By Dr. G. John Mullen, PT, DPT, CSCS of Swimming Science, Owner of COR PT , Creator of Swimmer’s Shoulder System, Swimming Science Research Review, Swimming Troubleshooting System , and Mobility for Swimmers System , Swimming World correspondent
SANTA CLARA, California, February 5. MANY swimmers report of shoulder, lower back, knee or some other orthopedic pain throughout their swimming career. I know this because I treat numerous swimmers every day! Pain is a highly complex subject with various causes, but there are simple tricks coaches and swimmers can do to improve their pain immediately.
The most pertinent self-treatment for swimmers and coaches is self-myofascial releases (SMR). SMR won’t cure every ache and pain or prevent every injury, but it is a simple tool for everyone seeking training continuance. Before I proceed, I must say if someone is having pain, a thorough evaluation is needed by a trained rehabilitation specialist, as simply resolving pain is not enough! Removing pain, then correcting the faulty movement pattern is the individualized key for pain resolution and re-injury prevention, both necessities for any experiencing pain.
With that out of the way, let’s talk about fascia and myofascia!
The sensations of pain that are caused by localized tightness in the fascia are generally referred to as “myofascial pain syndrome”, with specific localized tightness referred to as a myofascial trigger point. Myofascial trigger points are often described as “tender spots in discrete, taut bands of hardened muscle that produce local and referred pain” (Bron 2012). There is some confusion about the terminology, as it is not immediately clear whether fascia, muscle tissue or the combined unit (just as we often refer to muscle-tendon units, for example) is being described.
Dr. Janet Travell extensively studied referral patterns and trigger points and described them as a “hyperirritable locus within a taut band of skeletal muscle, located in the muscular tissue and/or its associated fascia. The spot is painful on compression and can evoke characteristic referred pain and autonomic phenomena.”
Since Travell spoke of trigger points in 1983, these hyperirritable loci are now classified further into active and latent trigger points. Active trigger points which are commonly caused by an increase in muscle tension, causing feelings of tightness, soreness, or pain (Travell 1983). Latent trigger points are also taut skeletal muscular bands, but are not painful.
Consider these two examples:
Active Trigger Points are trigger points that are currently referring their characteristic pain response. For example, you have some pain in the anterior shoulder, and when I push on your infraspinatus (a rotator cuff muscle in the back of your shoulder) you feel the anterior shoulder pain. That means you have an active trigger point. Typically after pressing on this point for some time the pain will also go away.
Latent Trigger Points are the trigger points that only produce pain when they are provoked. Using the above example, you would not be experiencing any anterior shoulder irritation, however, if I started to massage your infraspinatus, you end up feeling a referral pain in your anterior shoulder, which dissipates after treatment.
Active trigger points clearly can cause havoc as pain can inhibit strength and function. Yet, latent trigger points can also be problematic, as they are being suggested to cause the same inhibitions as active trigger points (Ge 2012)!
What Causes Myofascial Trigger Points?
The exact cause of trigger points is highly complex. A commonly-held hypothesis about myofascial trigger points is that they are caused when acetylocholine is released, localized sarcomere shortening occurs causing shortened muscle fibers (Hong 1998). However, the literature is very limited.
Others feel trigger points can develop from a slew of reasons (From Clinical Applications of Neuromuscular Techniques by Leon Chaitow and Judith Walker-Delaney (Vol 2, pg. 20)). Some of the primary activating factors include:
— Persistent muscular contraction, strain or overuse (emotional or physical cause)
— Trauma (local inflammatory reaction)
— Adverse environmental conditions (cold, heat, damp, draughts, etc.)
— Prolonged immobility
— Febrile illness
— Systemic biochemical imbalance (e.g. hormonal, nutritional)
Secondary activating factors include:
— Compensating synergist and antagonist muscles to those housing triggers may also develop triggers
— Satellite triggers evolve in referral zone (from key triggers or visceral disease referral, e.g., myocardial infarct)
— Allergies (food and other)
— Nutritional deficiency (especially C, B-complex and iron)
— Hormonal imbalance (thyroid, in particular)
— Low oxygenation of tissues
Additionally, recent research is connecting the existence of myofascial trigger points and musculoskeletal disorders. For example, Roach (2012) found individuals with patellofemoral pain syndrome had a higher prevalence of myofascial trigger points in the gluteus medius and quadratus lumborum muscles on both sides.
However, some researchers have been very skeptical about the presence and clinical care of myofascial trigger points, especially the capabilities of proper diagnosis. A recent systematic review by Myburgh (2008) concluded that only local tenderness of the trapezius and pain referral of the gluteus medius and quadratus lumborum were reproducible intra- and inter-examiner. Such research suggests that at very best we do not fully understand myofascial trigger points and different practitioners cannot differentiate these trigger points. What is actually going on is very difficult to say and reproducibility may be tough, as individuality likely exists in this realm, something research and evidence do not like. Also, the quality of studies is currently poor for myofascial therapy research for orthopedic conditions (McKenney 2013).
Why Should We Care About Trigger Points?
Simply put, muscle pain matters: it’s an important problem, for health care and especially elite sporting success. Basically, anything that causes pain is going to alter the way we move. One study suggested performing barbell squats prior to body weight squats greatly impaired the joint biomechanics (Hooper 2013). Soreness also will impair biomechanics and likely prevent improving biomechaincs, the main determinant of success in many sports, like swimming (Lätt 2012). Soreness and dysfunction may also lead to other dysfunctions and problems, as more trigger points may develop.
Aside from altering the way that we move and decreasing performance, one must question the psychological ramifications. If one has many myofascial triggers, they undoubtedly will not perform well, perhaps impairing their psyche and long-term mental edge.
In short, we should care about trigger points because they can negatively affect our performance on multiple levels! Yet, this doesn’t just apply to active trigger points.
Latent trigger points are extremely common in people without pain (Fernández-de-Las-Penas 2014). These latent triggers are likely unpreventable and perhaps a consequence of daily life (being upright, walking, swimming, sitting, etc.). Latent trigger points are also suspected to accelerate muscle fatigue (Ge 2012).
Treatment of soft tissue structures as part of the training process may be beneficial for keeping tissue healthy and keeping the athlete training. Myofascial trigger points are believed to be improved with myofascial treatments, such as self myofascial releases. Unfortunately, the research is still scarce on the subject.
Interested in learning more on trigger points, self myofascial releases and other forms of mobility? Check out the Mobility for Swimmers System.
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2. Travell, J. Simons, D. Myofascial Pain and Dysfunction. The Trigger Point Manual. Williams and Wilkins 1983.
3. Hong CZ, Simons DG. Pathophysiologic and electrophysiologic mechanisms of myofascial trigger points. Arch Phys Med Rehabil. 1998 Jul;79(7):863-72. Review.
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Dr. G. John Mullen received his Doctorate in Physical Therapy from the University of Southern California and a Bachelor of Science of Health from Purdue University. He is the owner of COR PT, strength and conditioning consultant, creator of the Swimmer’s Shoulder System, and chief editor of the Swimming Science Research Review.