Hal Blatman, MD
Cincinnati, OH
(513) 956-3200
During the last few years I have followed the postings to online Repetitive Strain
Injury (RSI) discussion lists with considerable interest, and have occasionally offered
some suggestions for myofascial pain sufferers. Scott Wright encouraged me to write this
FAQ to assist in understanding myofascial pain, a syndrome that is still quite a mystery
to many people including physicians, chiropractors, and therapists.
When muscles are overused, fatigued, and strained, trigger points form in the muscle
and its associated fascia. Fascia is the variable thickness connective tissue that holds
muscle fibers together, attaches muscles to bone, and holds bones together. These trigger
points can be felt as small knots within taught and ropy bands of muscle. The trigger
point causes the tightness along the muscle fibers, thereby forming the taught or ropy
band.
Each trigger point generates two pain patterns, whether the person is conscious of it
or not. One pain pattern is localized, causing local soreness and tenderness, while the
other may be local or distant. The distant or referred pain pattern will be interpreted by
the brain as numbness, tingling, burning or aching. All trigger points may generate some
degree of these pain patterns all of the time. Trigger points may also cause the muscle to
cramp.
Trigger points may be classified as active, latent, or satellite.
- An active trigger point is a focus of hyperirritability in the muscle or its fascia that
generates pain. It will usually cause more pain with use of the muscle.
- A latent trigger point is less tender than an active trigger point, commonly producing
pain with applied pressure. It will generally restrict motion, prevent full lengthening of
the muscle and cause weakness without atrophy (atrophy: muscle wasting or smaller in
size). A latent trigger point does not usually generate a noticeable level of pain.
- A satellite trigger point develops within the zone of referred pain from an active
trigger point. When a trigger point is active and refers a strong level of pain to another
area of the body, muscles in this other area develop "satellite" trigger points.
In this fashion a localized pain pattern may spread to other and larger areas of the body.
Repetitive strain injury causes formation of new trigger points and activation of
latent trigger points within the injured muscles. Sustained contraction of muscle to
maintain a position (sustained, posture) will also activate trigger points.
During medical and other therapy training programs, we are taught that repetitive
strain injury causes inflammation of the overused tissues. This can indeed occur. In the
extreme circumstance, there can be physical evidence of an inflammatory
condition—called crepitus. Crepitus is the "creaking" that occurs as
not-so-well-lubricated tendons fail to glide smoothly. It can sometimes be felt in the
swollen and injured tissues. This inflammation can be very serious.
Unfortunately treatment professionals are usually only aware of the "inflammation
model" or theory for the cause and treatment of pain due to repetitive strain. In
addition, the makers of non-steroidal anti-inflammatory drugs (NSAIDs) continue to educate
the public about inflammation in order to promote products like Naprosyn ("just Nupe
it"), and Motrin. Unfortunately, these drugs can be dangerous: there were a reported
100,000 hospitalizations and 15,000 deaths last year in the USA alone, due to side effects
of NSAIDs.
Most of the time, however, the primary pathology resulting from repetitive strain
injury is not inflammation, but rather it is myofascial pain generated primarily from
trigger points in the injured muscles. Later, satellite and latent trigger points also
contribute to the pain pattern.
Therefore, treatment of the myofascial component of the condition will generally result
in greater therapeutic success. The treatment for myofascial pain is to first minimize the
perpetuating factors. These are things which can perpetuate or worsen the pain condition.
The categories that may require change include:
- diet
- nutrition
- ergonomics
- stress reduction
- hormonal balance
- other factors which must be identified
Then the trigger points need to be made smaller. This is done mostly by physical
techniques. These include:
- maintaining pressure on a trigger point (acupressure)
- stretching the involved muscles to a more normal resting length
- use of fluori-methane or other vapo-coolant spray
- massage therapy
- trigger point injections (local anesthetic only and not cortisone)
- dry needling (generally more painful in my experience than trigger point injection)
- myotherapy
- chiropractic adjustment
- other forms of body work
Mental work such as relaxation therapy and biofeedback may also be important.
I hope this information is useful. The most complete source for information is the two
volume medical text by Travell and Simons: Myofascial Pain and Dysfunction, The Trigger
Point Manual, available through your local medical library or bookstore. (It is
available through Amazon.com, $189.00)
About the Author
Hal Blatman is a physician (M.D.), trained in the USA. Dr. Blatman has two years of
formal training in orthopedic surgery and two years of formal training in occupational
medicine and ergonomics. He is board certified in Occupational and Environmental Medicine.
In addition, he passed the American Massage Therapy Association examination and is
familiar with craniosacral therapy, myofascial release and healing touch. Most importantly
Dr. Blatman was trained in myofascial medicine by Dr. Janet Travell. Hal Blatman, MD can
be reached at 10653 Techwoods Circle, Suite 101, Cincinnati, OH 45242.
