Frequently Asked Questions Concerning Muscle and Joint Pain Syndromes

FAQs

Adaptive Equipment
Bracing
Bursitis
Calf Pain
Carpal Tunnel Syndrome
Co-dependency
Cold Intolerance
Falling
Fibromyalgia Pain Syndrome
Frozen Shoulder Syndrome
Growing Pain
Independence in the Elderly
Irritable Bowel Syndrome
ITB Syndrome
Joint Clicking
Low Back Pain
Modalities
Muscle Spasms
Myofascial Pain Syndrome
Myositis
Pharmacology
Referred Pain
Repetitive Stress Injury
Scanning (CAT/MRI)
Sleeping Postures
Tendonitis
TENS
TMJ Dysfunction
Total Joint Replacement
Trigger Points

Adaptive Equipment

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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Bracing

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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Bursitis

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 Pain

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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Co-Dependency

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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Cold Intolerance

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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Falling

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 health.

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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 muscular strength.

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Growing Pains

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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Joint Clicking

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

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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Muscle Spasms

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 stabilizing) function.

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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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Myositis

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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Pharmacology

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 resilient.

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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Referred Pain

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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Scanning (CAT/MRI)

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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Sleeping Postures

"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 compromising balance.

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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Tendonitis

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

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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TMJ Dysfunction

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 TMJ function.

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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

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 Paul J. Fransen, P.T.

 

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