Differentiating injuries from trigger points?

[sean.albo]

A brief history of pain:

So a few months ago, bad form on ring dips and overworking myself in capoeira led me to a decrease in ability to contract. I just felt weaker, not necessarily pain. Over time, as I refused to listen to the warning signals, inconvenience led way to pain. I tried minor rest, but never with any real dedication, and anybody who knows capoeira knows that it's impossible to really isolate the arms (of course, I tried to pretend that I would manage). Weeks turned to months, and at some point I began integrating a shoulder rehab routine I had been prescribed for my other shoulder with slight modification. I became so excited with this routine, that I turned it into a shoulder destroyed itself. It went something like this: 2 sets of Ido's shoulder ROM, 2 sets of his scapula routine, 3 sets of (sidelying external rotation - 10, pushups - 10, limited ROM/assisted dips - 10). No rest and daily. I supplemented this with self-myofascial release work (lacrosse ball to the teres minor, infraspinatus, supraspinatus). The SMR made a huge difference in the pain, but I woke up Monday with an intractable pain. No doubt in my mind it was caused by an overly aggressive rehab routine.

So yesterday I went with my friend to a gym he works at (he's a personal trainer) to show him Ido's explosive leg workout routine (my hamstrings are fried right now). Someone at the gym with his education in massage therapy took a look at my shoulder, finding various trigger points, holding them while I breath. He went from supraspinatus, teres minor, infraspinatus, to the pec minor, and subscapularis. Going through these spots, he said that there were several trigger points causing my difficulties. He said an injury to the tissue would be more debilitating than a trigger point.

So, after all that, here's my question: How can I differentiate between a trigger point and an injury? How should I approach them as separate entities? I want to believe I can just press my trigger points away and start dipping right away, but I doubt that anything in life would be so convenient. I'm not sure what to make of all this. I'm not even sure if my questions make sense in the way of having answers. Furthermore regarding the nature of an injury, what I keep reading is if it doesn't hurt, it's okay to do (I'm assuming this assumes that good form is maintained). Should I feel safe holding handstands, for example, if they cause me no pain. I'm open to any recommendations of literature that might enhance my comprehension of this matter (I'm currently waiting for Anatomy Trains).

Many thanks, and apologies for the thick introduction.

[Cole Dano]

That's a rough story, too much re-hab. It happens, it could be for any number of reasons, but it does sound like a factor was just doing too much with a weakened shoulder.

Of course it is possible to unwittingly do some of the rehab work in a way that actually causes more problems, the rehab exercises should never hurt, at least not the ones you listed.

Can you describe what kind of symptoms you are having? Even then its guessing on the internet but at least there's a chance with more info.

One thing i've noticed about the trigger point books is that they paint a world where all pain is caused by trigger points. They can be part of the problem but i've never seen them be the whole problem, in particular with shoulders. I don't mean stop the massage, its good on so many levels, its just that trigger points aren't the likely to be the whole problem.

That said, Anatomy Trains though an outstanding book won't help with trigger points, it might not even help right away with your shoulders, but if you live with what Myers is saying a while it will potentially help with the root problems.

If you want a cheap trigger point book The Frozen Shoulder Workbook is a good one. Just don't think it will fix you overnight. It will help you gain insight into shoulder function and perhaps spare you more trouble down the road.

In the meantime if its as bad as you say, get someone who's a professional to look at it. Torn rotator cuffs are real, and much more serious than trigger pints if not cared for properly.

I'm sure your buddy at the gym is a great guy and maybe a good body worker, but is he competent enough to diagnose the problem?

Of course the flip side is, who the hell is? I've had more than one student who just gave up on the medical profession with these kind of issues because they offered no clear answers. The thing is if its REALLY messed up they can tell you, and if it is you need to know or face years of problems.

Try to find someone competent to assess the damage, if that's impossible google everything you can about shoulders. Make some vids of yourself doing Ido's band routine etc there may be a glaring flaw that you've never noticed. Look at your Caporiera technique is there some thing that's not moving properly, maybe your friends can help you see if there are. We all need to take care of each other after all.

And good luck, shoulders can be rough once they get hurt.

[sean.albo]

Thank you for your reply!

The pain wasn't too consistent until that recent resurgence. Now there's pain mostly in resisted lateral rotation and resisted abduction, as well as a general and pervasive sense of weakness and dull pain. There's a sense of pressure against the bicep tendon and I feel sore along the scapula. The bicep tendon feels swollen compared to the other side. I also notice a good deal of restricted mobility in reaching behind my back, (e.g., horizontal extension).

I will definitely take your advice regarding the literature and recording the band work to assess form. I've been reading as much as possible, but I feel that I still have such gaps in knowledge. I've definitely learned a lot about my shoulder since this injury (a good thing, in my opinion).

I suppose my confusion relates to the idea of "damage." It seems like a concept I took for granted, "injury" is actually much more nuanced than I believed. What is this damage to connective and muscle tissue that limits our mobility? What is the relationship of this damage to the eventual development of an injury, and to trigger points? I'm not really asking for answers (I suppose they might exist as an entire graduate course), just expressing how confused I am.

Many thanks again for your answer. if I come across anything illuminating that I think can benefit others, I will be quick to share.

[Cole Dano]

What you describe are the classic signs of a rotator cuff issue. You must take this seriously, and protect your shoulder, it can be a slow heal. Assuming you are young its most likely impingement and or bursitis, if you still have full ROM without needing to compensate with your scapula its not a full tear, but there is the possibility of a partial.

In any case there is some inflammation. Right now, NSAIDs are fine to take, but don't stress your shoulder at all while taking them as they will weaken the connective tissue. Once the pain has become manageable get off them. Fish oil is also a must for many reasons, in your case primarily because its a fantastic anti inflammatory.

If you want to try something more exotic, get some L-Glutamine take it first thing in the morning on an empty stomach, and don't eat for an hour. This will trigger the release of Growth Hormone which can speed tissue repair. This only works if you are over 25 otherwise you already have enough GH.

[sean.albo]

Thank you very much for these suggestions. I am taking fish oil, and have ordered some liquid fish oil to be able to increase the amount I get daily.

I have just come back from an appointment with a doctor at my university's health care center. A brief history was taken, and my shoulder was looked at for about 3 minutes, and the doctor told me I have a labral tear (this is what you meant, I believe, Mr. Brady?) I do have near full mobility, with some weakness at extremes (shoulder extension). After using internal rotation and slizzardman's anterior capsule stretches, I was pain free, and was too aggressive when working through my shoulder rehab/strengthening, and came into some pain, which is finally receding.

I've been particularly uncertain about NSAIDS. The doctor recommended this, and I voiced my concern, which was the possibility of anti-inflammatories impeding the healing process by inhibiting the restorative elements of inflammation (which I assume, but am not sure, involve circulating metabolic waste away from the site?) He mentioned that although there is no conclusion on this, that medical doctors believe that NSAIDS improve healing by way of the reduction of inflammation. Anybody know of detrimental effects on healing process by NSAIDS?

It seems every time I begin rehabilitating, within a week or so I've aggravated my condition. I started pacing my exercises more, and found out that even the rest I was using then (45s) was not sufficient. I suppose I'm just starved for the training effect that I've been deprived of. (On a positive note, I've started running, and now have a 5000meter goal of 15 minutes and 100meter goal of 13seconds).

When rehabilitating, should I work both sidelying external rotation and resistance band external rotation, or should I use only one? Doctor suggested I avoid delt flyes, so I guess I'm pretty limited in what I can do. He also suggested internal rotation work, but I've read that this might contribute to muscular imbalance; should I worry about this?

I'm still confused regarding injuries, however. I suppose I held in my head the notion of frayed muscle fibers as an "injury" and fascial dysfunction as quite different. Does soft tissue work restore muscle fiber health by improving nutrient circulation perhaps, or some other mechanism?

Of course, all suggestions, thoughts, and ideas are appreciated! I apologize for the inability to summarize these thoughts more succinctly!

.sean

[sean.albo]

Just thought that, in my quest to understand the nature of injuries and the healing process, that I'd share this link.

http://www.gomoji.com/education/technic ... fits-icing

According to this pseudo-litreview, reducing temperature by cryotherapy will lead to reduced pain, cellular metabolism, and muscle spasm, which in turn minimizes the inflammatory response. I'm only going to provide a short summary, very badly written. This is more of an attempt to internalize what I've read by summarizing it, rather than a literature review of my own.

Injury

Inflammation arises from a disruption of the cellular wall. The damaged cell switches to glycolytic metabolism (something here is causing hypoxia, which leads to preference for the anaerobic pathway). Glycolysis meets energy demands short-term, and metabolic demands eventually overwhelm energy production. Somehow, this impairs regulation of concentration gradients, which results in water flowing into the cell, causing swelling and eventually rupture.

The adaptive response to this is a release and perfusion of some chemical mediators (cyclooxygenase, prostaglandins, leukotrienes, histamine, serotonin, bradykinin, and leukocytes), which regulate the inflammatory response and aid in the clearing of cellular debris (does this refer to metabolic waste product?).

Local vasodilation increases fluid and protein delivery. This increases intra-capillary pressure and causes pain through compression of nerve endings.

Cryotherapy

A reduction of temperature induces reduction of rate of local chemical reactions, which decreases metabolic demand, and increases likelihood of cellular survival of anaerobic energy production.

Cryotherapy also reduces velocity of fibers and motor nerve conduction, preventing muscle spasm and reducing pain.

The decrease in blood flow diminishes edema formation.

Reflexive Vasodilation resultant from cryotherapy

Although it doesn't contribute much towards my goal of better understanding the injury, I thought this was pretty fascinating. After a given amount of time (approx 20m), a "hunting response/reflix" will cause vasodilation as an attempt to increase temperature. This is a concern apparently because vasodilation will contribute to inflammatory response.

As an attempt to contextualize that tidbit, I'm supposing that this is why we avoid heating an area after traumatic injury.