Frequently Asked Questions Concerning Muscle and
Joint Pain Syndromes
Incorrect adjustment of adaptive equipment (cane, crutches, walker, etc.)
will aggravate posture. Correct adjustment requires that when the subject
is standing as straight as possible, while they are looking straight ahead
with the arm relaxed at their side, the handle of the device should come
up to the wrist crease. This setting should correspond to an approximate
15 degree angle of flexion, or bend, in the elbow when the subject is holding
the device and standing straight. If the device is too high, there will
be increased strain on the elbow and shoulder joints. If the device is
too low, there will be a tendency towards shortening of the anterior hip
musculature and an increased thoracic kyphosis ("hunchback"). Additionally,
there will be a forward displacement of the subject's center of gravity
and this will compromise balance.
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The over-use of a brace can limit joint and muscle mobility as well as
weaken muscle tissue. Unless your doctor recommends otherwise, you should
be performing at least limited range of motion exercises on the affected
knee, ankle, shoulder, elbow or wrist as tolerated, with the brace/sling
removed for a few minutes every hour or two. Some exceptions would include
the following situations: 1) if you have had a stroke or other neurological
condition resulting in profound weakness and joint instability, such as
a hemiplegic shoulder (whereby the muscles aren't strong enough to move
the involved extremity under its' own power against gravity); in such cases,
range of motion exercises should be performed in a very slow and gradual
manner to avoid over-stretching the shoulder joint ligaments; 2) when recovering
from a fracture (broken bone); or 3) when a patient is recovering from
orthopedic surgery and has been told not to perform any range of motion
exercises until a specific date.
I am not a big advocate of braces unless the joint is very unstable
or there is a lot of pain or the presence of severe muscle spasms. Braces
promote rapid shortening of muscle and ligaments while the surrounding
musculature atrophies and weakens. In the case of back pain, you are usually
better off if you can slowly perform back stretching exercises throughout
the day, rather than try to be immobile.
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At or near several joints there is a protective connective tissue structure
known as a bursa, which acts to cushion tendons and dissipate joint forces
over a larger surface area. However, when muscles become chronically shortened,
connective tissue structures near the joint become restricted, and then
the bursa can become compressed (which typically occurs at the shoulder,
especially during repetitive movements of shoulder abduction, as in raking
leaves and sweeping). A friction syndrome may develop, producing localized
inflammation, such as subtrochaneric bursitis at the hip, which is related
to shortening of the iliotibial band (ITB), a common finding amongst runners
as well as the elderly.
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Calf (Gastrocnemius) Shortening. Everyone has a tendency to develop shortening
of the calf muscles, primarily because during sleep the ankle is plantarflexed
(points downward). This relative immobilization results in shorter calf
musculature by morning. Women who make frequent use of high-heels without
having a stretching program further contribute to this soft-tissue restriction.
If these individuals engage in running sports, they are more likely to
incur a muscle pull or tendon injury. Additionally, shortening of the calf
muscles places increased compressive force upon the knee joint since some
of the calf muscles (gastrocnemius) span the knee joint. There is also
a tendency to produce hyperextension of the knee joint, making the knee
unstable. When there is generalized calf pain (gradual but firm manual
compression of the calf with both hands fails to produce sharp pain, which
is a positive sign of a blood clot, in which you should seek immediate
medical attention while keeping all weight off that leg) but a Doppler
Ultrasound produces negative findings, the pain can be related not only
to muscle sensitivity, but impoverished dynamic circulation due to blood
vessels being excessively compressed during continuous walking.
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Carpal Tunnel Syndrome
Carpal Tunnel Syndrome is especially related to shortening of the wrist
and finger flexors, in combination with a relative decrease in strength
of the wrist and finger extensors. Over a period of time, (shorter if the
individual performs an occupation requiring repetitive stress trauma type
motions) the increased muscle tension of the wrist and finger flexors becomes
pathological and causes a ventral (anterior) shift of the eight carpal
bones, compromising the carpal tunnel. Proper ergonomics require keyboard
users to maintain the hand in a neutral position so that the hand is not
significantly higher or lower than the wrist. Detected in the early to
mid stages, the best treatment is to stretch the wrist and finger flexors
to a level of normal flexibility, and then to strengthen the wrist extensors.
Strengthening the wrist and finger extensors and stretching the wrist and
finger flexors will stabilize the forces at the wrist and pull the carpal
bones back into their normal anatomical position. If one continues to engage
in overuse of the wrist and fingers flexors due to occupational or recreational
demands, the tendency will be for a more severe dislocation of the carpal
bones and compression of the median nerve within the carpal tunnel. In
many cases, local and/or systemic anti-inflammatories can resolve joint
pain sufficiently to permit the stretching of the wrist and finger flexors
and strengthening of the wrist and finger extensors. Pursuing the resolution
of this syndrome via exercise is most desirable, considering the minimal
effectiveness of medications and surgery in effecting long-term resolution
of this pain syndrome. After surgical correction, scar tissue inevitably
forms, and ironically, can further entrap the nerve. I have never observed
a patient obtain full pain-free motion in the wrist after receiving surgical
carpal tunnel release.
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After months or years of suffering from various muscle and joint pain syndromes,
an individual may have consulted with a number of physicians and related
specialists, and still have failed to obtain any consistent or notable
relief. The old adage, "misery loves company" is very true and is all too
frequently observed in the medical field. Individuals frequently become
desperate to find a way to resolve their physical pain.
Unfortunately, it can be rather easy to become co-dependent upon fellow-sufferers
who have no professional knowledge or training. This leads only to conjecture.
Which brings to mind another adage: "A little information can be dangerous".
With the proliferation of the Internet, many individuals now have access
to prompt answers by economical means, and can make the effort to become
informed consumers. The flipside of this is that many lay individuals end
up counseling other lay individuals and many individuals are failing to
receive the timely and appropriate medical care they deserve.
There seems to be a pervasive tendency for individuals to desire a "quick-fix"
for all of their problems, without having to take any direct personal responsibility
for effecting the cure. By focusing in too closely on a handful of clinical
signs such as irregular enzyme levels, the attention may be directed away
from the personal responsibility every one of us has to perform daily health
maintenance activities, such as stretching for 30 minutes daily. By using
such a narrow focus, many individuals are missing the big picture: 1) the
average human body requires approximately thirty minutes of passive stretching
each day; in combination with: 2) attainment of correct postural alignment
(this is not a theory, but rather proven fact--the specific anatomical
reference is cited in my web document: "How Adaptive Muscle Shortening
(AMS) Causes Pain, Dysfunction, and Injury").
Many individuals become so accustomed to being part of a co-dependent
relationship that they fail to observe the insidious changes that have
occurred in their personality. Rather than go to a medical bookstore or
library to verify the truth of new disclosures, it is more time-efficient
and less threatening to simply cling to our personal belief systems, and
avoid any published work that might require us to reconsider our thinking.
This is a very unhealthy perspective, and through this attitude many years
are allowed to become unproductive and unfulfilling because of obstinance.
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During cold exposure, muscles increase their tone, or "shiver" in attempt
to produce body heat, but in the individual with shortened musculature,
exposure to cold can trigger a hyper-sensitive muscle stretch reflex. Daily
performance of stretching promotes normal muscle length and "re-sets" the
muscle stretch reflex to normal (less sensitive) levels.
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Recent research has shown that at speeds under 2.0 mph, there is a notable
increase in lateral displacement of the upper body, frequently resulting
in falls, especially in the elderly. While adaptive muscle shortening affects
everyone, the elderly are especially prone to developing movement dysfunction.
When the hamstrings shorten, there is a resultant shortened stride length.
Tight calf muscles restrict stride length. The inherent tendency is to
take short strides, which results in a slower walking speed.
In addition to causing joint pain and a slower walking speed resulting
in decreased balance, muscle shortening has another victim: your heart.
Shortened lower extremity musculature limits your physical abilities and
makes you walk slower, weakening your heart and decreasing pulmonary endurance.
There is an increased risk for the development of blood clots because circulation
is allowed to deteriorate. Heart attack and stroke risk increase. Major
health conditions could be avoided simply by initiating a daily stretching
program when you are still basically physically independent.
In most cases, simply attaining normal muscle flexibility of the lower
extremities will allow an older individual to at least double their normal
walking speed, resulting in improved balance, and enhanced cardiopulmonary
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Fibromyalgia Pain Syndrome
FIBROMYALGIA PAIN SYNDROME (FMS). In recent years, the medical establishment
has cited the existence of a supposedly "newly" recognized syndrome referred
to as Fibromyalgia Pain Syndrome, or FMS. In previous decades, this "syndrome"
was alternatively referred to as fibrositis, interstitial myofibrositis,
muscular rheumatism, nonarticular rheumatism, myofascial syndrome, myalgia,
and myofascitis. A book that recently became available at medical bookstores
refers to this state as "Tension-Myositis". All of these fancy names refer
to the same condition. For the purpose of discussion, I will refer collectively
to this syndrome as "Fibromyalgia Syndrome (FMS)", which is the in-vogue
medical reference at the current time.
These signs and symptoms have further been classified as acute, sub acute,
and chronic, with acute symptoms including severe pain and pressure sensitivity
with reflex spasm, swelling, impaired mobility of the joints, and an increased
temperature of the area. Most frequently involved sites are the lumbar
spine (lower back), thigh, and neck regions (especially the upper trapezius).
The sub acute phase is the condition in which pain and stiffness have decreased
but are still present; the chronic phase is one in which the nodule is
present without any symptomatology. Many of the nodules are reported as
having persisted even during deep anesthesia of the patient, therefore
eliminating the probability that myofascitis is a psychogenic condition
exclusively. Fibromyalgia pain syndrome patients have widespread body pain
which arises from their muscles. Some FMS patients feel their pain originates
in their joints. Pain that emanates from the joints is called arthritis;
extensive studies have shown FMS patients may or may not have arthritis.
Although many FMS patients are aware of pain when they are resting, it
is most noticeable when they use their muscles, particularly with repetitive
activities. Their discomfort can be so severe it may significantly limit
their ability to lead a full life. Patients can find themselves unable
to work in their chosen professions and may have difficulty performing
everyday tasks. As a consequence of muscle pain, many FMS patients severely
limit their activities including exercise routines, which can quickly lead
to general deconditioning, which eventually makes their FMS symptoms worse.
In addition to widespread pain, other common symptoms include a decreased
sense of energy, disturbances of sleep, and varying degrees of anxiety
and depression related to the patients' physical limitations. Furthermore,
certain other medical conditions are commonly associated with FMS, such
as: Tension headaches, migraine, irritable bowel syndrome, irritable bladder
syndrome, premenstrual tension syndrome, cold intolerance (cold exposure
makes musculature contract to maintain warmth, frequently resulting in
spasm of the already shortened musculature) and restless leg syndrome.
This combination of pain and multiple other symptoms often leads doctors
to pursue an extensive (and costly!) course of medical testing, which nearly
always result in negative findings, a source of confusion to both patient
and doctor. Muscle and joint pain and fatigue experienced by FMS patients
is a chronic problem which tends to have a waxing and waning intensity.
There is currently no generally accepted cure for this condition. According
to recent research, most patients can expect to have this problem lifelong.
Long-term follow up of fibromyalgia patients has shown that it is very
unusual for them to develop another rheumatic disease or neurological condition.
However, it is quite common for patients with "well established" rheumatic
diseases, such as rheumatoid arthritis, systemic lupus and Sjogren's syndrome
to also have FMS. Patients with FMS can suffer joint dysfunction due to
shortened musculature, and there is probably a general predisposition towards
a shortened lifespan due to declining cardiopulmonary health as a result
of their limiting physical activity. Due to varying levels of pain and
fatigue, there is an inevitable contraction of social, vocational and vocational
activities which leads to a reduced quality of life. As with many chronic
diseases, the extent to which patients succumb to the various effects of
pain and fatigue are dependent upon numerous factors, in particular their
psycho-social support, financial status, childhood experiences, sense of
humor and personal ambition.
Prevalence. Statistics recognize that 7 to 10 million Americans suffer
from FMS. It affects women much more than men in an approximate ratio of
20:1. It is seen in all age groups from young children through old age,
although in most patients the problem begins during their 20s or 30s. Recent
studies have shown that FMS occurs world wide and has no specific ethnic
predisposition. These are official figures from patients who seek treatment
for consistent complaints and dysfunction arising from muscular and joint
pain. However, in twelve years of clinical experience, I have yet to meet
one individual (other than some conscientious physical therapist colleagues)
who demonstrated both correct posture and normal muscle flexibility throughout
their body. Many individuals demonstrate shortened musculature without having
any notable complaint of pain symptoms. Yet. For as time progresses, additional
shortening will develop, and then pain will spontaneously occur. The subject
merely needs to be observed over a wider time window. As for FMS being
more prevalent amongst females, this is most likely due to the fact that
very few females have normal strength in the upper back and scapular musculature
(middle and lower trapezii), resulting in a chronic forward head and forward
shoulder posture, placing excessive strain on muscles that have already
been posturally weakened in the neck and upper back. These weak muscles
work over-time in a failed attempt to provide adequate dynamic stability
in place of the passive stability that is lacking because of decreased
muscle tone. The weaker upper back muscles fatigue faster due to being
in a faulty biomechanical position, and in the forward head/protracted
shoulder posture essentially function as guide wires, being under constant
tension in the upright posture.
Conventional Tests Fail to Reveal Pathology. There are no blood test
or x-rays which show abnormalities diagnostic of FMS. This initially led
many doctors to consider the problems suffered by FMS patients were all
"in their heads" or that FMS patients had a form of masked depression or
hypochondriasis. Extensive psychological tests have shown these impressions
were unfounded. A physician's diagnosis of FMS is based on taking a careful
history and the finding of tender areas in specific areas of muscle. These
locations are called "tender points" or "trigger points". They are tender
to palpation and often feel somewhat hardened if the muscle is stroked.
Frequently, pressure over one of these areas will cause pain in a more
peripheral distribution, hence the term trigger point. The treatment of
FMS is frustrating for both patients and their physicians. In general,
drugs used to treat muscle and joint pain (such as aspirin, non-steroidals
and cortisone) are not particularly helpful in this situation. It is important
for a patients' physician to discover whether there is an emotional cause
for sleep disturbances. Such sleep problems include sleep apnea, restless
leg syndrome and teeth grinding. Unless it has been determined that the
patient's postural alignment is correct and there is no imbalance of strength
or flexibility in the upper body and neck, medication should not be the
first line of treatment when the patient complains of pain and muscle tenderness
or spasms. But frequently the primary cause of tension can be attributed
to muscle shortening alone.
Because FMS victims suffer from structural (postural) faults created
by muscle imbalances of strength and/or flexibility, testing (and treatment)
that is based upon the chemical model of medicine will fail to provide
any useful information, and will only waste your time and money. The wide
variance of symptoms present within Fibromyalgia Pain Syndrome are explained
by comparing relative time windows at the time of specific complaints.
First muscles are allowed to shorten, posture becomes faulty, then the
connective tissue known as fascia becomes overstretched in some regions
and retracted in others, resulting in Myofascial Pain Syndrome. But this
wide array of symptoms is actually related primarily to a combination of
chronically shortened musculature and faulty posture, and the symptoms
vary as the time window enlarges.
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Frozen Shoulder Syndrome
This term implies that a good amount of time has passed since the original
symptoms manifested. By the time an individual receives this diagnosis,
usually there has been at least a 50% loss of normal joint range of motion,
with related muscle shortening and weakness. Performing simple range of
motion exercises (such as Codman's routine, where you bend over and rock
your body side to side and back and forth to effect passive movement in
the affected shoulder) will be largely ineffective, since there has been
such profound shortening of not only the musculature, but of the shoulder
ligaments and joint capsule as well. Only aggressive daily stretching of
the surrounding soft tissues will resolve this condition, and it usually
takes 2-4 months to regain normal joint range of motion and functional
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Adaptive muscle shortening will affect any sports participant, regardless
of age. Young children are not immune from the effects of heavy exercise
upon their musculature. In fact, they are perhaps more susceptible to the
effects of muscle shortening due to the fact that the length of the extremity
bones tend to grow at a faster rate than the musculature. Young children
who have encountered sudden growth spurts can experience the sudden onset
of muscle and joint pain due to the relative sudden shortening of the musculature
as the extremity bones lengthen. This situation is made worse when young
children engage in structured sporting activities without giving any regard
to muscle stretching. Ironically, when stretching is referenced during
organized sporting activities, the recommendations are frequently inadequate
for attaining normal muscle flexibility.
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Independence in the Elderly
The current lack of emphasis on the importance of stretching is permitting
unnecessary debility to occur in the elderly. Individuals who might have
maintained their physical independence and continued to live in their own
homes are prematurely becoming physically dependent. It is tragic for seniors
to have to encounter circulatory disorders when a brief daily stretching
program could have resulted in a more effective and confident walking pattern.
Many of my elderly patients never had a physical limitation until experiencing
a fracture or hospitalization which resulted in deconditioning. Most of
my patients have been able to return to an independent lifestyle, and many
have commented that they have greater physical abilities following treatment,
than before their injury or hospitalization. Many spontaneously admitted:
"I guess I just didn't realize what was possible, nor what I was missing".
By promoting normal flexibility of the leg musculature, the program
allows seniors to take larger strides, which in turn spontaneously results
in a faster walking speed and greater stability during walking. Cardiovascular
health and pulmonary endurance are enhanced due to the faster walking speeds
that can be achieved with this exercise program.
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Irritable Bowel Syndrome
Faulty posture has to potential to cause more than just orthopedic problems.
Frequently the peripheral nervous system becomes involved as inter-vertebral
spaces narrow and nerve compression occurs. But nervous system involvement
can become even more complex with the potential to disrupt normal functioning
of the autonomic nervous system. Delicate nerve pathways that innervate
the internal organs and their circulation can become dysfunctional as a
result of faulty posture. Many faulty postures apply unnatural traction
or torsion to these delicate nerve structures, compromising enzyme flow
within the nerves and altering nerve communication to the visceral organs.
Another source of IBS is a general lack of physical activity and restricted
hip joint range of motion. Simply having the ability to bend your hip to
the point of being able to kiss your kneecap can apply pressure to the
abdominal wall and stretch the intra-abominal fascia, which is frequently
all that is needed to promote normal bowel patterns. Taking fancy pharmaceuticals
can't replace the natural mechanical stimulation the intestines receive
through the performance of fast-paced walking.
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ITB (Iliotibial Band) Syndrome
The iliotibial band (ITB) is a strap-like non-contractile connective tissue
structure that is created by the proximal (upper) convergence of the gluteus
maximus muscle (primary hip extensor) and the tensor fascia latae (secondary
hip abductor, hip flexor and lateral hip rotator). The distal (lower) portion
of the ITB inserts on the lateral surface of the proximal tibia. Shortening
of the gluteus maximus or tensor fascia latae muscles can eventually lead
to fascial restrictions within the ITB, resulting in increased medial (valgus,
or "knock-knee") stress at the knee. This is particularly problematic in
the female, since the wider pelvis naturally promotes an increased valgus
stress at the knee. Friction syndromes can be caused by a shortened ITB,
and these generally include lateral knee pain or subtrochanteric bursitis
at the hip. Corrected in a timely manner, sub acute inflammation will spontaneously
resolve. However, if the situation is chronic, local injection of an anti-inflammatory
may be required.
Shortened muscle can even result in fracture within the articular joint
surface. A colleague cited having treated a 25 year-old college student
who was a runner averaging 60-80 miles/week. The patient performed only
infrequent stretching, and for an inadequate duration. What was unusual
was that he did not incur his injury while running. Over time, the additive
compressive forces effected by the shortened musculature and transmitted
by the ITB combined with the repetitive impulse loading of jogging resulted
in an undetected stress fracture in the proximal (upper) tibia. One day,
while walking to class, the he sustained a spontaneous comminuted (multiple)
fracture of the lateral tibial plateau (upper portion of the leg bone)!
Muscle and connective tissue shortening can cause tremendous injury if
stretching is not performed with the goal of attaining and then maintaining
normal muscle and joint flexibility.
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Many folks complain of having the regular experience of hearing joint sounds
or feeling that a joint "wants to pop" while still others are "self-manipulators"
and abruptly move their head into various positions in an attempt to loosen
a restricted vertebral facet joint, or bend their ankle to make it "pop".
These situations are all indications that early joint restrictions have
occurred. What is needed is for the subject to perform a daily stretching
program to avoid these conditions in the first place. The problem is that
these individuals usually don't have any substantial pain yet, so they
only think about stretching when it feels like they need it. But what they
may not be aware of, is that they are unnecessarily subjecting themselves
to premature arthritic joint deterioration (osteoarthritis) because of
their failure to perform a daily stretching program. Their muscles have
shortened enough to cause excessive wear and tear upon the cartilage joint
surfaces, although they may not yet have chronic muscle or joint pain.
The hip joint is a special situation, since clicking in the hip joint
is usually due to joint instability related to weakness in the hip abductor
musculature. Weakness in the hip abductors is a pervasive finding in nearly
all females and in many males. The simple exercises required to promote
normal strength in the hip abductors is cited within my exercise regimen.
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Low Back Pain
There are several conditions that can result in low back pain. The persistent
use of faulty body mechanics is a frequent culprit. Over time, disc damage
can occur, resulting in a partial or complete tear of the disc with extrusion
of discal matter into the spinal canal, where nerve compression can occur.
Low back pain related to disc injuries is much more common in subjects
under 50 years of age. After around 50 years of age, the discs begin to
dessicate, or dry out, and lose vertical height. The latter condition is
responsible for shortening of stature that is common in the elderly. The
vertebrae literally approximate and in some extreme conditions, cause a
spinal stenosis (narrowing of the inter-vertebral space) and nerve compression.
Nearly without exception, low back pain may be traced to incorrect alignment
of the pelvic girdle due to muscle imbalances of strength and flexibility
in the hip, abdominal and lower back musculature. An analogy would be that
the pelvis provides a base of support for the spine much in the same way
a foundation supports a house. Once the pelvic and hip musculature shorten,
the pelvis tilts out of position. With shortening of the anterior hip and
lower back musculature, the pelvis tilts forward, with a tendency to promote
a lumbar spinal stenosis. With shortening of the abdominals and/or hamstring
musculature, the pelvis tilts posteriorly, with a tendency to promote premature
disc failure. Ideally, the lower back, abdominals, hip and thigh musculature
act to maintain the correct force couple at the pelvic girdle so that maximum
lower extremity mobility is possible all while providing stable support
to the spinal column.
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Modalities include heat, ultrasound, cold, high-voltage electrical stimulation
for pain-control, paraffin, etc. The use of these treatments during the
acute stage (2-3 weeks) of an injury can be appropriate. Unfortunately,
there is definitely a tendency within the health-care field to over-utilize
these treatments while frequently neglecting to educate and empower the
patient regarding the performance of a comprehensive daily stretching program.
With each individual modality costing your insurance company approximately
$ 30, it is easy for an unscrupulous clinician to create a $ 50 to $ 60
office visit before you even get any hands-on treatment. If your physical
therapist doesn't spontaneously recommend at least 30-45 minutes of daily
exercises, beware. Many centers have figured out that they don't want the
expense of providing appropriate care with frequent ongoing care by a medical
professional when an aide with no formal training can pass a hot pack or
cold pack. If you are frequently receiving modality treatment, be sure
that you are also receiving a good amount of attention from your attending
physical therapist as regards exercise instruction. Too many health-care
institutions have determined the economic benefits of promoting the over-utilization
of modality treatments (where the patient can effectively be abandoned
for 20-30 minutes) vs. providing hands-on treatment of the patient by a
professionally trained physical therapist.
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What Causes a "Charley-Horse"? Shortened muscles tend to display a hyper-active
stretch reflex. Muscle tissue contains pressure and stretch receptors that
provide feedback to the brain regarding the muscle's contractile state.
This is a built-in protective mechanism so that we don't injure a muscle
by performing extreme movements that might over-stretch the muscle. But
when muscles are permitted to lose flexibility, receptors are over-stimulated
with even light physical activity, and the stretch reflex becomes hyper-active.
It becomes easier to develop a spasm, or "charley-horse". For example,
when your neck muscles have shortened, and you try to raise your arms,
the neck muscles tend to spasm due to their hyper-active stretch reflex.
This is a common finding in whiplash-injury victims. Correct shoulder movement
can not occur until normal neck range of motion is acquired. When the adjacent
musculature is shortened, it becomes hyperactive and begins to act more
like a primary mover, rather than performing its proper synergistic (assistive
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Myofascial Pain Syndrome
The effects of posture are additive as time progresses. When posture is
chronically at fault, every wrong move and individual joint strain tends
to accumulate, just like radiation exposure. These faulty changes can encompass
not only the muscular but the fascial system as well. Consider a civil-war
era cemetery. Tombstones from the 1920s are found to be tilting forward
at 10 to 20 degrees. But some tombstones from the 1860s are leaning at
a 45-60 degree angle. When bad postural habits are consistently utilized,
persistent fascial dysfunction can lead to contractures in the fascial
sheaths. This induces semi-permanent changes in posture, usually with the
fascia on one side of the body being over-stretched (frequently resulting
in laxity in the ligaments, resulting in joint instability), while the
fascia on the opposite side is placed into a shortened state and is allowed
to retract (resulting in increased compressive force on the retracted side
of the joint). The progressive tilt of the aging tombstones is analogous
to the development and progression of the "hunchback" posture that occurs
once the upper body mass becomes anteriorly displaced (if corrective exercises
are not instituted in a timely manner). In time, these new fascial tension
lines redistribute the fascia, altering joint position and an individual
begins to become "trapped" within the faulty mechanics of the affected
fascia. Fascial restrictions also place an enormous amount of compression
force on affected joints. This situation results in muscle imbalance and
altered joint mechanics, can disrupt balance, and can produce a multitude
of muscle and joint pain syndromes. Such postural defects are biomechanically
inefficient since the body supports itself by passive muscle and connective
tissue (fascia, ligaments, etc.) tension in order to minimize energy usage.
Spinal weaknesses, then, are basically comprised of muscular and fascial
problems, and not joint dysfunction per se. Exercise restores fascial integrity,
posture and bodily function. Connective tissue can be quickly regenerated.
Even after a certain degree of calcification starts to make the aberration
permanent, using exercise to correct posture will improve overall joint
movement. Such spines can become effective, given appropriate support and
assistance from the myofascial system. The spinal disc can then spontaneously
reshape itself; restored structure restores function. As the fascial framework
shifts into a more correct position, spatial relations of the embedded
nerves and vascular structures return towards their normal position. This
offers an opportunity for improved local tissue nutrition and can benefit
the functioning of the nervous system. This results in better physical
coordination and greater emotional serenity. Corrective stretching and
strengthening exercises are the only viable means of restoring correct
posture and normal joint function.
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Muscles act as pumps moving nutrients and oxygen-carrying fluids (lymph,
etc.) to and from cells. Myositis, or inflammation of muscle tissue, can
occur when there is chronic shortening of a muscle. Whatever the cause
of muscular tension, due to emotional trauma or faulty posture, the source
of the pain is ischemia, or inadequate blood supply to the muscle tissue.
As a muscle shortens, the fibers bunch closer together. The problem with
this is that there are tiny blood vessels entering the muscles at a right
angle. As a muscle shortens due to lost flexibility, these tiny blood vessels
are partially compressed due to increased muscle tension. This results
in delayed recovery from exercise due to the gradual accumulation of metabolites,
and a diminished oxygen supply to the muscle tissue; inflammation is inevitable.
This is why it is so important to maintain normal muscle flexibility and
joint range of motion: to maximize the effectiveness of this muscular pumping
mechanism in removing metabolites that accumulate during repetitive and
strenuous physical activity.
Several other factors can ultimately be responsible for muscle pain.
These include a single physical trauma or the cumulative effects of faulty
daily posture; local infection; immobilization; and the presence of emotional
tension. These factors cause local irritation which produce varying levels
of muscular ischemia (decreased circulation). The combination of decreased
oxygen supply and retention of metabolites in the muscle tissue causes
inflammation and produces pain, and this in turn produces greater amounts
of muscle tension, creating a vicious cycle. Left untreated, this series
of physiological events will produce some form of functional disability.
Emphasis must be placed on the fact that until posture is corrected,
muscles will become sore from decreased circulation and a hypersensitive
stretch reflex and joints will become painful due to increased compressive
forces occurring within them. The ultimate long- term solution for resolving
muscle and joint pain is to achieve correct posture by balancing muscle
strength and flexibility across the joints.
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Pain and anti-inflammatory medication provide only symptomatic treatment.
Anyone who has ever used the topical creams and gels that are so popular
(and highly advertised!) would reach a much better and more stable clinical
outcome through the performance of this exercise regimen. Such topical
ointments are merely "counterirritants" which inflame the skin and can
only briefly take your mind off the pain. The downside of this is that
many subjects will be encouraged to further overuse their joints because
their pain has momentarily subsided. Later, they will tend to apply more
cream. So a vicious cycle ensues. Much to the happiness of the pharmaceutical
companies. The television advertising of these products is absolutely incorrect
for implying that these cream penetrate deep into the joint, because this
fails to recognize the fact that skin has a basement membrane, which prevents
most topically applied chemicals from contaminating our bloodstream. So
now it can be understood that such ointments only penetrate a millimeter
or so and have no potential penetrating deeply, or for "warming up an arthritic
joint". There is absolutely no long-term curative value is using topical
ointments, (whether over the counter or by prescription) when treating
muscle and joint pain. On the contrary, the proliferant use of analgesic
cremes permits further joint destruction to take place since the primary
cause of muscle pain and joint dysfunction is shortened muscles, which
will then be allowed to remain shortened. It is only be correcting structural
faults within our posture that the body can be made more efficient and
When you achieve something close to correct posture, and attain normal
joint and muscle flexibility, you really shouldn't expect to have any pain
in the first place. Running out to the local drugstore to buy those popular
and highly-advertised backache relief pills won't resolve your problem.
In contrast, a back that is flexible and that is connected to a flexible
body will have no difficulty in painlessly lifting 100 and even 200 pounds
while performing chores around the house. A back with shortened musculature,
however, is a walking time-bomb and can spasm if you move the wrong way,
or merely bend over to wipe off the kitchen table.
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The phenomenon of referred pain is related to the fact that any particular
segment of the spinal cord innervates a localized region of anatomical
tissues, including muscle, bone, skin and visceral organs. Due to inflammation
or other mechanical irritation, pain is sometimes referred to nearby structures,
away from the original site of injury and dysfunction. A proficient clinician
can perform an accurate assessment to determine the true cause of the pain.
As an example, frequently there are complaints of radiating pain down the
arm to the elbow, when the restricted shoulder joint is the source of the
pain. Here the pain is not due to nerve compression per se, but due to
the phenomenon of referred pain.
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Repetitive Stress Injury
Repetitive Stress Injuries (RSI; also referred to as cumulative trauma
disorders) are becoming increasingly prevalent, especially amongst secretaries
and computer users. While improving work-station ergonomics is helpful
in reducing postural-induced muscle and joint strain, the fact remains
that most workers are required to maintain a static posture throughout
most of the workday, which results in stereotypical postures that are job-related.
If normal flexibility is not maintained throughout the musculature and
other soft tissues, the ensuing faulty postural alignment will eventually
cause a muscle and/or joint pain syndrome. Unfortunately, many occupations
require workers to perform physical movements that are restricted in that
only a small portion of the normal joint range of motion is utilized. Over
time, and with a lack of stretching, the muscles undergo adaptive shortening
and place more strain upon the joint surfaces. Joint trauma further increases
if a worker is required to perform heavy lifting over a short range of
motion. Here there will be a tendency to wear down a specific portion of
the joint's articular surface due to increased compression and joint loading
that is occurring throughout only a narrow arc of the total joint surface.
This tendency to perform work activities throughout a narrow joint range
of motion is the principle cause of repetitive-stress injuries, due to
increasing joint compression forces over a limited range of motion and
due to accelerating the adaptive muscle shortening process.
The potential for joint debilitation that can occur due to the preferential
usage of select muscle groups could be effectively offset by the performance
of daily stretching. Preventative medicine is still the best medicine.
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Inconsistencies in computerized axial tomography (CAT) and magnetic resonance
imaging (MRI) are common when muscle pain syndromes are being evaluated.
Many patients have been perplexed that these expensive testing procedures
have come back completely negative. In these cases, careful evaluation
by a physical therapist will usually detect a seemingly minor rotation
of a spinal vertebrae that was not detected by the scanner. This is commonplace.
If the condition has been persistent, inflammation of the facet joints
can occur, and become quite painful. Therapeutic exercises to stretch shortened
muscles and strengthen weak muscles are used to correct posture and to
maximize inter-vertebral and facet joint spaces. Another elusive source
of muscle and joint pain is when posture becomes faulty during the increased
demands of athletic and work-related activities, due to muscle shortening.
Since X-rays and scans observe the patient at rest (static posture), the
failure to maintain correct dynamic posture (occuring during activity)
is frequently overlooked.
Therapists are specialists in correcting movement dysfunction that results
from muscle imbalances of strength and flexibility. Physical Therapists
receive extensive medical training in accurately performing a comprehensive
assessment of muscle and joint dysfunction. This assessment information
is used to identify the muscles at fault and to create a Physical Therapy
Diagnosis. These diagnostic findings are used to individually design a
corrective home exercise program that will promptly resolve muscle and
joint pain, while correcting posture and enhancing the quality of movement
(speed, stability, economy).
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"Morning stiffness" is not reserved for octogenarians. If you are in tune
with your body, you will notice the tendency to feel stiff in the morning.
This is especially noted in the calves, because during sleep the feet point
downward, placing the calf muscles in a shortened posture. After eight
hours of sleep, the calves physically shorten in length in response to
the sleeping posture. Since our daily postures pattern muscle length, it
is important to utilize an effective sleeping posture, especially when
we consider the extended period of time spent in the sleeping posture.
A common postural fault that occurs during sleep is lying supine with
more than one pillow under your head. This promotes a forward head and
forward shoulder posture, with a weakened upper back leading to kyphosis
("hunch-back" posture) and tight chest muscles, which will interfere with
normal shoulder function to some degree. The most effective sleeping posture
is supine (lying on your back). In supine, no pillow should be used, or
a very thin one. If you have become accustomed to using a thick pillow,
or more than one pillow while supine, you should be making gradual efforts
to reduce pillow height in addition to performing the stretching program.
If you lie on your side, take turns. Try not to favor lying on just one
side. This is because the shoulders are usually broader than the pelvis,
and the side lying posture results in the trunk shifting to one side. If
you take turns lying on each side, these forces neutralize each other.
When side lying, it is recommended that you use a pillow of sufficient thickness
to maintain the head in a horizontal posture. Lying prone (on your stomach)
is not recommended as this places a tremendous amount of strain on a healthy
neck, let alone a neck with shortened musculature. Avoid using a fetal
posture as this promotes a great deal of soft tissue shortening, primarily
in the hip, knee and abdominal musculature. Frequent use of the fetal posture
when sleeping will result in shortening of the anterior hip musculature,
making it difficult if not impossible to maintain an erect standing and
walking posture, as well as shift the center of gravity forward, thereby
Adopting Pain-Free Postures. Once muscle shortening occurs, the mistake
is in trying to passively support the body in a relatively pain-free (but
faulty) posture. For example, when the hip flexors shorten in response
to overuse of the sitting posture, people will frequently start sleeping
in a recliner to avoid discomfort that occurs in the supine position which
would actually stretch the tight hip flexors. Instead, they sit most of
the day and then make matters worse by sleeping in a recliner with the
hips bent! Another faulty adaptation is when people place several pillows
under the knees while supine. This promotes shortening of the hamstring
tendons and hip flexor musculature, creating a "hunch-back" posture. What
is needed is stretching of the hip flexors so that a supine sleeping posture
is tolerated and an erect standing posture is possible.
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When muscle shortening is allowed to occur, there are inherently greater
forces and lines of tension being applied through the tendons. Over time,
this increased pressure causes excessive compression of the tendons against
the bone surfaces and can result in microscopic abradement of the tendons
due to excessive friction forces. This ultimately can result in tendonitis,
or inflammation of the tendons. Receiving local injections is appropriate
if the pain is so intense that oral pharmaceuticals are ineffective. However,
the long-term goal should be to control pain only until the subject can
perform a daily stretching program. The ultimate goal is to achieve normal
muscle and joint range of motion so that the original mechanical cause
of the inflammation can be resolved.
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TENS is an acronym for "trans-cutaneous electrical nerve stimulation".
Basically this is an attempt to trick your brain into forgetting about
the original source of your pain syndrome by providing a mutually competing
stimulus (electrode placement on the surface of the skin near the spinal
column, usually) to distract attention from the real site of pain. This
treatment should only be used in extreme chronic cases. I have too frequently
seen this procedure over-utilized during the acute stage, and this results
in the patient not receiving adequate evaluation and treatment. To promptly
attempt to seek pain-relief without undertaking any thorough attempt to
determine the original mechanical source of the pain syndrome is foolhardy.
By providing transient pain relief, the subject is encouraged to continue
performing activities that are inappropriate due to their physically demanding
nature. Further joint and muscle damage can occur.
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The temporo-mandibular joint (TMJ) is the only bilateral joint in the body.
Therefore, any asymmetry of postural alignment will tend to promote TMJ
dysfunction. I treated a 45-year-old downhill skier who broke his leg during
a downhill race. The affected lower extremity was casted for 6 months and
the lower leg placed in a short leg cast for an additional 3 months. The
ankle was in plaster for nine months and during that time the fracture
site settled resulting in at least a 3/8" shrinkage in the length of the
tibia (lower leg bone). Post-fracture shrinkage of the weight-bearing bones
is not uncommon. During the first treatment period, I recommended the subject
consult with an orthotist to correct his true leg-length discrepancy. I
advised him that he would be subject to low back pain and possibly TMJ
pain if he failed to correct the leg length discrepancy. Being the procrastinator
type, he ignored my professional advice and did nothing. Five years later
he came back to me with the diagnosis of "low back pain". The leg length
discrepancy has resulted in pelvic mal-positioning and mal-alignment of
the lumbar spine. I then reminded him of my initial recommendation to see
the orthotist, and additionally advised him that he could develop TMJ dysfunction
as the unnatural forces being encountered during his faulty walking cycle
were transmitted further along the spinal column. At this, he promptly
admitted that he had been consulting with a dentist for the treatment of
TMJ pain for the past few months, without resolution. The patient performed
corrective stretching and strengthening exercises, consulted with an orthotist,
and the low back pain and TMJ pain was then promptly resolved.
A more common source of TMJ pain is the forward-head and forward-shoulder
posture that is so prevalent today. Most individuals use seating devices
that are too high for their desk, so they slump. Additionally, people tend
to over-develop their chest muscles by performing many push-ups while neglecting
to strengthen their upper back muscles, which would effectively counteract
the muscle tension within the chest region. Usually one shoulder becomes
more restricted and that's all it really takes to disrupt the normal alignment
and function of the TMJ. Only a full-body stretching and strengthening
program aimed at promoting normal flexibility and correct posture can resolve
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Total Joint Replacement
Total joint replacement surgery is not singularly an end-all solution.
Once a hip, knee or shoulder replacement is performed, the patient tends
to think that since the pain is absent, all that they need to concentrate
on is strengthening the adjacent musculature. One must recognize that since
the articular surface of these joint replacements is made of a high-grade
plastic, over the span of 10 to 15 years, the plastic articular surface
degrades, and small portions become "joint mice" in the same manner that
bone disintegrates within a true anatomical joint. This internal derangement
alters joint mechanics and frequently results in shortened joint life,
resulting in the need for a second joint replacement surgery in a premature
manner. Ironically, the author has noted that there exists a real trend
for the medical establishment to fail to instruct patients of the necessity
of maximizing muscle and joint flexibility following total joint replacement
surgery, the patient thereby being predestined to incur premature failure
of the implant. It should be understood that to obtain maximum function
from a joint replacement, the surrounding musculature must attain normal
flexibility and strength.
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Trigger points are localized regions of hyper-sensitive muscle tissue.
Receiving massage and "trigger point therapy" such as acupressure can only
provide transient relief of pain symptoms, since the underlying cause of
the dysfunction is faulty posture and compromised circulation related to
shortened musculature and the unnatural tension that is resultantly produced
within muscle tissue. Exercise-induced metabolites are not efficiently
removed from the muscle tissue as a result of the compromised circulation
effected by the shortened musculature. Achieving normal muscle and joint
flexibility and correct postural alignment are required in combination
to enjoy a healthy, pain-free existence. The importance of achieving correct
posture is emphasized in my documents "How Adaptive Muscle Shortening (AMS)
causes Pain, Dysfunction and Injury" and in "Muscle Balance".
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site last updated on February 11, 2010 by
J. Fransen, P.T.
Copyright © 1997-2011 Paul J. Fransen, P.T. All Rights Reserved