On a daily basis patients ask questions about trigger points: what exactly are they? How are they treated? What can I do to prevent them? The following article was written by Dr. Rich Berkowitz and published in our Fall '09 newsletter.
Life demands physical exertion. In response to this exertion, muscles are fatigued and become "tight". If prolonged, this tightness (called hypertonicity) can result in the formation of trigger points in the muscle. Trigger points are areas in muscles that are painful and tender when pressed upon. Trigger points can interfere with normal muscle function, restrict normal range of motion, and weaken the muscle. Trigger points can also refer pain to other areas; for example, a trigger point in your shoulder muscles can create a pain in your neck. These trigger points presenting themselves as pain may be associated with long term difficulties, deconditioning, and injury.
Both direct and indirect stimuli can result in the formation of trigger points. Direct stimuli include acute overload, overwork fatigue, gross trauma, or chilling. Indirect stimuli, such as other trigger points, visceral pain, arthritic joints, and emotional stress, can created these painful areas as well.
We regularly come in contact with these stimuli during our daily activities. Getting bumped from behind while driving and receiving a whiplash-type injury is an example of acute overload. The muscles in your neck are forced to contract quickly to prevent your head from traveling forward and backward. The sudden, forceful contraction of these muscles leads to the creation of tender areas, or trigger points.
Overwork fatigue can be the result of repetitive or sustained contraction, as one may find with poor posture. If this posture is assumed day in and day out, this may lead to hypertonicity of the muscles. Many occupations tend to create the postures (commonly seen in hairdressers and auto mechanics) due to the constant raising of the arms and bending at the trunk.
Trigger point therapy done by a licensed chiropractor can help relieve the pain and spasm. Using hand, finers, elbow, or a small instrument, the muscle is compressed with sustained pressure to relax it. In addition, proper instruction on body mechanics, gentle stretching, and adjustments of the spine and other joints can help to prevent trigger points from occuring. When used in conjunction with chiropratic treatments, trigger point therapy is a highly effective way to reduce muscle spasm, restore nomral range of motion, promote faster healing, and reduce pain and discomfort.
Thursday, May 13, 2010
Thursday, May 6, 2010
Wet & Wild Sunday
The weather, that is.
On Sunday, April 25, seven of us from CHCC completed the More/Fitness Magazine Women's Half-Marathon in Central Park. Two years ago Dee, Tina Haig (Bryan's wife) and I walked in this race, kind of on a whim, and had a great time. So this year we recruited several more of our colleagues to join the fun: Kari and Elaina (whom you'll see manning our front desk in Lawrenceville); Liz, who may have set you up with heat and electric stim; and Val, our part-time PT who was Bryan's fill-in on Monday evenings. We walked every Sunday morning in Tyler Park in Newtown, the one place we could find with some formidable hills not unlike Central Park.
We were ready, mentally and physically. The only thing out of our control was the weather - and was it ever out of control. Saturday evening before the race, we gathered at Dee's house for excess carbs and a pep talk. We could no longer deny what each of us had been fretting about all week - the rain. All reports indicated a Nor'easter would be squatting right over top of Central Park from 8am to 11am - precisely race time. We quickly rethought our plans for footwear, gear, and travel, then parted to try and get a good night's sleep.
I awoke at 4:30am Sunday morning to a slight drizzle, which, as the morning progressed, became a solid downpour. Dee's husband Larry was kind enough to drive us through a mess of wind and rain on the NJ Turnpike and deliver us almost to the start point of the race; yet even that short walk to the start point was enough to drench us. Still, our spirits were high; I remember thinking, this isn't so bad.
The rain was relentless, then joined by a cold wind about 90 minutes into the race. We did our best to stay together throughout, since this one was more about camaraderie and fun than personal records, but keeping track of your friends amongst thousands of women - all looking the same as you, sopping wet in hoods and baseball caps - was nearly impossible. By mile 8 I was alone, soaked to my skin, cold, and in a battle with a thought that kept pushing itself to the foreground of my mind: this just sucks.
While we spent most of the time walking, there came a point where breaking into a run was actually a relief. So run I did, splashing through the rivulets running down the side of the path, fighting the blasts of cold wind, scanning the crowd for a familiar hood. Aside from the additional weight of my saturated shoes, running felt right.
Two miles later I heard a voice: "JILL!" It was Tina, and she, too was alone. So she caught up to me and we finished the last 1.1 miles together. As we rounded the last bend, I saw Bryan under a dripping umbrella, his jeans soaked up to his knees, running along the side with us. (He spent the morning criss-crossing the park in that mess, looking for at least one of us, never able to discern a familiar face in the crowd of women). It was nice to cross the finish line with a companion.
So we finished, all of us: soaked, frigid, plastered with wet leaves, starving, tired, but triumphant. Later, as the bedraggled lot of us sat in a warm restaurant on the Upper East Side eating omlettes and giant hamburgers, I momentarily thought of asking cheerily, so who's ready to do this next year?!? I reconsidered, deciding that the warm slices of raisin bread I would probably be pelted with were too valuable at that moment to be wasted.
Almost two weeks later, all our aches and pains have dissipated and we're none the worse for wear. I think it's safe to bring up the subject of next year to my compadres. My answer: sign me up!
On Sunday, April 25, seven of us from CHCC completed the More/Fitness Magazine Women's Half-Marathon in Central Park. Two years ago Dee, Tina Haig (Bryan's wife) and I walked in this race, kind of on a whim, and had a great time. So this year we recruited several more of our colleagues to join the fun: Kari and Elaina (whom you'll see manning our front desk in Lawrenceville); Liz, who may have set you up with heat and electric stim; and Val, our part-time PT who was Bryan's fill-in on Monday evenings. We walked every Sunday morning in Tyler Park in Newtown, the one place we could find with some formidable hills not unlike Central Park.
We were ready, mentally and physically. The only thing out of our control was the weather - and was it ever out of control. Saturday evening before the race, we gathered at Dee's house for excess carbs and a pep talk. We could no longer deny what each of us had been fretting about all week - the rain. All reports indicated a Nor'easter would be squatting right over top of Central Park from 8am to 11am - precisely race time. We quickly rethought our plans for footwear, gear, and travel, then parted to try and get a good night's sleep.
I awoke at 4:30am Sunday morning to a slight drizzle, which, as the morning progressed, became a solid downpour. Dee's husband Larry was kind enough to drive us through a mess of wind and rain on the NJ Turnpike and deliver us almost to the start point of the race; yet even that short walk to the start point was enough to drench us. Still, our spirits were high; I remember thinking, this isn't so bad.
The rain was relentless, then joined by a cold wind about 90 minutes into the race. We did our best to stay together throughout, since this one was more about camaraderie and fun than personal records, but keeping track of your friends amongst thousands of women - all looking the same as you, sopping wet in hoods and baseball caps - was nearly impossible. By mile 8 I was alone, soaked to my skin, cold, and in a battle with a thought that kept pushing itself to the foreground of my mind: this just sucks.
While we spent most of the time walking, there came a point where breaking into a run was actually a relief. So run I did, splashing through the rivulets running down the side of the path, fighting the blasts of cold wind, scanning the crowd for a familiar hood. Aside from the additional weight of my saturated shoes, running felt right.
Two miles later I heard a voice: "JILL!" It was Tina, and she, too was alone. So she caught up to me and we finished the last 1.1 miles together. As we rounded the last bend, I saw Bryan under a dripping umbrella, his jeans soaked up to his knees, running along the side with us. (He spent the morning criss-crossing the park in that mess, looking for at least one of us, never able to discern a familiar face in the crowd of women). It was nice to cross the finish line with a companion.
So we finished, all of us: soaked, frigid, plastered with wet leaves, starving, tired, but triumphant. Later, as the bedraggled lot of us sat in a warm restaurant on the Upper East Side eating omlettes and giant hamburgers, I momentarily thought of asking cheerily, so who's ready to do this next year?!? I reconsidered, deciding that the warm slices of raisin bread I would probably be pelted with were too valuable at that moment to be wasted.
Almost two weeks later, all our aches and pains have dissipated and we're none the worse for wear. I think it's safe to bring up the subject of next year to my compadres. My answer: sign me up!
Monday, April 5, 2010
Testing My Limits - Part IV
What at first sounded like bad news has turned out to be good news after all.
I did my re-screen with Dr. Clancey and Bryan...well, part of it. I completed the first few test exercises , but then everything came to a halt when I got to the deep squat test. I don't want to believe I was completely delusional when last week I was so sure my squat was getting better, but apparently I was. My squat looks exactly the same, even with all the calf stretches and exercises (and positive thinking) I've been doing for the past four weeks. Totally disappointing.
Originally the theory was that my soleus muscle - the deeper calf muscle that attaches to the Achilles tendon - was super tight. But as they put me through a few more tests for that muscle, I said, you know, I don't really feel an actual stretch in my calf - it actually feels more like something is just blocking the movement. (Right after my first screen I posted that I really couldn't feel anything or tell in any way that my soleus was tight, but I went with it). I could see Dr. Clancey's wheels turning.
They had me lie facedown on the treatment table in the PT room, and they started flexing and bending my feet. No sensation whatsoever in the calf; yet, I had almost zero dorsiflexion (bending the foot up toward the shin) in either foot. Bryan, at one point, grabbed my feet and starting trying to move the bones that are situated where the foot meets the leg - particularly the talus http://www.podiatrychannel.com/pod/Images/ftbns_sdvw.gif).
I did my re-screen with Dr. Clancey and Bryan...well, part of it. I completed the first few test exercises , but then everything came to a halt when I got to the deep squat test. I don't want to believe I was completely delusional when last week I was so sure my squat was getting better, but apparently I was. My squat looks exactly the same, even with all the calf stretches and exercises (and positive thinking) I've been doing for the past four weeks. Totally disappointing.
Originally the theory was that my soleus muscle - the deeper calf muscle that attaches to the Achilles tendon - was super tight. But as they put me through a few more tests for that muscle, I said, you know, I don't really feel an actual stretch in my calf - it actually feels more like something is just blocking the movement. (Right after my first screen I posted that I really couldn't feel anything or tell in any way that my soleus was tight, but I went with it). I could see Dr. Clancey's wheels turning.
They had me lie facedown on the treatment table in the PT room, and they started flexing and bending my feet. No sensation whatsoever in the calf; yet, I had almost zero dorsiflexion (bending the foot up toward the shin) in either foot. Bryan, at one point, grabbed my feet and starting trying to move the bones that are situated where the foot meets the leg - particularly the talus http://www.podiatrychannel.com/pod/Images/ftbns_sdvw.gif).
The way Bryan explained it, when the lower leg comes forward over the foot (that's dorsiflexion), the talus is supposed to rotate out of the way to allow forward motion of the tibia (that's the shin bone). It's likely that my talus - on both feet - is locked up and won't rotate. It could have begun back in high school, when I played lots of basketball and ran hurdles on the track team. The impact on my heels, particularly during the hurdling, could have, over time, pressed up into my talus and caused subtle changes in the soft tissue surrounding it. Adhesions and scar tissue could very well limit the mobility of the talus. And after all those years, I'm left with almost no dorsiflexion. And I never knew.
For good measure, Dr. Clancey decided to treat both my calves using a technique called Active Release. Active Release is a sort of movement-based soft tissue treatment designed to help "release" muscles, tendons, ligaments, and even nerves that can become bound by dense scar tissueor adhesions. It involves shortening the tissue, applying pressure, then lengthening the tissue while under pressure. So while Dr. Clancey pressed (ow), Dee slowly flexed my foot to its end range of motion (double ow). Mercifully, it lasts only a few minutes.
Finally, Bryan did a joint mobilization exercise with me to see if he could get the talus to rotate. I stood on the treament table and lunged forward while he applied pressure on the talus. At the same time he pulled me further into the lunge using a wide strap looped around his waist at one end and my calf at the other. (This hurt almost as much as the ART...). He was able to get a bit more motion out of the joint.
The conclusion: it could still be lack of mobility in my soleus, but it's looking likely that it's actually my locked-up talus bones. There are some treatment options, which involve trying to break up the scar tissue and some additional manual joint mobilization by Bryan. The other option is to just compensate for it by raising my heels during my squats, either by putting something under my heels or purchasing power lifting shoes, which come with a raised heel built in. The shoes are ugly and expensive, but might be necessary for some of the Olympic lifts Crossfit promotes, where you have to sort of "drive" your body under the bar and both feet leave the ground a fraction of an inch for a fraction of a second. Not sure I want to be thinking about where to place my heels when there are so many other positional subtleties in those lifts to focus on.
Over the weekend - which happened to involve two squat-centric workouts - I placed my heels on weight plates to do the squats. It gave me about an inch of lift, and my squats felt great and looked almost perfect. I was quite pleased (okay, I was thrilled...). This doesn't mean, though, that I can stop stretching my soleuses (soleii?).
There is a point to all this: while TPI didn't directly solve my my squat issue, it certainly opened the door for my favorite top-notch professionals (blatant shout-out to Dr. Clancey and Bryan) to figure it out. Now I know how to proceed from here. And that is freedom, my friends.
But I still have that thoracic mobility issue to contend with...stay tuned.
JillThursday, March 25, 2010
Testing My Limits - Part III
Two weeks in, and I swear I'm seeing a difference in my squat.
I'll be honest, though: at first I was annoyed by this whole thing. The first night I did the exercises, it took me 40 minutes. I thought, come on. Then I looked at the workout schedule they post for you on myTPI.com...six days a week! I grumbled about this to Bryan the next day but he refused to indulge me in any kind of human sympathy.
After a few days of pouting and muttering around in my mind about it, I did a little cost/benefit analysis. Is the potential result worth the extra time (and, to be fair, my subsequent workouts took much less time once I learned the exercises and didn't have to watch a video for each one)? The answer was a resounding YES: not only will being able to perform a proper squat propel me forward in my workouts, addressing all my other mobility (or lack thereof) issues could potentially stave off injuries and boost my fitness gains and my performance even further.
That was all it took.
Now...just today, two weeks in, I was able to do 10 pretty decent-looking squats, holding a lacrosse stick over my head. I noticed two significant changes: 1) I felt much more balanced at the bottom of the squat, which tells me my soleus (lower calf) muscles are starting to loosen up, and 2) there was much less strain in my lower thoracic area, which indicates my torso mobility is improving also.
This is working. When I think about what it could do for my golf game, it makes me want to actually take up golf...
Now I'll celebrate with a spoonful of Nutella!
I'll be honest, though: at first I was annoyed by this whole thing. The first night I did the exercises, it took me 40 minutes. I thought, come on. Then I looked at the workout schedule they post for you on myTPI.com...six days a week! I grumbled about this to Bryan the next day but he refused to indulge me in any kind of human sympathy.
After a few days of pouting and muttering around in my mind about it, I did a little cost/benefit analysis. Is the potential result worth the extra time (and, to be fair, my subsequent workouts took much less time once I learned the exercises and didn't have to watch a video for each one)? The answer was a resounding YES: not only will being able to perform a proper squat propel me forward in my workouts, addressing all my other mobility (or lack thereof) issues could potentially stave off injuries and boost my fitness gains and my performance even further.
That was all it took.
Now...just today, two weeks in, I was able to do 10 pretty decent-looking squats, holding a lacrosse stick over my head. I noticed two significant changes: 1) I felt much more balanced at the bottom of the squat, which tells me my soleus (lower calf) muscles are starting to loosen up, and 2) there was much less strain in my lower thoracic area, which indicates my torso mobility is improving also.
This is working. When I think about what it could do for my golf game, it makes me want to actually take up golf...
Now I'll celebrate with a spoonful of Nutella!
Wednesday, March 24, 2010
The Great Debate: Ice Vs. Heat
Following injury, many people choose to apply heat because heat feels good and they can use the heat for hours without any pain. But is heat the best treatment for injury? The answer is: Not exactly.
When ice is applied, the body experiences four stages of cold therapy. First, your body feels cold, followed by burning, then achiness, and finally numbness. Cold therapy, also known as cryotherapy, works on the principle of heat exchange: When you place a cooler object in direct contact with an object of warmer temperature - such as ice against skin - the cooler object will absorb the heat of the warmer object.
Why is heat exchange important in cryotherapy? Following an injury, the body responds with vasodilation (an expanding of blood vessels) and a rushing of blood to the area for protection. The injured area becomes swollen and inflamed and will remain this way until treated. This period is known as the acute inflammatory phase and can last one hour, one day, one week, or six weeks depending on what action has been taken to reduce or eliminate the blood that has pooled in the area.
During the acute inflammatory phase of recovery, examination findings include varying levels of pain, swelling, heat, and redness. The goal during this phase is to decrease these four symptoms as much as possible. Cryotherapy is the initial therapy of choice to decrease blood flow and control the resulting inflammation. Following an injury, applying the "RICE" principle is the best treatment: Rest, Ice, Compression, and Elevation.
We also need to be aware, however, that cryotherapy can potentially be counterproductive to the recovery process if not used properly. Keep ice on the injured area for no longer than 20 minutes, then wait at least 40 minutes before applying ice again. After 20 minutes, ice becomes much less effective and you risk damaging soft tissue; beyonhd 30 minutes, ice has the same physiological effect as heat and draws blood back into the area.
To recap, ice: 1) decreases blood flow and inflammation; 2) blocks pain by numbing; 3) should be used immediately after injury; and 4) should be used after activity which utilizes the injured area.
In contrast, heat: 1) increases blood flow and promoted healing; 2) decreases stiffness and increases elasticity of tissue; 3) relaxes muscles; and 4) can be used before activity for tight muscles.
Failure to timely prescribe the proper therapy can result in delayed recovery. When injuries are treated quickly and properly, the result is less time away from work, sports, and everyday activities.
--Bryan Haig, MSPT
When ice is applied, the body experiences four stages of cold therapy. First, your body feels cold, followed by burning, then achiness, and finally numbness. Cold therapy, also known as cryotherapy, works on the principle of heat exchange: When you place a cooler object in direct contact with an object of warmer temperature - such as ice against skin - the cooler object will absorb the heat of the warmer object.
Why is heat exchange important in cryotherapy? Following an injury, the body responds with vasodilation (an expanding of blood vessels) and a rushing of blood to the area for protection. The injured area becomes swollen and inflamed and will remain this way until treated. This period is known as the acute inflammatory phase and can last one hour, one day, one week, or six weeks depending on what action has been taken to reduce or eliminate the blood that has pooled in the area.
During the acute inflammatory phase of recovery, examination findings include varying levels of pain, swelling, heat, and redness. The goal during this phase is to decrease these four symptoms as much as possible. Cryotherapy is the initial therapy of choice to decrease blood flow and control the resulting inflammation. Following an injury, applying the "RICE" principle is the best treatment: Rest, Ice, Compression, and Elevation.
We also need to be aware, however, that cryotherapy can potentially be counterproductive to the recovery process if not used properly. Keep ice on the injured area for no longer than 20 minutes, then wait at least 40 minutes before applying ice again. After 20 minutes, ice becomes much less effective and you risk damaging soft tissue; beyonhd 30 minutes, ice has the same physiological effect as heat and draws blood back into the area.
To recap, ice: 1) decreases blood flow and inflammation; 2) blocks pain by numbing; 3) should be used immediately after injury; and 4) should be used after activity which utilizes the injured area.
In contrast, heat: 1) increases blood flow and promoted healing; 2) decreases stiffness and increases elasticity of tissue; 3) relaxes muscles; and 4) can be used before activity for tight muscles.
Failure to timely prescribe the proper therapy can result in delayed recovery. When injuries are treated quickly and properly, the result is less time away from work, sports, and everyday activities.
--Bryan Haig, MSPT
Tuesday, March 9, 2010
Testing My Limits Part II
Finally, some answers: I finally did my TPI screen with Bryan Haig, our PT. To say it was a humbling experience is putting it mildly. He led me through a series of physical tests, such as standing on one leg, rotating my torso, and doing a squat, all the while studying me, circling me, saying "Hmm...", and typing on the computer. Unsettling.
Then Bryan gave me the results: 3 pages explaining everything from how many degrees of internal rotation I have in my right hip to how well I stabilize my upper body. The descriptions were written to be golf-specific (e.g., "You have limited mobility rotating your thoracic spine...this may limit your ability to maintain a good stable posture during your backswing...). Still, my patterns were clear: limited thoracic mobility, limited strength and mobility in both shoulder blades, some limited lower body flexibility (primarily hip flexors and quads), and, of great interest to me, limited calf flexibility. The sentence read: It is tough for you to perform a full deep squat while keeping your heels on the ground due to limited calf flexibility bilaterally.
I knew this, I guess. Lots of running, especially the last two years, sporadic stretching (I know...), and even though it wasn't something I could necessarily feel or detect when I was in the squat, it makes sense.
The next stack of pages Bryan handed me was my exercise routine, which consisted of 17 exercises. What?! My first thought: yeah, and I'm going to fit this in on top of my regular workouts when, exactly? My second: if you want to do better, then you will fit it in, missy.
So off we go. My "re-screen" is in 4 weeks. Wish me luck.
Jill
Then Bryan gave me the results: 3 pages explaining everything from how many degrees of internal rotation I have in my right hip to how well I stabilize my upper body. The descriptions were written to be golf-specific (e.g., "You have limited mobility rotating your thoracic spine...this may limit your ability to maintain a good stable posture during your backswing...). Still, my patterns were clear: limited thoracic mobility, limited strength and mobility in both shoulder blades, some limited lower body flexibility (primarily hip flexors and quads), and, of great interest to me, limited calf flexibility. The sentence read: It is tough for you to perform a full deep squat while keeping your heels on the ground due to limited calf flexibility bilaterally.
I knew this, I guess. Lots of running, especially the last two years, sporadic stretching (I know...), and even though it wasn't something I could necessarily feel or detect when I was in the squat, it makes sense.
The next stack of pages Bryan handed me was my exercise routine, which consisted of 17 exercises. What?! My first thought: yeah, and I'm going to fit this in on top of my regular workouts when, exactly? My second: if you want to do better, then you will fit it in, missy.
So off we go. My "re-screen" is in 4 weeks. Wish me luck.
Jill
Tuesday, March 2, 2010
Testing My Limits
I want to know why I can't do a squat.
Seriously. My body should be able to do it: I'm pretty fit, relatively strong, acceptably flexible, have played sports since I was 9 and exercised regularly since I was 15. My mind knows how to do it: I've been certified as a personal trainer for 12 years, trained and instructed in a gym for eight. I should be able to do a proper squat. And it bugs me immensely that I can't.
Soon, though, I'll know why. Dr. Clancey and Dr. Berkowitz, fresh from a second-level certification at the Titleist Performance Institute, are going to be screening our entire staff for muscular limitations and imbalances. Through this screening process, TPI helps physicians, therapists, and trainers to identify functional imbalances in the body, then provides "rehabilitative" exercises to correct these imbalances. TPI was developed with golfers in mind, but, as Dr. Clancey explained, its value reaches far beyond the country club. I'd be willing to wager that most of us have some kind of muscular imbalance that's either diminshing our performance or contributing to our injuries. In my mind, knowing my limitations is the first step to getting me into a beautifully executed, biomechanically perfect squat.
Clearly I'm a bit obsessed with the squat,and here's why: I've recently found an incredible workout regimen called Crossfit (http://www.crossfit.com/), and the squat is one of its fundamental movements. The squat fires a myriad of muscles in the body, it's practical, it's challenging, it builds leg strength and endurance, and it's a movement the body understands. It's also key to many of the Olympic lifts Crossfit uses in its workouts. I feel I can't progress until I master the squat; ergo, my obsession.
It's freeing, in a way, to know your limits.
*Jill Settembrino, Director of Ops. (and aspiring Crossfitter), Lawrencville office
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