published 11/28/08

Into the Fire

Trigger point pain as a major injury complication, and how I finally “miraculously” healed from a serious and stubborn shoulder injury by untying the muscle knots

by Paul Ingraham, Vancouver, Canada MORE
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Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.

In late July, I tried to stop someone else from catching a Frisbee, and things went badly. I was playing goaltimate (a variation of the intense Frisbee sport, ultimate). I leapt high in the air, tumbled clear over the other player who was catching the disc, and fell a couple of feet onto the tip of my shoulder. It should have been a collarbone cracker.

My ligaments tore instead. 2nd prize.

My acromioclavicular joint, on the shoulder-end of the collarbone, gave way with a wet rip. And over the last several months of healing, that injury has given me an opportunity to practice much of what I preach as a therapist.1

Just to add insult to injury … the other guy caught the Frisbee. And scored. Winning the game. (Now that’s painful!)

Two kinds of hurt

First the pain of an injury (the frying pan), and then the pain of seriously irritated muscle (the fire). A much more detailed version of this graph is presented at the end of the article.

Sprains

A ligament tear is called a “sprain.” Joints are held together by both muscle and ligament. When ligaments tear, it causes severe pain, and takes a minimum of many weeks to heal. A serious sprain can leave a joint more or less permanently damaged — people often talk about never really recovering from their sprains. Sprained joints are never quite the same again.

I could feel the joint moving in a disturbing way, clunking and bulging and almost dislocating.

Ligament is tough stuff, but once it is torn, it just does not heal particularly well.

I knew I was in trouble, because my joint was so damaged that it was loose — a sure sign of actual ripping. Yikes. I could feel the joint moving in a disturbing way, clunking and bulging and almost dislocating and causing vicious, sharp pain with every unwise attempt to use my arm.

I could barely drive home from the field. I probably shouldn’t have.

I couldn’t lift my arm more than a few degrees. I couldn’t sleep on that side … for months to come.

Muscle pain

Muscle pain is a routine complication of most injuries. Contrary to popular professional opinion, it has been scientifically clear for decades that muscles do not “go into spasm” to protect an injured joint. Au contraire: they go limp to protect the joint.2

And yet they also become “tight”3 and painful. If they aren’t in “spasm,” why do they hurt so much in the days and weeks after an injury? Although unproven, the answer is almost certainly “because of trigger points.”

Trigger points are a common and painful muscular dysfunction — a small patch of muscle tissue in spasm, as opposed to a whole-muscle charlie horse.4 They are to muscle what pimples are to skin: a little bit of tissue that has gone wrong.

Trigger points, colloquially known as muscle knots, are the cause of most of the world’s aches and pains, nearly all the minor ones, and a surprising number of the severe ones. They are a complex and fascinating topic. If you’d like to read about them, see my advanced tutorial on that subject, Save Yourself from Trigger Points & Myofascial Pain Syndrome!

My shoulder story illuminates the relationship between trigger points and injury, and understanding it is of great potential value to anyone with an injury. This article will convince the injured of exactly why they need to know how to self-treat trigger points … but the tutorial can teach you how to do that.

Complications! Out of the frying pan, into the fire

The crazy thing about muscle pain is that it often becomes worse than the original injury, and it lasts much longer. It is more than a “complication” of injury — it is a common, serious, and long-term consequence of physical traumas.5

It is primarily the pain of the injury itself that provokes trigger points. Exhaustion probably also plays a role. Although initially inhibited by the injury, muscle soon starts working hard to “work around” the injury — contracting a lot and in unfamiliar new patterns as you try to achieve functional goals without pulling on any broken tissue. It’s awkward. All of those contortions we learn when we are injured, all the limping and squirming and fidgeting, requires unfamiliar and often intense muscle activity. The exhaustion it causes probably drives trigger point formation, or makes any trigger points that were already there — a common scenario — much worse.

Never underestimate a trigger point. They can produce far worse pain than most injuries. Injury pain is straightforward and “honest.” It hurts to move in a certain way, so you don’t move in a certain way. I’m not saying it’s easy to be injured, just that you more or less know what you’re dealing with. Muscle pain is sneaky and low and poisonous feeling. It feels like your tissue has been poisoned, because it has — every trigger point is a toxic little bomb of metabolic waste products, something that has been suspected by science for decades, but was only proven by an excellent bit of scientific research early in 2008.6

And untreated trigger points can last forever. No one really knows why a trigger point would ever go away, or why it would stop once its started. Fortunately, they often do go away. But they often don’t! And they especially tend to be long-lived in the aftermath of injury. While the injury heals, trigger point pain overstays its welcome.

Therapist, heal thyself

That trigger points complicate injury recovery is an important therapeutic principle which I have been trying to teach to my own patients and readers for the last decade.

But there is nothing quite like personal experience to really test a complex idea.

Personal experience offers both much more and much less than scientific research. Nothing can be proven from personal experience alone, but the subjective data it supplies is rich: a torrent of sensory data to parse and correlate with my detailed knowledge of the subject. Many times per day I had the opportunity to compare my expectations with my experience.

It was almost worth being injured.

I knew within days that I was growing a nice crop of trigger points around my injury. I also knew that there wasn’t much I could do about it, at first — even if I relieved the trigger points, the joint would still be very sensitive, and the trigger points would quickly come back. So I did some basic therapy for trigger points to try to keep the area healthy, but mostly I just waited for the joint to slowly calm down, which it seemed to be doing.

And then I re-injured it.

I had underestimated how messed up and fragile and vulnerable the joint was, and I tore it again, and worse, simply by reaching up for something too quickly. A Frisbee again, as it happens. Oops.

Therapists are always their own worst patients.

Things get ugly

After re-injury in late August, the bulk of the autumn of 2008 was a blur of pain. Every hour, every minute was coloured by shoulder misery. I couldn’t sleep on my right side at all, which disrupted my sleep significantly. I couldn’t pull things out of cupboards, couldn’t carry even a light bag, could not do my job without pain, pain and more pain.

Like most injured people, I was adaptable, and founds ways of getting by. I really had to work — my wife and I were still paying for an expensive flooding incident that occurred around the time of the initial injury. I just couldn’t work without pain. My muscles could hold my shoulder together, but they were becoming extremely tired and riddled with trigger points as a result.

I knew, of course, that things might be really bad. I knew I might need surgery to bolt my shoulder back together. I knew that, just possibly, it was never going to heal as long as I kept using my shoulder as a power tool in my work, day in and day out.

My muscles could hold my shoulder together, but they were becoming extremely tired and riddled with trigger points as a result.

But the Great Recession of ’08 had officially started and there was debt to pay, so I opted to watch and wait and hope for signs of progress. If I could detect signs of healing under these circumstances, then they would probably continue, and I could suffer through.

The first attempt at trigger point therapy

In about late September, I took my first stab at serious trigger point therapy. I knew full well that many of my worst symptoms were now caused by trigger points. A deep pain had set in, a low rumble that never let up, with a toothachey epicentre that was much more acute, and yet too dull to be the injured joint itself — classic trigger point sensations.

But I was also still getting a lot of sharp stabbing joint pain with incautious shoulder movements. Clearly, the joint was still in a pickle. Would relieving the trigger points really do much?

It was worth a shot.

My first impression was really positive. Trigger points throughout the region felt incredibly important. Pressing on them caused dramatic referral pain to slice through my shoulder every which way. A trigger point in the infraspinatus muscle, way on the back of the shoulder blade was especially impressive. It radiated pain in a spike right into the acromioclavicular joint, almost as if it was causing the injury pain. (See more about this phenomenon in the sidebar below.)

And I got a small but distinct dose of relief. I almost started celebrating. I re-treated several times over the next few days. I threw everything I had at my trigger points.

But the relief was short-lived. I quickly hit bottom. I was still just too injured — there was a distinct limit to what trigger point therapy could do. It was like digging a hole in easy soil for a couple of feet … and then hitting bedrock. The worst of the trigger point pain could be dealt with, but there was that bedrock of ripped-ligament pain that was not budging.

Back to the drawing board.

A deep pain had set in, a low rumble that never let up, with a toothachey epicentre that was much more acute — classic trigger point sensations.

Will this ever end?

There is a stage in every healing process when the patient begins to think, This is never going to end. I am going to hurt forever.

I had sunk into that state of despair sooner than most of my patients. It was only early November. Only two months had passed since the re-injury. That’s not really that long for ligament recovery, which can take months. But by early November, I was starting to fear the worst, and starting to plan for taking time off and pursuing surgery, perhaps because I saw no sign of improvement whatsoever. In fact, if anything, I was worse than ever.

But I was being fooled.

I was being fooled by trigger points. Even after years of teaching this stuff, I was being fooled by trigger points. Damn!

It ends!

In fact, my acromioclavicular joint was healing. In fact, it was healing surprisingly well. I just couldn’t tell. I had transitioned seamlessly from the frying pan of ligament injury to the fire of trigger-point pain … and I hadn’t noticed the difference. They were both really hot and unpleasant.

Why couldn’t I tell the difference?

How was I fooled? Don’t the two kinds of pain feel different? They do — but the switcheroo is gradual — by the time that trigger-point pain had replaced sprain pain, I had been feeling a little bit more of the former and less of the latter each day for several weeks.

There’s some interesting neurology that probably also explains it, especially the neurological phenomenon of “convergence.” The brain has difficulty isolating internal pain. The result is essentially a confusing mess of sensation that seems to be coming from several different places, like trying to figure out where a sound is coming from in an echoey room. The brain literally has trouble telling the difference between the trigger-point pain and the injury pain, and starts to treat them as essentially the same message — which makes sense in a way, doesn’t it? It’s basically the same problem. This is why the trigger point in the shoulder blade felt so much like the injury itself — that’s the phenomenon of “referred pain” at work. The brain detects a disturbance in adjacent tissue and it just can’t tell the difference any more.

Convergence and referred pain are really fascinating. For keen patients and physiology students, the full trigger point tutorial discusses convergence in detail, comparing several different prevalent theories about it.

I did not suspect what had happened until the second week of November, when I decided it was time to “take the edge off” my pain again with a good dose of trigger point therapy … and virtually cured myself overnight.

This time my shovel didn’t hit bedrock. The joint pain wasn’t there to defy me anymore. As my trigger points eased, I simply felt better. A lot better. 90% better.

And it lasted. Because, of course, there was relatively little joint pain remaining to re-aggravate the trigger points.

Epilogue and a fun graph of pain

As I write this, it’s been about three weeks since my surprise victory, and I am still doing very well.

I have cancelled my plans to take time off work, and there is no longer any thought of surgery. The shoulder isn’t perfect, not by a long shot. It’s probably still quite vulnerable to re-injury. But the overall suffering is down to only about 5% of what it was before, and holding steady with no sign of further trouble.

My experience strongly validates the vital therapeutic principle that muscle pain can replace and supercede injury pain, and create a compelling illusion that the injury isn’t healing. Of course, as long as the trigger points carry on, in a sense it is not healing — but whereas the original injury was relatively untreatable and simply required adequate time for recovery, trigger points can almost always be at least partially relieved, and often banished from tissues, especially if they are in an area where there was no history of problems.

My experience strongly validates the therapeutic principle that muscle pain can replace and supercede injury pain.

To wrap this up, I want to retell the story graphically.

I’ve saved this for last because it’s a complicated scenario and a complicated graph. It probably would not have made an awful lot of sense at the beginning of the article. But, hopefully, the interwoven tales of these two types of pain will now seem quite obvious …

Notes

This isn’t the first time I’ve had the opportunity to “study” my own injuries, either — not hardly. I’ve had several other sports injuries. This is partly how I earn my credibility as a publisher on this subject! Return to text.
Simons et al. Muscle Pain, p259. “The old concept of a pain-spasm-pain cycle does not stand up to experimental verification either from a physiologic point of view or from a clinical point of view. Physiologic studies show that muscle pain tends to inhibit, not facilitate, reflex contractile activity of the same muscle ... In 1989, Ernest Johnson, editor of the American Journal of Physical Medicine, summarized overwhelming evidence that the common perception of muscle pain being closely related to muscle spasm is a myth and that the myth has been strongly encouraged by commercial interests.” Return to text.
It’s more that they feel tight than an actual limitation of extensibility. Return to text.
Travell et al. Myofascial Pain and Dysfunction. 1999. The ultimate myofascial pain syndrome reference, the product of decades of extraordinary dedication by two doctors famously devoted to the subject of soft tissue pain. The two-volume set is also brilliantly illustrated. The introductory chapters constitute an excellent overview of the subject, albeit a dauntingly technical one. Note: although a landmark and important text, more recent information has been published in Muscle Pain: Understanding Its Nature, Diagnosis and Treatment by Siegfried Mense and David Simons. Return to text.
So far, this is a theory, currently unsupported by any direct scientific evidence. But it’s a reasonable theory, and has about a thousand pounds of indirect scientific support. Return to text.
Shah et al. Archives of Physical Medicine & Rehabilitation. 2008. This important paper demonstrates that the biochemical milieu of trigger points is strongly acidic and full of large quantities of pain-causing metabolites: powerful evidence that the energy crisis theory of trigger point formation and perpetuation is correct. It’s an improvement on an earlier paper from 2005 (Shah), with improved methods. It is cogently summarized by Simons, and in my short article Toxic Muscle Knots. Return to text.