pain can have a wide variety of causes.  These can range from problems in the spinal column with ligaments, discs, inflammation, bony spur growth, and nerve root impingement; through to muscular spasm and other soft tissue disturbances both adjacent to and further away from the spine.

 

Nobody has a perfect spine.  X-rays can show minor malalignment of the vertebrae, with moderate degeneration and osteoarthritis.  This is not necessarily the primary cause of chronic pain.  Some sufferers of back pain believe they have a "vertebrae out", or a "slipped disc", but this may not be true.

 

Many chronic pain sufferers continue to suffer because no organic diagnosis can be found to account for their pain.  Most people are not generally aware that muscles can develop active Trigger Points, with associated referred pain/symptom patterns.  This mechanism is known as Myofascial Pain Syndrome (M.F.P.S.).

 

In most cases of chronic pain, protective postures adopted by the sufferers lead to chronic shortening of one or more muscle groups. This can lead to the development of active Trigger Points in these muscle groups, together with their own referred pain/symptom patterns (M.F.P.S.). The M.F.P.S., unless treated, may then go on to become the main cause of ongoing pain and poor posture long after the source of the original pain has been eliminated.

 

Referred symptoms from active Trigger Points can vary from feelings of numbness, coldness, burning, aching or weakness, through to pain so intense that it can totally immobilize the sufferer.

 

M.F.P.S. is a common cause of chronic pain.  A recent U. S. University study found that Myofascial Trigger Points were the primary clause of pain in 85% of chronic pain sufferers.

 

 

WHAT ARE TRIGGER POINTS?

 

Trigger Points are tender points in characteristic locations.  Sometimes Trigger Points are referred to as fibrositis, fibrositic nodules or muscular rheumatism.  Muscular damage, chronic tension or pain almost invariably result in the development of active Trigger Points - with associated local ischemia (restricted blood supply), muscle shortening, tension and weakness.  The result is a taut band of muscle with hyper-irritable points in characteristic locations.  Each active Trigger Point will generally have its own characteristic pain/symptom referral pattern.

 

If an active Trigger Point is untreated for some time, satellite Trigger Points may become active, producing their own pain/symptom referral patterns.  Chronically active Trigger Points are generally self perpetuating and cannot be released unless correctly diagnosed and then properly treated by a therapist with appropriate specialist training.

 

Factors leading to the development of active Trigger Points include disease, injury, surgery, bad work practices, prolonged bad posture, muscular tension or spasm, P.M.T., stress, overstretching and chilling.

 

 

TREATMENT WITH TRIGGER POINT THERAPY

 

Trigger Point therapy is the least frequently used, yet often the most appropriate form of treatment for most chronic muscular pain.

 

The majority of muscular pain can be given dramatic relief with an appropriate combination of heat and Trigger Point therapy. Usually light stretching of the affected muscles will be given to produce a long-term relaxing effect.

 

When just about all other methods of treating chronic pain have been tried unsuccessfully, Trigger Point therapy will often produce excellent results.

 

Once the Trigger Points responsible for the pain have been identified and released, advice can often be given as to how work practices or posture can be altered to prevent recurrences.

 

 

PAIN PATTERNS

 

Each active Trigger Point generally exhibits its own characteristic pain/symptom referral pattern.  Often in more chronic cases, one or more patterns can overlap, resulting in a sometimes confusing pattern of symptoms.  Sometimes less chronic cases may show only part of a pattern.

 

The following are some common examples of referred pain patterns caused by active Trigger Points:

 

 

  

 

 

 

 

LEVATOR SCAPULAE 

This muscle causes a "stiff neck", with limited neck movement due to pain on rotation.  Looking sideways tends to be performed by turning eyes or body, but not the neck.  Because of pain and restricted movement many become worried that "something is out".   

 

 

 

MIDDLE TRAPEZIUS

 

Refers a superficial burning pain adjacent to the spine at the base of the neck.

 

LOWER TRAPEZIUS 

Refers pain severely to the neck and point of the shoulder.  The pain is often described as an annoying deep ache with widespread tenderness over the shoulder region.

 

  

 

 

SERRATUS POSTERIOR SUPERIOR 

A strong, deep ache is felt beneath the shoulder blade, with intense pain to the back of the shoulder and down the arms.  Some pain may also be referred to the chest.  A steady deep ache at rest is often felt.

 

 

MULTIFIDI & ROTATORES 

Active Trigger Points in these deep spinal muscles cause reduced range of movement of the spinal column.  Pain on relative movement between adjacent vertebrae restricts flexion and rotation of the spine.  Midline tenderness and pain results in many sufferers feeling that "a vertebrae is out".  This can happen at any location throughout the spine.  

 

 

 

SUPRASPINATUS 

A deep ache is felt around the shoulder and elbow.  This ache often extends down the arm and forearm.  Some have difficulty reaching their head to comb hair, brush teeth, or shave.

 

ILIOCOSTALIS THORACIS

 

Referred pain from active Trigger Points in this paraspinal muscle group is upwards towards the shoulder, and sometimes into the chest.  It can be extremely painful just taking a deep breath.

 

 

 

INFRASPINATUS 

Pain is usually felt deep within the shoulder joint, at the front of the shoulder and arm, and sometimes down the side of the arm.  Pain prevents lying on the involved side at night.  Sufferers often wake up with their arm "numb or asleep".  Some complaints are "I canít fasten my bra behind my back" or "I canít get my sore arm into my coat sleeve last, but must put it in first".

 

 

 

REFERENCES

 

1. TRAVELL J, SIMONS D: Myofascial Pain and Dysfunction:   The Trigger Point Manual.  Williams and Wilkins, Baltimore USA, 1983

2. BALDRY P: Acupuncture, Trigger Points and Musculoskeletal Pain.  Churchill Livingstone, Melbourne Australia, 1989

3. FRICTON J: Myofascial Pain Syndrome.  Neurologic Clinics 1989 May; 7(2); 413-27

4. LEWIS J: Myofascial Pain Syndrome: A Review of the Literature.  The Australian Massage Therapy Journal 1992 May                 

 

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Lower Back Pain and Trigger Point Therapy

 

 

CAUSES OF PAIN

 

Back pain and sciatica can have a wide variety of causes.  These can range from problems in the spinal column with ligaments, discs, inflammation, bony spur growth, and nerve root impingement; through to muscular spasm and other soft tissue disturbances both adjacent to and further away from the spine.

 

Nobody has a perfect spine.  X-rays can show minor malalignment of the vertebrae, with moderate degeneration and osteoarthritis.  This is not necessarily the primary cause of chronic pain.  Some sufferers of back pain believe they have a "vertebrae out", or a "slipped disc", but this may not be true.

 

Many chronic pain sufferers continue to suffer because no organic diagnosis can be found to account for their pain.  Most people are not generally aware that muscles can develop active Trigger Points, with associated referred pain/symptom patterns.  This mechanism is known as Myofascial Pain Syndrome (M.F.P. S.).

 

In most cases of chronic pain, protective postures adopted by the sufferers lead to chronic shortening of one or more muscle groups. This can lead to the development of active Trigger Points in these muscle groups, together with their own referred pain/symptom patterns (M.F.P.S.). The M.F.P.S., unless treated, may then go on to become the main cause of ongoing pain and poor posture long after the source of the original pain has been eliminated.

 

Referred symptoms from active Trigger Points can vary from feelings of numbness, coldness, burning, aching or weakness, through to pain so intense that it can totally immobilize the sufferer.

 

M.F.P.S. is a common cause of chronic pain.  A recent U. S. University study found that Myofascial Trigger Points were the primary clause of pain in 85% of chronic pain sufferers.

 

 

WHAT ARE TRIGGER POINTS?

 

Trigger Points are tender points in characteristic locations.  Sometimes Trigger Points are referred to as fibrositis, fibrositic nodules or muscular rheumatism.  Muscular damage, chronic tension or pain almost invariably result in the development of active Trigger Points - with associated local ischemia (restricted blood supply), muscle shortening, tension and weakness.  The result is a taut band of muscle with hyper-irritable points in characteristic locations.  Each active Trigger Point will generally have its own characteristic pain/symptom referral pattern.

 

If an active Trigger Point is untreated for some time, satellite Trigger Points may become active, producing their own pain/symptom referral patterns.  Chronically active Trigger Points are generally self perpetuating and cannot be released unless correctly diagnosed and then properly treated by a therapist with appropriate specialist training.

 

Factors leading to the development of active Trigger Points include disease, injury, surgery, bad work practices, prolonged bad posture, muscular tension or spasm, P.M.T., stress, overstretching and chilling.

 

 

TREATMENT WITH TRIGGER POINT THERAPY

 

Trigger Point therapy is the least frequently used, yet often the most appropriate form of treatment for most chronic muscular pain.

 

The majority of muscular pain can be given dramatic relief with an appropriate combination of heat and Trigger Point therapy.  Usually light stretching of the affected muscles will be given to produce a long-term relaxing effect.

 

When just about all other methods of treating chronic pain have been tried unsuccessfully, Trigger Point therapy will often produce excellent results.

Once the Trigger Points responsible for the pain have been identified and released, advice can often be given as to how work practices or posture can be altered to prevent recurrences.

 

 

PAIN PATTERNS

 

Each active Trigger Point generally exhibits its own characteristic pain/symptom referral pattern.  Often in more chronic cases, one or more patterns can overlap, resulting in a sometimes confusing pattern of symptoms.  Sometimes less chronic cases may show only part of a pattern.

 

The following are some common examples of referred pain patterns caused by active Trigger Points:

 

 

  

 

 

 

 

QUADRATUS LUMBORUM

 Refers pain that is deep and persistent, and may be particularly piercing during movement.  Pain refers to the lower back, hip, buttock and sometimes to the front thigh, abdomen and to the groin/testicle.  An acute, severe onset of M. F. P. S. from this muscle may be totally immobilising and render standing intolerable, and is often described as a feeling that the "hip is out".  If both sides are involved, pain is felt horizontally across the lower back. 

 

 

 

LONGISSIMUS

 Referred pain markedly restricts spinal motion and activity.  When the initial complaint of "lumbago" is due to Trigger Point activity in this muscle, there is usually a unilateral, extremely disagreeable, steady ache deep in the spine.  The ache becomes bilateral as the muscles on both sides become involved, and the sufferer has difficulty rising from a chair and climbing stairs.  Changing position provides little relief, and many are mistakenly convinced that the pain originates from within the spine, not from the muscles. 

 

 

 

 

GLUTEUS MEDIUS 

Refers pain that is commonly identified as lower back pain or lumbago.  Some Trigger Points refer pain and tenderness along the pelvic crest and down to the sacrum on the same side.  Pain may also be felt over much of the buttock.  Some Trigger Points refer pain over the sacrum on both sides.  

 

 

ILIOCOSTALIS THORACIS 

Trigger Points in this muscle can refer pain upwards towards the shoulder blade, through to the abdomen, and downwards over the lumbar area.  Abdominal pain may be mistaken for internal organ pain.

 

 

GLUTEUS MINIMUS 

Refers myofascial sciatic pain to the side or back of the leg that can be intolerably persistent and excruciatingly severe.  The Trigger Point sources of the pain are deep in the buttock muscles and much of the pain is so far away that its true origin is easily overlooked.  Some sufferers complain of hip pain that may cause a limp during walking.  Lying on the affected side may be so painful that rolling over onto that side during the night interrupts sleep. 

 

 

 

SERRATUS POSTERIOR INFERIOR

 Pain from this muscle is usually described as an aching discomfort over and around this muscle.  The ache is annoying, but not severe.

 

ILIOPSOAS 

Refers a distinctive vertical pattern of pain down the lumbar spine, the upper thigh, and usually the groin.  Sufferers are likely to have difficulty getting up from a deep seated chair and are unable to do sit ups.  In severe cases, mobility may be reduced to crawling on the hands and knees.  Painful symptoms are worse when standing upright and relieved by reclining or adopting a stooped posture. 

 

 

 

PIRIFORMUS

 Refers pain mainly to the lower back, buttock and back of the thigh that is usually increased by sitting, standing and walking.  Sometimes this muscle can entrap the sciatic nerve causing "sciatica" down the back of the leg.

 

RECTUS ABDOMINUS

 Referred pain from the lowest part of this muscle can be felt as a band of pain across the lower back in the sacral region.  Activation of other Trigger Points in this muscle (eg by stress or P. M. T. ) can refer severe abdominal pain, and can mimic dysmenorrhoea (period pain).

 

 

 

 

 

REFERENCES

 

1. TRAVELL J, SIMONS D: Myofascial Pain and Dysfunction:   The Trigger Point Manual.  Williams and Wilkins, Baltimore USA, 1983

2. BALDRY P: Acupuncture, Trigger Points and Musculoskeletal Pain.  Churchill Livingstone, Melbourne Australia, 1989

3. FRICTON J: Myofascial Pain Syndrome.  Neurologic Clinics 1989 May; 7(2); 413-27

4. LEWIS J: Myofascial Pain Syndrome: A Review of the Literature.  The Australian Massage Therapy Journal 1992 May     

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Upper Limb Pain and Overuse Syndromes - Treatment with Soft Tissue Therapy

 

 

OVERUSE SYNDROMES

 

This syndrome is common among industrial workers, office workers, musicians and athletes that are subjected to regular or excessive static loading and/or repeated microscopic injuries to the musculoskeletal system (Repetitive Strain Injury).  The ability of tissue to withstand overload varies greatly between individuals, due to differences in strength, endurance, flexibility and other anatomical factors.  External factors such as poor technique, poor posture, poor conditions and poorly designed equipment may also contribute to overloading.

 

The onset of the syndrome can be sudden as with unusually heavy static overload at normal or high frequency or heavy load at normal frequency.

 

An overuse injury is generally characterised by pain and weakness, mainly due to inflammation in the initial stages.  The injury often becomes pain free after a short warm up period, however.  If the activity which caused the injury is continued, tissue damage, inflammation and their symptoms become more extensive, and become reinforced by the systematic development of active myofascial and other trigger points.

 

Chronic muscle tension invariably leads to tendonitis (Motyer's Rule), and appropriate management including protection against further aggravation and reduction of inflammation is a priority.

 

 

WHAT ARE TRIGGER POINTS?

 

Trigger Points are tender points in characteristic locations, generally in muscles and their tendons.  A variety of non-myofascial soft tissue can also develop active trigger points, eg skin, scar tissue, joint capsules, and ligaments.  Sometimes myofascial trigger points are referred to as fibrositis, fibrositic nodules or muscular rheumatism. 

 

Repeated soft tissue damage, chronic tension or pain almost invariably result in the systematic development of active trigger points, with associated local ischemia (restricted blood supply), pain/symptom referral patterns, and dysfunction. 

 

Factors leading to the development of active trigger points include disease, injury, surgery, bad work practices, prolonged bad posture, muscular tension or spasm, stress, overstretching and chilling.

 

 

HOW THE BODY IS AFFECTED

 

Inflammation is the body's response to tissue injury.  During overuse, tissue injury, inflammation, pain and healing are going on at the same time.  Pain should be interpreted as a warning sign of tissue injury and should lead to a rest from activity.  Repeated microscopic injuries to the musculoskeletal system are characterised by the growth of fibrous (scar) tissue, with associated inflammation at various sites of injury in muscles, tendons, tendon-bone attachments, ligaments and joint capsules.  The continued formation of inelastic scar tissue in ligaments and muscles will result in stiff joints and shortened muscles.

 

The development of scar tissue and muscle tension/spasm can sometimes result in nerve impingement at the spine, or entrapment some distance from the spine.  Connective tissue restrictions may also be involved in nerve or blood vessel entrapment.  These problems can result in numbness, tingling, puffiness of the hands and other sensations.

 

In many cases, an individual's anxiety about their injury can lead to muscular tension.  Muscles held in sustained contraction become overloaded and trigger points and other soft tissue problems can be perpetuated.

 

Many sufferers of chronic pain tend to avoid all painful movements, perpetuating muscle tightness and joint stiffness.  A state of hopelessness and depression sets in.  On the other hand, some individuals have a stoic attitude towards pain, resulting in the injury receiving inadequate rest in its early stages.  The same attitude can disrupt progress once the syndrome has been identified.    

 

 

COMMON OVERUSE INJURIES

 

Tendonitis (Inflammation of the tendon)

Inflammation of a tendon and its sheath can be caused by repetitive movements or mechanical irritation.  As overuse continues, myofascial and other trigger points develop, and the condition becomes chronic and difficult to treat.  The supraspinatus tendon, the tendon of the long head of the biceps and the extensor tendons of the wrist  are most frequently affected.

 

Lateral Epicondylitis (Tennis Elbow)

Classic tennis elbow involves chronic inflammation of the common extensor origin, usually due to repetitive injury.  Players of sports like tennis, squash and golf, as well as those carrying out repetitive one-sided movements, can be affected.

 

Carpal Tunnel Syndrome (Pressure on the median nerve)

Thee carpal tunnel is a narrow channel in the palmar aspect of the wrist which houses the median nerve.  Pressure due to inflammation of tendons and tendon sheaths of the wrist flexor muscles can compress this channel, putting pressure on the median nerve.  The result is a persistent dull ache, with pain and numbness in the thumb and first three fingers.  Occasionally the median nerve can be entrapped by the pronator muscle in front of the elbow, causing numbness in the fingers.  Active trigger points in the hand and finger flexor muscles, referring pain to the wrist, thumb and fingers may also be involved in this syndrome. 

 

 

TYPICAL PAIN PATTERNS

 

The diagram below shows a typical combination of pain patterns due to the activation of trigger points in the levator scapula, multifidis, serratus posterior superior, supraspinatus, infraspinatus, and wrist extensor muscles.  Less chronic cases will generally only show part of this pattern.  Besides pain, other referred symptoms can include weakness, stiffness, burning, coldness, aching, numbness and tingling.  Sometimes chest pain can cause difficulty in breathing.

 

 

 

Persistent tension headaches, due to tension and trigger point activity in muscles in the neck/shoulder region, are a common feature of upper limb overuse syndromes.  In most cases these muscles were not involved in the primary stages of the injury, and inactivation of their trigger points is generally simple and effective.

 

 

TREATMENT WITH SOFT TISSUE THERAPY

 

Specialised massage techniques (soft tissue therapy) can be useful for the treatment of a variety of overuse syndromes relating to office or industrial overuse injuries (eg chronic neck/shoulder/arm/hand pain, carpal tunnel syndrome), or sporting injuries (eg tennis elbow, tendonitis).

 

In the early stages of injury management, proper resting in order to minimise stretching and loading of structures that are undergoing healing is very important.  Protective taping can be very useful.  Heavy actions should be avoided, and in most cases, slow careful movements of affected muscles and joints are advisable.  In some cases, anti-inflammatory medication may be prescribed by a doctor.

 

Initially treatment should concentrate on pain management, commencing with massage and advice for the management of general and interstitial inflammation.  Then, with a knowledge of individual myofascial pain syndromes and the mechanism of injury, it is generally possible to specifically identify which muscles are causing pain.

 

Trigger point therapy generally provides a dramatic reduction of pain levels in overuse syndromes over the first few treatments.  Heat and light stretching of the affected muscles should also be given to produce a long-term relaxing effect.  If full muscle stretching cannot be tolerated initially, local stretching techniques (micro stretches) may be useful to restore local mobility and eliminate local ischemia.  Light stretches and soft tissue techniques can then be used to identify and eliminate non-myofascial trigger points or other problems in tendons, tendon-bone attachments, ligaments, joint capsules or other connective tissue.  In more chronic cases the release of connective tissue restrictions will allow the reversal of trophic changes such as nerve end budding.

 

When pain and inflammation are under control, properly graduated exercises should be undertaken to improve strength, stamina and mobility.  In the initial phase these should comprise isometric exercises, without load.  Later, dynamic exercises can be performed and should be combined with careful stretching.  At no time should these exercises exceed the pain threshold.

 

In both acute and chronic cases, advice should also be given on work practices, posture, general exercise, and the gradual restoration of flexibility and strength.

 

 

REFERENCES

 

1.   1. TRAVELL J, SIMONS D: Myofascial Pain and Dysfunction:  The Trigger Point Manual.  Williams and Wilkins, Baltimore USA, 1983

2.   2. BALDRY P: Acupuncture, Trigger Points and Musculoskeletal Pain.  Churchill Livingstone, Melbourne Australia, 1989

3.   3. PETERSON L, RENSTROM P: Sports Injuries: Their prevention and treatment.  The Law Book Co. Ltd., North Ryde USA, 1990

4.   4. VICTORIAN SCHOOL OF MASSAGE: Upper Limb Overuse Syndromes: Prevention and Treatment: Post Grad Workshop Notes, 1991

5.   5. VICTORIAN SCHOOL OF MASSAGE: Pathology Notes, 1984

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Stretching to Release Chronic Hip Tension
 

 

Flexibility can vary enormously from individual to individual, and even within various parts of the same personís body!  Stretching exercises can improve flexibility, but must be performed regularly, otherwise muscles will return to their 'normal' state within a few weeks.

 

Research has shown that muscle lengthening (flexibility improvement) is optimised by low force, long duration stretching at high temperatures (390 C to 430 C - the warmer the better) followed by tissue cooling prior to stretch release.  Cooling the muscle to normal temperatures (370 C or less) before releasing the tension apparently allows the collagenous microstructure to restabilise in its new stretched length. 

 

Conversely, high force, short duration stretching at cold temperatures provides little flexibility improvement and tends to cause muscle weakening.

 

Research findings on the best duration and frequency of stretching vary.  Most suggest high frequencies and long durations such as 4 sets of 30 seconds, twice a day, with stretch discomfort but not pain for maximum rate of improvement.  However, more recent research indicates the best results are obtained with stretching exercises which conclude by holding a strong passive stretch (which exceeds the normal muscle length) for at least 30 seconds, and no more or less than 2 to 3 times a week, with the ideal time between sessions a rest of 3 days i.e. 72 hours.

 

Strength and flexibility can be developed simultaneously using 'resistance techniques'.  Muscles are contracted and relaxed cyclically while a light external stretching force is applied to move the muscle through its full range of movement.  Stretching is enhanced in this technique due to tension in some fibres producing extra stretching in others. Muscles are stretched and strengthened at the same time in their various lengths in their range of movement.

 

The opposite approach can be even more effective...

 

When a muscle is 'doing work', it is contracting.  Conversely, when it relaxes it can lengthen, and the more it relaxes the more easily and fully it can lengthen. When working to improve flexibility, it is worth keeping in mind that the purpose of a muscle stretching in body movement is to allow the antagonistic muscle to shorten.  The body is designed so that when muscles contract their antagonists are automatically inhibited by the nervous system i.e. their ability to contract is suppressed. This is known as 'reciprocal inhibition'.

 

'Active stretching' is a technique that uses the concept of reciprocal inhibition to facilitate greater relaxation of a tight muscle.  In a good approach using this technique the muscle opposite the tight muscle (agonist of the desired movement) is concentrically contracted through the available range using its own strength, with little or no external assistance to create the movement.  An external resisting force can also be used.  Immediately following the contraction the limb is passively stretched to increase its range of movement.  The cycle can be repeated several times, or alternatively the exercise can be done with a continuous light external stretching force.  This technique develops strength and flexibility in antagonistic muscle groups, an ideal combination and probably the best approach to increasing flexibility.

 

The range of exercises based on active stretching are limited only by the imagination and the equipment available.  The obvious approach is to make the exercise 'specific' i.e. reasonably close to the action that needs to be improved.  Performing the action slowly, with correct posture, and using the antagonistic muscles as a natural resistance would be a good start.  A simple example suitable for beginner martial artists to help develop good hip adductor (groin) flexibility is to practice side kicks while sitting in a chair and sliding one foot along the floor.  A more advanced variation is to stretch both knees apart, first actively then passively, as a warm up to the straddle splits. Both exercises can also be used to help rehabilitate a chronic groin strain. 

 

 

 

 

 

 

A young taekwondo student

demonstrates the straddle splits

using 'turnout' of the hips

 

 

 

 

 

A combination of chronic hip and lower back pain and stiffness is commonly caused by problems with the psoas muscle.  The psoas muscle attaches to the lumbar spine L1 to L5 and plays an important role in hip flexion.  When chronically tight, the psoas can cause lumbar stiffness by restricting extension.  This can be exacerbated by almost all activities except lying down.

 

Chronic muscle tension invariably leads to tendonitis (Motyer's Rule), and appropriate management including manipulation to release inflammation is a priority.

 

Chronic psoas tightness can be very obstinate, but can be eased with inflammation management and treatment with heat and local pressure combined with active stretching, followed by passive stretching with ice. 

 

 

For very chronic cases, sufferers must learn to relax the psoas themselves, since this should be done several times per day for good progress.  A useful procedure is to concentrically contract the upper hamstring, gluteals, and lumbar extensors (hip extensor group) to trigger a relaxation of the psoas via reciprocal inhibition.  Hold for 6 seconds, then repeat a couple of times with gradually increasing hip extension. Conclude with a passive psoas stretch for 5 to 10 seconds.  Repeat regularly throughout the day, particularly when the psoas feels tight.

 

REFERENCES

 

Alter, M. J. (1996).  Science of Flexibility.  Human Kinetics.

 

Hiskins, B. (2002).  Tissue Tension Techniques.  Massage Australia, 40(10), 26-33.

 

 

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Strengthening Exercises to Prevent Back Pain
 

 

When exhaustive medical examinations and X-rays show no obvious cause of hip/back pain, it is likely that the problem is soft tissue related.  If the problem is chronic despite massage, stretching or similar treatment, it is likely that there are weak muscles involved which are being easily strained/re-hurt.

 

Here is a simple strengthening program that requires no equipment and takes only 2 minutes a day.  It should be done daily but don't expect results for several days (if not weeks), as muscles take time to get stronger.  The premise here is that the spine and hip joints are structurally sound, there is no serious soft tissue damage, and that chronic weakness is the underlying cause of repetitive injury and pain.

  

Each of the following exercises should be done as isometric contractions for 5 to 10 seconds at 50% to 70% of maximum effort, then repeated 2 more times (3 sets).  

 

Exercises 1 to 7 can be done on a chair or exercise ball, and Exercise 8 on the floor.

EXERCISE 1

Place the hands on the knees and press forward by contracting the hip flexors and abdominals.

EXERCISE 2

Place the hands below the knees and pull back by contracting the hamstring, gluteal and back muscles.

EXERCISE 3

Place the hands below one hip and press sideways by contracting the lateral lumbar flexors.  Repeat on the other side.

EXERCISE 4

Turn left, place one hand behind the back and one hand outside the left leg.  Pull back by contracting the back rotators and left hip external rotator muscles.  Repeat on the other side.

 

EXERCISE 5

Turn left, place one hand behind the back and one hand inside the right leg.  Pull back by contracting the back rotators and right hip internal rotator muscles.  Repeat on the other side.

EXERCISE 6

Place the hands outside the knees and push the knees apart.

EXERCISE 7

Lock a forearm between the knees and push the knees together.

EXERCISE 8

Lie on the back holding knees to chest.  Rock back and forth to massage the sacral/lumbar area.

 

DISCLAIMER/WARNING

1. These exercises should not be done if they hurt.

2. These exercises could be dangerous if spinal/disc or other injuries exist and should not be done without medical approval.

 

 

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Kyphosis Correction Exercises

 

 

Make sure you are adequately warmed up before exercising or stretching.

 

EXERCISE 1

A good stretching exercise involves lying on the stomach and performing a press-up, keeping the hips on the floor.

 

Exercises for the neck should focus not only on basic range of motion, but also on specific neck stretches and strengthening exercises, especially of the supporting postural muscles.

EXERCISE 2

A useful neck exercise is called cervical retraction.  Sitting up straight, keeping the chin LEVEL, gently pull the chin straight in as if you are hiding against a wall or sideways behind a tree.  Your head should not bob up or down.  The back of your neck should feel long.  The highest point of your body should be the top back of your head.  This is a good postural correcting exercise to perform during the day, for example while doing computer work.  It counters the tendency most people have in sitting to slip into a forward head posture (chin poke).

 

EXERCISE 3

Another neck exercise is called upper cervical nodding which stretches the (often chronically cramped) muscles at the base of your skull called the sub occipital muscles.  Sitting up straight (the top, back portion of your head is the highest point), nod your head up and down about 1 centimetre. With the down motion, you should feel stretching at the base of your skull.

EXERCISE 4

Next, a really good postural exercise is called the breastbone lift.  In sitting, practice lifting the front of your upper chest about 5 centimetres.  As you lift, gently squeeze your shoulder blades DOWN and together.  Sometimes it is helpful to picture a string tied to the top 2nd or 3rd button on a shirt, pulling straight up to the ceiling.  Doing this breastbone lift/shoulder blade depression repeatedly helps to correct your posture and strengthen the lower trapezius muscles, which "anchor" you in a good sitting posture.

A variation of this exercise is to simultaneously "roll" both shoulders first back, then down, then forward, then up.  When the shoulders are on the way down, protrude the upper chest forward and up.  This is sometimes referred to as the "Aunty Grace" stretch. Repeat several times with a continuous circling motion.

Finally, taping to restrict excessive lengthening of the erector spinae and lower trapezius muscles can be helpful in the postural retraining process.

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The Use of Taping in Injury Management

Not all injuries respond well to manual manipulation - for example acute soft tissue injuries need to be protected from further injury and need P. R. I. C. E. (protection, rest, ice, compression, elevation).  The use of sports tape is becoming increasingly popular to allow activity to continue while at the same time 'unloading' (giving protection against stretching) of damaged soft tissue.


The principle of unloading is based on the premise that inflamed soft tissue does not respond well to stretch. Examples of inflamed tissues are recent muscle lesions, sprained medial collateral ligaments, inflamed fat pads, irritated iliotibial bands, or pes anserinus bursitis.  If under strain, the inflamed tissue needs to be shortened or unloaded.  To unload an inflamed fat pad, for example, "anchor" tape is placed above and below the fat pad, then two "tension" tapes are attached to the lower anchor tape on either side of the fat pad.  As the tension tape is being pulled towards the upper anchor line, the skin is lifted, thus shortening the fat pad.  If protection against horizontal stretching is also needed then the anchor tapes are also applied as tension tape.  The same type of taping may be used to unload the distal end of the ITB when treating iliotibial friction syndrome, or the proximal end of the ITB when treating trochanteric bursitis.

 

 

   An example of taping for trochanteric bursitis

 

 

 

 

 

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Tennis Elbow (lateral epicondylitis) - Strapping Scientifically

This article describes a new tennis elbow counterforce brace that includes a new patented vibration damping component called a GOSTRAPTM, which makes it more effective than standard braces.  This same component also provides an adjustable external force to carry the load of the injured tissue and protect it from excessive strain.  A more detailed description is given at the end of this article. 

 

The load carrying ability of the new brace was evaluated in an independent University biomechanics study.  With the subject using a controlled tennis backhand stroke, and swinging a 2kg dumbbell but not striking a ball, the University study showed a significant reduction in muscle activity in the protected region with the modified counterforce brace compared to a normal counterforce brace.  There were also lower Maximum Peak Values in muscle activity with the modified brace compared to a normal counterforce brace as measured by an electromyograph (531uV & 618uV).

 

The brace was assessed by renowned massage educator and Melbourne physiotherapist Mr. Andrew Gallagher, who gave the following report:

"I have used Mr. Neil Motyer's tennis elbow splint to great effect in the management of my own elbow pain and would certainly recommend its use to my patients.  The one clear advantage I see in its design is that it attaches more security to the limb providing greater support and stability particularly when using the arm."  Andrew Gallagher, Director, Australian School of Therapeutic Massage.

 

Tests performed on 5 symptomatic subjects confirmed previous research findings that the standard counterforce brace allows increased passive stretching of the wrist extensor muscles prior to reaching the threshold of pain.  Additional tests showed that when the modified counterforce brace was applied a further increase in pain free stretching was achieved.

 

Further tests were conducted to determine the vibration damping effect of the brace using cinematography and a frame by frame analysis.  The stabilizing effect of the strapping on tissue vibration was clearly evident.  Ball striking with a tennis racquet using a backhand volley and a consistent peak impact force of 300N showed a 80% reduction in vibration amplitude of soft tissue in the protected region with the modified brace compared to a 60% reduction with a normal counterforce brace.

 

 

Tennis elbow is primarily caused by inflammation at the attachment site (just above the elbow) of the common wrist extensor muscle group tendon.  In fact, however, the situation is usually also complicated by inflammation and damage of the tendon itself (tendonitis/tendinosis) and soreness, tension and (pain inhibited) weakness of the wrist extensor and supinator muscles. 

Chronic overuse of tendons leads to microscopic tears within the collagen matrix, which gradually weaken the tissue. Swelling in a region of microdamage or partial tear can be detected visually or by palpation.  The disorganised collagen matrix in tendon lesions may be broken down by cross fibre manipulation, in preparation for repair with improved collagen alignment.  This technique applied correctly will quickly result in an analgesic effect over the treated area and is not at all a painful experience.

Good treatment regimes start with P. R. I. C. E. (protection, rest, ice, compression, elevation) during the acute stage - generally 48 hours.  This stage focuses on protection and inflammation management.  The rehabilitation (post acute) stage focuses on healing and strengthening exercises that don't stress or strain damaged tissue.  There are a plethora of websites providing advice on these issues - an interesting web page is:

www.injuryupdate.com.au/injuries/arm_&_hand/tennis_elbow.php

You can also follow the links to these 2 pages:

www.injuryupdate.com.au/injuries/arm_&_hand/tennis_elbow_exercises.php www.injuryupdate.com.au/issues/nitratepatches.php

- nitrate patches require a medical prescription.

 

In cases where inflammation is an ongoing problem, fish oil capsules taken at the recommended daily dosage are a good healthy alternative to anti inflammatory drugs.

 

When work or activity must continue, as they usually must, commercially available braces and supports can be useful for mild injuries, and can be bought at most good pharmacy shops for $15 to $50.

These supports are placed around the upper third of the forearm and are tensioned to restrict full clenching of the fist - this stops the extensor muscles and tendons from stretching fully and therefore offers some protection.  These braces provide only limited support.

 

For more severe cases, adhesive rigid sports tape is sometimes used to restrict extension of the wrist extensor group by placing an anchor tape around the upper third of the forearm, then a tension strap from the anchor to the upper arm roughly following the line of the wrist extensor tendon.  The tape is applied with the elbow bent and the forearm supinated so that it restricts both elbow straightening and forearm pronation  - applied properly this provided better support than the forearm brace. 

 

An example of a popular method of taping to restrict both elbow straightening and pronation using rigid sports tape (McConnell Method).  For a  description visit http://3msports.co.nz/pdf/strappingtechniques.pdf and scroll to page 22.  Note that elbow straightening puts a lot of stress on the tape as well as the skin/fascia and additional layers of taping and lock down tape were required for this strongly built client.  This form of taping is more suited for providing protection during sporting activity as it tends to stress and cut/irritate the skin with time, and even with extra layers of tape usually weakens after one to two days.

 

Another taping method more suited for rehabilitation is 'Kinesio Taping', which uses flexible tape to virtually eliminate the problem of discomfort.  Unfortunately this tape product provides only a very gentle tensile force and even with several tapes/strands of tape does not adequately unload the common wrist extensor tendon.  For more information visit https://www.sportstek.net/kinesio/kinesio_3.hTM.

 

In the author's opinion, a better form of support for tennis elbow can be provided with non adhesive materials using a modified counterforce brace with an added component called a GOSTRAPTM.

 

The device is simple to use and is designed to carry the load and/or reduce the tension of an injured muscle, tendon and its attachment site during activity or rest.  A tensioned strap is fitted as an anchor to the upper third of the forearm.  An elastic GOSTRAPTM is stretched around the elbow, and both ends of the elastic GOSTRAPTM are attached to the anchor so as to protect the injured tissue through the application of an external tension force provided by the GOSTRAPTM

How to apply a GOSTRAPTM for lateral epicondylitis:

 

a typical method of fitting would be:

  1. Attach the widest end of the elastic GOSTRAPTM to the anchor strap.
  2. Align the widest end of the elastic GOSTRAPTM over the tendon or injury to be protected.
  3. Fasten the anchor strap over the forearm with a light tension, using only a portion of the Velcro fastening surface.
  4. Stretch the elastic GOSTRAPTM around the elbow to provide the desired unloading force.
  5. Attach the Velcro portion of the free end of the elastic GOSTRAPTM onto an unused portion of the Velcro fastening surface of the anchor strap.
  6. Check the tension in both the anchor strap and the GOSTRAPTM, and adjust if necessary.
  7. Complete the fastening of the anchor strap onto the remaining unused fastening surface.  

 

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An example of non adhesive strapping to unload the common wrist extensor tendon, using an elastic GOSTRAPTM.  Note the line of the elastic strap (3) follows the wrist extensor group muscle and tendon, and this means that the support from the elastic strap increases when the extensor muscle group lengthens, i.e. the elbow straightens or the forearm is pronated.  This form of strapping provides well directed support forces and can be continually used during activity or recuperative periods.  The strapping can be easily applied or removed as required.  The method is simple yet effective and is ideal for self management. 

For enquiries about GOSTRAPTM contact the author or visit www.gostrap.com

A self help guide to beating tennis elbow

Imagine this scenario (it probably applies to most of us!)...

A while ago you may have hurt a muscle, or been in a stressful situation for a bit too long.  Your muscles tensed up in an automatic protective response to limit range of movement (ROM) so as to prevent further injury.  To free up your conscious mind, your sub-conscious mind took over the job of maintaining the tension.  Some time has passed, the injury has healed, and the need for the ROM limiting tension is no longer there.  You try to relax the muscle to stretch it, but because the sub-conscious mind is still fighting against you to restrict ROM, it hurts.  The sub-conscious mind wins, and another "stiff muscle" develops as we get older.  Its now time to re-program the sub-conscious mind to let go the tension, but this can be very difficult because most people don't know it needs to be done, let alone how to do it! 

Re-programming the sub-conscious mind is a bit like self hypnosis.  Before you can send a message to your sub-conscious mind to re-program it, you have to believe it first!  You have to genuinely believe that its not going to hurt if you relax and let that muscle stretch - and that's hard to do if its got a recent history of hurting every time.  The best way to stretch tight muscles is to take the time to totally relax first, using as many techniques at your disposal as necessary.  Wear loose, warm clothing.  Warm up the muscles before stretching with heat or exercise.  Get as comfortable as possible, with soft padded support under all areas subject to local pressure forces - the sofa could be ideal.  You need a relaxing environment with no interruptions.  Think relaxing thoughts - relaxing music or relaxation tapes can be useful. 

All this leads up to the most important point I have saved for last - consciously relax when stretching (breathing out helps) to release all tension and pain.  If you are conscious of the possibility of overstretching, you will probably subconsciously tense up, so make sure your muscles are fully supported to prevent overstretching - preferably with soft firm padding.  Also make sure that you have no unpleasant pain (sometimes a mild "stretch pain" can feel good and this is ok).  The ROM of your stretch should not exceed your pain threshold if you want to successfully re-program your sub-conscious mind into "permanently" releasing the protective spasm.

Use the "contract-relax" method of stretching (described below) - it is probably the most efficient and effective method developed to date.

All muscles, particularly those that are damaged, should be protected from excessive overload at all times.  In some cases, support systems such as braces may be appropriate.   

Stretching and strengthening exercises can be a useful part of the rehabilitation process because controlled loading improves collagen alignment of the tendon and stimulates collagen cross-linkage formation, which improves tensile strength. It is important that the state of the muscle/tendon injury is given due consideration when prescribing the loading forces.  The exercises should focus on improving the flexibility, strength, power and endurance of the entire muscle-tendon unit.  The duration of this program would generally be at least 12 weeks. 

Before starting any specific forearm exercises it recommended to loosen up the neck, shoulders, upper back and chest muscles with a hot shower or bath, followed by a few stretching exercises.  After that, it is beneficial to heat the most problematic area (probably the wrist extensor muscles in the elbow region) before stretching, to improve its ability to stretch.  Heat to 390 C to 430 C - the warmer the better.  For best results follow up with tissue cooling prior to stretch release on the last passive stretch.  Cooling the muscle to normal temperatures (370 C or less) before releasing the tension allows the passive stretch to be held longer and apparently allows the collagenous microstructure to restabilise in its new stretched length.   

Check with your therapist to make sure you are ready for these stretching or strengthening exercises.

The exercises described below should be done carefully and are based on the well established principle of progressive overload to gradually improve both strength and flexibility.  As a rule of thumb, don't exceed pain-free muscle loading or stretching by more than 5%.  In other words, slowly stretch further (or push harder) until extremely slight pain is felt, then go a comfortable small margin past this point.  These pain levels should not be unpleasant.  If your injury is substantial, expect the flexibility and strength to be low, and the appropriate amount of "overload" will also be small.  Progress will be slow and patience is required.

Stretching the wrist extensor group using the widely used "contract-relax" method provides the benefit of also strengthening the extensor muscles and the damaged extensor group tendon.  A typical exercise is shown in the first photograph below for a right arm injury. First gently stretch the extensor group with the method as shown below - note that your range of movement will probably be less than that shown in the photograph if you are injured.  Notice that the hand has also been rotated so the little finger approaches horizontal - this also stretches the elbow supinator muscle which is commonly involved in tennis elbow injuries.  Hold the stretch position for about 30 seconds or 5 slow breaths.  Next (while breathing out slowly through the nose) push carefully with a very light effort for about 5 seconds with the back of the right hand against the left hand, which is held steady.  After that slowly breathe in through the nose, then breathe out slowly through the mouth and at the same time gently stretch a little further (try to relax and release any tension).  Hold for one slow breath cycle, then repeat the procedure two more times.  Unless you have overdone the stretch, you should be able to hold the last stretch position for 30 seconds or 5 slow breaths.  I like to finish off with a slow "yawn stretch" to further accentuate the stretch, using the antagonist muscles to create the additional movement (reciprocal inhibition).  Repeat the exercises twice a week.  Allow about 3 days rest between exercise sessions.

A strengthening exercise for the wrist flexor group is shown in the next two photographs.  Push from position 1 to position 2, with the left hand providing a resistance force which allows a pain free movement.  The right hand would be typically pressing with approximately 20 to 30 percent of full strength, but this could be significantly less for more severe injuries.  The number of repetitions would also vary with the severity of the injury, but would typically be one to three sets of 6 repetitions, building to 12 repetitions, done twice a week.  Allow about 3 days rest between exercises.   Using position 1, the contract-relax method can be used as described earlier for the wrist extensor group to provide a stretching exercise for the wrist flexor group.  This exercise can be useful for carpal tunnel injuries.  A more comprehensive set of exercises for the arm and hand, and a method of doing them can be seen in an excellent book by Kit Laughlin, see reference 2 below. 

Stretch for extensor tendon Strengthening - position 1 Strengthening - position 2

 

GOSTRAP SELLERS:

 

Australia - Sportstek, www.sportstek.net 

 

Canada - Gostrap Canada, web link

 

UK - Actesso, www.actesso.co.uk

      - Body Logic Health, www.bodylogicsupplies.co.uk

 

USA  - Gostrap USA, web link

          - Hat Trick Sports, www.Hat-Trick-Sports.com

References

  1. Hammer, W: On Stretching.  Dynamic Chiropractic February 12, 1993, Volume 11, Issue 04
  2. Laughlin, K: Overcome Neck & Back Pain, Edition 4.  Simon & Schuster, 2006 

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