Muscles and fascia with limited flexibility lack compliance and resiliency. Non-compliant muscles are more susceptible to injury and pain. Myofascial trigger points are a major factor in non-compliant muscles. Latent trigger points cause stiffness and restricted range of motion, and are more common than painful active trigger points. This paper suggests ways in which the healthcare provider can therapeutically release active myofascial lesions.
Myofascial release and trigger point therapy are terms often used interchangeably. Myofascial release techniques stem from the foundation that fascia, a tough connective tissue found throughout the body, reorganizes itself in response to physical stress and thickens along lines of tension.1 Barnes2 claims that as a result of myofascial release there is a change in the viscosity of the ground substance to a more fluid state. He comments, “Myofascial release can eliminate the fascia’s excessive pressure on pain sensitive structures and restore proper alignment.” He claims the effectiveness of manipulation can be enhanced and that myofascial release procedures can safely and effectively free osseous structures.
Myofascial trigger points are hyperirritable spots, usually within a taut band of skeletal muscle or in the muscle’s fascia, that is painful on compression and can give rise to characteristic referred pain, tenderness and autonomic phenomena.3 Myofascial pain is characterized in part by a trigger point in a taut band of skeletal muscle and its associated referred pain.4 Myofascial pain syndrome is a regional muscle pain disorder characterized by localized tenderness in taunt muscle bands and referred pain. Frequently myofascial pain is overlooked as a common cause of chronic pain because of the frequent association with joint dysfunction and other pain disorders.5
Benefits of Flexibility
Apart from pain, the most common objective finding and subjective complaint in myofascial pain syndrome is shortened or contracted tissue in both muscle and fascia. If we test these shortened fibers, we find not only lack of flexibility but also reduced strength. One of the greatest limiting factors among working and playing athletes is lack of flexibility. In addition to decreasing the incidence and/or severity of injury, improved flexibility will expedite significant gains in power development. While flexibility is 1/3 of power, it may be the most important component in the power formula. The greater the range of motion over-which force can be applied, the greater the potential to generate power.6 A good example of dynamic flexibility and power is Tiger Woods, the young professional golfer who has recently taken the sport to a new level. Small in stature, yet long off the tee, this phenom can attribute his unexcelled driving power to his fluidity and exceptionally flexible swing.
Developing and maintaining an adequate level of flexibility is important to every person’s general good health.7 Freedom from repetitive musculoskeletal injuries, and speeded recovery from injuries that do occur, are benefits that come with increased flexibility.8 Interestingly reduced ranges of motion, stiffness and tight muscles are usually the precursor to chronic myofascial pain. Unfortunately pain is what drives the patient to our offices where, upon examination, we often view restricted movement as an effect and not a cause. According to Travell,9 “Relief of the patient’s pain and return of normal function require inactivation of myofascial trigger points, which achieves restoration of full muscle length and strength.” If fact, myofascial pain syndrome is now being considered by some as a movement dysfunction.
Healthy compliant myofascia can be stretched, shortened, twisted or compressed without restriction or pain. It exhibits good circulation, flexibility, strength and endurance.10,14 Because compliant muscles are flexible and can fluidly adapt to mechanical stresses, it follows that compliant muscles are less prone to injury. According to Travel,l,13 “Normal muscle does not contain trigger points, is not tender to ordinary pressure, and does not give a jump sign.” The jump sign is described as a general pain response of the patient, who winces and may cry out and withdraw, in response to pressure applied on a trigger point.3 On the other hand non-compliant tissue is stiff, tender and sore with a feeling of painful knots or tight bands in the muscle. It exhibits poor circulation, reduced flexibility, weakness and easily fatigues. It is not surprising that stiff, non-compliant muscles lack strength and endurance. Muscular endurance is profoundly affected by reduced blood flow and the concomitant reduction in tissue oxygen tension.5,10 Local aerobic metabolism in such hypertonic muscles may be limited due to the lower level of oxygen.11
Segmental Muscle Shortening
It is well known that when muscle shortens it builds up tension and increases internal pressure. In fact when you make a muscle the internal pressure is heightened and the muscle becomes hard. As pressure builds inside the muscle, the capillary beds [endomyseal] that feed the muscle are squeezed closed.11,14 This is particularly true when muscles shorten by prolonged insometic contractions. An example of this would be sitting or standing for hours. Your stabilizing muscles must contract and maintain this contracted state for an extended period in order to hold your body erect. The unhappy experience of sitting or standing for extended periods is usually soreness and stiffness, or even aggravating pain.
Sustained isometric contractions are also present following injury to muscle. When a muscle is damaged it will reflexively contract in an effort to splint itself to prevent any further mechanical damage from occurring. The problem occurs when the spasm-splinting outlives its usefulness. If prolonged, the spasm will reduce nutrient-dense blood flow, thereby limiting true healing. In fact, without an adequate nutrient-rich and oxygen-laden blood flow, a damaged muscle will tend toward scar tissue formation.11 It is, therefore, imperative that rehabilitation protocol include frequent and precise soft tissue techniques in order to insure favorable functional adaptation. Such techniques include therapeutic stretching and deep tissue release to increase flexibility of hypertonic myofascia. Similar stretching and release procedures are used to desensitize and inactivate, myofascial trigger points.
From a therapeutic viewpoint the usual approach to stretching is less than optimal because muscle rarely stiffens uniformly.12 Typically, an isolated and random segment of muscle will become chronically shortened and non-compliant. In order to better understand segmental shortening of muscle, a brief review of the muscles’ segmental anatomy is in order.
Fascia encases muscle fiber groupings and extends past the ends of the muscle tissue to form tendons. Muscle fibers accumulate into bundles or segments. An accumulation of muscle segments or bundles constitutes the muscle. Each segment must have its own blood supply.14 This is so because each of the muscle’s segments is literally walled off from its neighbor by a tough barrier of fascia. This design prevents the spread of infection from one segment to another. However, it also prevents blood from gaining free access from bundle to bundle.
Typically, the whole muscle will stretch only to the degree that the shortened segments will allow. The therapeutic goal is to cause the shortened muscle segments to relax. This localized release of myofascial tension will reduce the biomechanical pressure barrier caused by the shortened segments. The resultant muscle relaxation encourages a copious return of blood and oxygen, which dramatically elevates pain threshold and encourages healthy, compliant tissue.
Implications for Therapy
Hong, et al.15 recently published the most interesting scientific paper that I have been able to find regarding a comparison of the immediate effectiveness of physical medicine modalities on an active myofascial trigger point. Dr Hong is Associate Professor and Clinical Director, Department of Physical Medicine and Rehabilitation, University of California Irvine Medical Center. He and his colleagues studied 84 patients with myofascial pain syndrome and 24 normal subjects. The onset of pain ranged from 3 to 23 months prior to the study. Each candidate upon examination demonstrated an active myofascial trigger point in the upper trapezius muscle. The 4 modalities selected for the study were spray & stretch, hydrocollator superficial heat, ultrasound deep heat, and deep pressure soft tissue massage. The placebo selected was sham ultrasound. The purpose of the study was to determine which physical modality would effectively increase the pain threshold of active myofascial trigger points immediately after treatment. Dr. Hong and colleagues concluded, “Deep pressure massage was more effective than the other modalities in reducing the tenderness of an active myofascial trigger point immediately after therapy.”
Although this study did not document the physiological reasons for the effectiveness of massage, there were some interesting suppositions. The researchers speculated that deep pressure can offer better stretching to the taut bands of muscle fibers than manual stretching. They theorized that more direct pressure to a relatively small area in the muscle may offer ischemic compression to the taut fibers. Norkin & Levangie16 noted difficulty in uniformly stretching muscle because many of the muscles of the body cross more than one joint. Typically, muscle is shortened across one joint and lengthened across another.14 Travell3 addresses the specific needs of muscle segments by what she refers to as stripping massage. She mentions that sufficient repetitions of stripping massage will cause the nodularity of the trigger point to disappear along with the local trigger point tenderness and the referral phenomena. It is important to note that local treatment of myofascial pain syndromes must be primarily directed at trigger points where the pain originates, rather than reference zones where pain is noticed by the patient. Wakim, et.al17 reported that blood flow of the lower extremities increased significantly after applying hand massage to the limbs. Hovind and Nielsen18 confirmed the effects of massage on lymphatic drainage as well as changes in blood flow. Bonci12 reported addressing the specific therapeutic needs of muscle segments with a biomechanical muscle device. He states, “The Intracell muscle device appears to solve the problem of specificity.” Belcher19 examined a convenience sample of 20 subjects with low back pain due to trigger points [as described by Travell and Simons]. 3 The pre/post test design showed highly significant changes [p<0.01] in pressure threshold measures following use of the Intracell muscle device.
The management of myofascial pain syndrome through inactivation of active trigger points is best obtained by deep tissue massage and segmental myofascial release of renegade muscle bundles. Further study is needed to obtain the immediate effects of physical modalities on the pain threshold of latent trigger points or on normal muscle.
1 Singer, D W: Manual Therapy Techniques, Rehab Management, June/July 1994, 153-56
2 Barnes, J F: Mind & Body, The Bio-Energy of Healing, PT & OT Today, November 1996
3 Travell, J G; Simons, D G: Myofascial Pain and Dysfunction: The Trigger Point Manual, Vol 1. Baltimore, Williams & Wilkins, 1983
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6 Brittenham, D: Shiley Sports & Health Center of Scripps Clinic, Shiley Elite Athletic Excellence, LaJolla, CA, 1995
7 Astrand, P; Rodahl, K: Textbook of Work Physiology: Physiological Basis of Exercise, 2nd edition. New York, McGraw-Hill, 1977.
8 Fox, E L; Bowers, RW; Foss, M L: The Physiological Basis of Physical Education and Athletics, 4th edition, edited by I A Dubuque, C W Brown Publishers, 1989.
9 Travell, J G; Simons, D G: Myofascial origins of low back pain, Postgraduate Medicine Low Back Pain, Part 1, Vol 73(2), 1993.
10 Bonci, A S; Belcher, P E: Modulation of muscle pain and tissue compliance with the ROM device: enhancing battlefield survivability, The Journal of Myofascial Therapy, Vol 1, No. 3, October 1994.
11 Bonci, A S: The Physics of Nutrient Delivery, Nutritional Biomechanics, New York, 1995.
12 Bonci, A S: Intracell Technology – A Brief Review; Sport Biomechanics Laboratory, New York 1993.
13 Travell, J G.: Myofascial Trigger Points: Clinical View, Advances in Pain Research and Therapy, Vol I, edited by J J Bonica; D Albe-Fessard; Raven Press, New York, 1976.
14 Bonci, A S: personal communication
15 Hong, Chang-Zern; et al: Immediate effects of various physical medicine modalities on pain threshold of an active myofascial trigger point, Journal of Musculoskeletal Pain, Vol 1(2), The Haworth Press, 1993.
16 Norkin, C C; Levangie, P K: Joint Structure and Function: A Comprehensive Analysis. Philadelphia, FA Davis Co, 1985.
17 Wakims, K G; et al.: The effects of massage on the circulation in normal and paralyzed extremities. Arch Phys Med 1949; 30:135-44.
18 Hovind, H; Nielsen, S L: Effect of massage on blood flow in skeletal muscle. Scand J Rehab Med 1974; 6:74-77.
19 Belcher, P E: The Intracell as an instrument of choice in the management of myofascial back pain, Atlanta, RPI of Atlanta, Inc., 1993.