Robyn Edge attended the Congress of the World Federation of Training and Therapy in Madrid Spain last fall and came back with some of the latest insights in rehab. One of the systems looked at was fascia and how we tune our therapy to get better results.
The first of our three part series discussed everything and anything fascia! What is it? Why it’s important? What happens when it’s not healthy? What do you feel or experience as symptoms when this is the case? What can we, your therapists, do to help manipulate the fascia to help you move better, feel better, heal and prevent injuries? You won’t need to have read the first article to understand this one, but it may be of interest to you so here’s the link. Part 3 is coming in the next few weeks. Let’s jump out of the technical stuff about fascia and move into the stuff that matters to you: the muscle knots, the symptoms, the aches, the pains. What does it all mean!?
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Again, this can be a bit of a denser article. If you want the quick info, skip forward to the summary sections. If you like the details read on!
A muscle can be described, basically, as many individual fibres grouped together in bundles with many bundles grouped together. Holding all these parts together is, you guessed it, fascia! Fascia encases each fibre then each bundle and finally all of the bundles or the whole muscle. This wrapping ends up making the tendons at either end of the muscle which attach the muscle to the bones. At a microscopic level, individual fibres have moving parts that create the contraction of a muscle. For the contraction to happen the muscle fibers need energy and nutrients as well as the ability to get rid of the byproducts of using that energy and nutrients.
We all know that in order for our bodies to function all parts require adequate supplies of blood. A muscle receives blood supply from an artery; this blood brings in oxygen and nutrients. Veins take away byproducts from the muscles once oxygen and nutrients have been used. Both the arteries and the veins enter/exit the muscle at the same place. Once the artery enters into the muscle, it branches off into smaller and smaller vessels called capillaries. These capillaries provide each fibre of the muscle with what it needs and take away what it’s already used up.
Nerves usually enter at the same place as the blood supply and branch off in a similar way. Each skeletal muscle fibre is supplied by a single nerve ending. As the nerve approaches the muscle fibre, it splits again and becomes the motor end plate. The nerve is what brings the message to cause a muscle contraction. The combination of the nerve ending and muscle fibre is terms a motor unit. This contraction causes movement.
Skeletal muscle, or the muscles that we use to move our body, work on an all or nothing principle. This means groups of muscle fibres within a specific muscle are either on or off. The amount of tension we create in the muscle is dependent on how many fibres of the muscle contract at one time. The heavier and harder the task, the more bundles we will need to recruit. The more practice we have at this harder task, the more efficient and synchronized our body gets at contracting and relaxing the muscle bundles. Under less intense conditions the motor units of one muscle take turns, meaning some are working while others are not so that the task can be accomplished for longer with less effort.
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Muscle gets its commands from the nerve, its supplies from the artery and it gets rid of it’s garbage via the veins. All this is to allow us to contract and relax a muscle which allows us to move. The more we train, the more synchronized the contraction and relaxation of the muscle is, the more efficient we become at our task at hand.
In our previous article, we touched on the nitty gritty details surrounding fascia. Fascia involved with the muscles is called myofascia. When it gets injured or strained, it can become shorted, condensed and tight. Pesky nodules of tension manifest as a result; you can sometimes feel them. These are called trigger points.
We’ve all heard of them. We’ve all felt them. We’ve all commented, “Pretty sure that trigger point is giving me a headache”. Other times we say to ourselves, “my elbow is painful but I can’t reproduce that pain when I push on where I’m feeling the pain.” But what does that actually mean? What is a trigger point? It is a localized spot of tenderness in a palpable nodule located in a taut band of muscle. Sometimes these tight bands cause a specific pain pattern when stimulated. This is called referred pain.
These hypersensitive localized spots vary in size depending on the size, shape and type of muscle they belong to. Their consistent quality is tenderness with applied pressure. Pain/symptoms may be due to the active trigger point or it may build up over time from latent or inactive trigger points:
Active Trigger Point
- What happens in the tissues?
- High levels of substance P (triggers inflammation)
- Increase bradykinin (inflammatory mediator)
- Increased norepinephrine (neurotransmitter that stimulates the body like the ‘fight or flight’ response)
- Increased interleukin-1 (inflammatory response regulator)
- Moderate levels of hypoxia (oxygen deficiency)
- Lower pH (tissue gets more acidic)
- What do we feel?
- PAINFUL AT REST
- Increased irritability when host muscle is used
- Lower pain threshold (more pain with less effort)
Latent Trigger Point
- What happens in the tissues?
- Moderately increased substance P
- Moderately increased bradykinin
- Moderately increased Norepinephrine
- Moderately increased interleukin-1
- What do we feel?
- PAINFUL WHEN PRESSURE IS APPLIED
There are several factors influencing trigger point development. Some of these include: age, genetics, posture, demands placed on the musculoskeletal system, weight gain or loss and how we developed as kids.
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Trigger points are sensitive nodules in muscles that have a bit of a different environment compared to the rest of the muscle.
In 1957, Dr. Travell found that trigger points generate and receive small electric currents. We know in order for our bodies to move, electric signals go along the nerve pathways to the motor end plates (where the nerve meets the muscle fibre). In a relaxed non-contracted state, the electrical signal of a muscle is nil. With a trigger point, a small part of the muscle stays in a contracted state and we see a small localized spike in electrical activity. Meaning, the muscle is always on at that location.
HOW DO TRIGGER POINTS ACTUALLY FORM?
The exact cause is still unknown as to why trigger points form. We know changes occur within muscles that house trigger points. There are a few theories about why they occur and each addresses these notable changes. Trigger points manifest where muscle fibre and motor end plates become overactive.
It helps to understand how a muscle contracts in the first place. When the brain wants a muscle to move, it sends a message along the nerves that goes to the muscle fibres. Once that message gets to the end of the nerve, acetylcholine (ACh) is released. ACh triggers muscle activity, which takes energy. Energy is supplied by the blood and is stored in the mitochondria of the muscle fibre. Calcium ions released by another structure of the muscle fibre (sarcoplasmic reticulum) cause the muscle fiber to shorten.
Each of the theories with regards to trigger points involve a different part of this process. Which theory is correct? We aren’t sure but the changes seen in the muscle housing trigger points are consistently noted by researchers as follows:
- Increased ACh production – too much communication between the nerve and muscle
- Excess calcium release – too much binding of the muscle
- Hypertension – low level sustained contracted state of the muscle fibre
- Localized neurological hyper-stimulation – excessive ACh release and increased electrical activity in environment.
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The amount of communication from the nerve and the constant contracted state of the muscle fibre contribute to why trigger points develop. There are many theories why trigger points develop but these factors are consistent findings.
TRIGGER POINT CLASSIFICATION
Trigger points develop in predictable locations and can be classified based off of their location within a muscle.
- Most commonly known and referred to
- Location: centre of the muscle belly
- Muscle type and direction is important for treatment
- Created in response to central point in neighbouring muscles within the referred pain zone
- Location: within the referral pain zone
- Primary point is key to therapeutic intervention; resolves when primary resolves
- Result of existing forces travelling across the region; can be secondary to primary
- Location: where tendon inserts into bone
- Suggested that if a chronic situation occurs where the primary and attachment trigger point remains untreated, degenerative changes within the joint may be precipitated and accelerated
- Multiple satellite trigger points exist secondary to multiple central trigger points
- Location: along lines of altered stress and strain patterns
- Severe postural deformity such as scoliosis
- Secondary to a primary point, not painful and do not elicit a referral pain pattern
- Location: not central
- May lead to increased muscular stiffness; more common in those who live a sedentary lifestyle; points my reactivate if the primary point is stimulated following injury/trauma
- Variety of stimulus can active an inactive point
- Location: Primary or Satellite
- Trigger point is both tender to touch and elicits a referral pain pattern
WHAT DOES THIS MEAN FOR YOU?
Painful trigger points restrict your ability to function for a few reasons:
- Activating the muscle that houses the trigger point is painful.
- Activation is weaker than usual because the muscle is already fatigued before you ask it to work.
- How the muscles work together changes. Muscles often work in opposing pairs, ie. our quad straighten our knee whereas our hamstrings bend our knee. If a trigger point in the quad muscle is always on, this will interfere with your hamstrings ability to bend your knee.
- Under or over-activation limit your ability to be strong and do your desired task.
REFERRED PAIN PATTERNS
Referred pain patterns can produce pain in more than one place. Pain can be felt locally at the trigger point and/or in locations further away from the muscle and trigger point. As an example, trigger points that create pain in the upper traps can send pain up the back of the neck and head to the forehead above the eyebrow.
This is why we tend to ask questions about where and what your pain is doing.
Understanding what increases the pain and where you feel the pain sensation is helpful to your therapists. Referral pain tends to be broad, diffuse, nauseating pain that is not painful to the touch in the area. Asking the muscle to contract or stretch can increase the intensity of this pain, ie. shrugging the shoulders or stretching the head to the shoulder makes that forehead pain stronger.
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Pain can be felt locally at the trigger points nodules or at a distant, but predictable location when a trigger point is activated.
Here are a few examples of more seen referral pain patterns:
FASCIAL LINES INTERRUPTED
Unlike our muscles which have a start and end point, fascia is continuous. Yet, we can separate it into sections based off of the direction and function the fascia has in our bodies. We won’t go into the details about these lines, but we’ll highlight a few examples for your understanding:
Different treatment techniques and movement practices influence the fascia along these lines. Part 3 of this article series (coming soon) will discuss some techniques and movement strategies.
If these lines, or chains, are healthy, every tissue within that chain moves well. What happens when we interrupt or interfere with that continuous connective tissue? Surgeries, incisions, scrapes, cuts, or tears all interfere with the structure and function of the fascia.
When the fascia gets damaged it heals with a scar. Like what we see on our skin, like a new scab, this tissue is tight, tough and stuck together. This is all a part of the natural healing process that occurs. This is a good thing! We are binding back together. Scar tissue is the building blocks of these tissues and has to be there in order for us to heal.
Scar tissue becomes a problem if the body doesn’t remodel it to be like the rest of the tissue. Movement gets interrupted when tissues don’t match. For example, if the tissue direction is up and down but a scrape or incision is in the opposite direction to that, how well will that tissue move? What does this mean for you? Less mobile, and less extensible. Picture a piece of lumber with the grain in it all moving in a one direction, with a wood knot right in the middle of that wood grain.
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We move well when there are less friction or interruption points in our body. We move well when all of the fibres are aligned, are adaptable and are working with each other instead of against each other.
The good news is, like trigger points, we can work through and improve these binds in the fascial lines. In Part 3 we will show you options to healing and optimal function of these systems. We will also discuss what techniques, practices and strategies best influence the fascial system. That way you can make sure you’re getting the most out of your workouts and movement practice.
Gimberteau, Jean-Claude. (2017) Endoscopic exploration of human living matter. What are mobility, suppleness, and flexiblity and how to improve them? World Federation of Athletic Therapy and Training. Madrid, Spain.
Goodman, C.C., Fuller, K., & Boissonnault, W. (2003) Pathology Implications for the Physical Therapist, 2nd Edition.
Myers, Thomas W. (2014) Anatomy Trains, 3rd Edition.
Niel-Asher, Simeon. (2008) The Concise Book of Trigger Points, 2nd Edition
Sue Falsone. (2017) How important is myofascial in sport? World Federation of Athletic Therapy and Training. Madrid, Spain.
Robyn Edge is the therapist leading the charge of Movement Lab. She has an extensive background in her own athletic pursuits, and injuries, as well as an extensive background in functional rehab, functional training and injury prevention. Employing modalities such as acupuncture, myofascial cupping, and active release, she manages pain and promotes healing in addition to her active style of practice.