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Muscle strains strike most often in the big muscles of the body. But sometimes the pain is not what it seems …

last updated 41 days ago, Mar 30th, 2012

Save Yourself from Muscle Strain!

AN ADVANCED TUTORIAL FOR PATIENTS AND PROFESSIONALS

Muscle strain (pulled muscle) and muscle pain explained and discussed in great detail, plus every imaginable treatment option

by Paul Ingraham, Vancouver, Canada BIO
Credentials & qualifications. I am a science journalist, and I was a massage therapist for ten years. I’m close to the end of a Health Sciences degree — 2 courses left! — and I am on the editorial team of Science-Based Medicine. I have spent many years studying therapy science, and my work is greatly enriched by thousands of conversations with readers and experts from around the world. I make a living from this website, selling some of my most detailed tutorials as ebooks. For more, see Who Am I to Say?

Welcome to the most detailed information about muscle strain and pain available anywhere, especially for tough and stubborn cases. This is more than just a web page: it’s bigger than it looks, a pair of online books — many dozens of chapters and over 100,000 words — for both patients and professionals that explores every myth and controversy, and every possible way of reducing pain coming from muscle. It is more scientifically current than any competitive information source, yet also more user-friendly and readable.

What is muscle injury? Is your muscle actually injured? What works? What doesn’t? Muscle strain and pain are usually woven together. Somewhere in your body, something hurts and you think it’s got to be a muscle strain or a muscle spasm or … well, something to do with a muscle anyway. If you’re like most people with muscle pain, you’re not sure exactly what the problem is, and you’re looking for some answers.

About footnotes. There are many footnotes here. Click to make them “pop up” without losing your place. There are two kinds: fun and boring. Try one!1Footnotes with more interesting “fun” extra content are bold and blue, while “boring” footnotes (citations and such) are lightweight and gray. You can also close footnotes by just re-clicking the number.

2“Boring” footnotes usually contain scientific citations from my giant bibliography of pain science. Many of them actually have pretty interesting notes.

Example citation:
Berman et al. Acupuncture for Chronic Low Back Pain. New England Journal of Medicine. 2010. PubMed #20818865. ← That symbol means a link will open in a new window.

Muscle strain and pain myths and misconceptions

Believe it or not, muscle pain is a subject of great scientific mystery and many myths and misconceptions. A torn muscle is arguably among the most medically neglected of all common injuries.12 Odds are good that your family doctor is not competent to assess and treat musculoskeletal problems, including muscle strains.3

And so, although most muscle pain is relatively simple to diagnose and self-treat, an incredible number of people end up in my office who either have muscle strains that have been misdiagnosed as something else, or they have “something else” that’s been misdiagnosed as a muscle strain. Strain, pain, spasm, contracture, scar tissue, tone and tension are all poorly understood and routinely confused. They are not only surprisingly complex topics scientifically, but clinicians are not generally aware of the research that has been done.

It would be nice, for once, if someone came to my office with a muscle pain that had been accurately diagnosed … but it almost never happens! So I wrote this tutorial, because clearly there is a need for it. The world obviously needs more and better information about muscle pain. And if you’ve read this far, then so do you!

How can you trust this information about muscle strains?

What would Adam & Jamie do? You know, if they were doctors?

I’m inspired by the MythBusters approach: I question everything and I have fun doing it. (No explosions, alas.) I assume that anything that sounds too good to be true probably is. I make no big promises, and I do not claim to know the “one true cause” of muscle strain and pain. When I don’t know something, I admit it. I actually read scientific journals, I clearly explain the science behind every key point (there are more than 40 footnotes here), and I always link to the original sources.

So all the science and all the options for muscle strain treatment are here. If you’ve been struggling with pulled muscle injury, I think this tutorial will feel like a “good find” to you!

You are going to know all about muscle strain by the time you get to the end of this document. In fact, you’re going to know more about muscle pain — and how to treat it — than all your friends and neighbours, and probably more about it than your family doctor or your physiotherapist!

As with all the tutorials on SaveYourself.ca, I’ve worked hard to provide you with the best information available anywhere — not just better researched and referenced, but also regularly updated, and presented in a clear, friendly style that’s just like coming to my office and having a nice long conversation about it, where all your questions get answered.

So what is a muscle strain?

Actually, it's simple: any torn muscle is called a muscle strain (and this is the same as a “pulled muscle”).

(A torn muscle is never called a “sprain.” Sprains always refer to torn ligaments. There’s actually no such thing as a “muscle sprain” — it’s a contradiction in terms.4).

Although you might have problems that make you vulnerable to a muscle strain, the direct cause of every muscle strain is traumatic ripping of the muscle tissue — arg! — usually at the point where the muscle meets its tendon. Muscle will tear under the force of your own muscular contraction, or excessive stretch.

The more muscle fibres are torn, the worse the strain. In the case of a serious strain, the entire muscle may completely rupture — literally ripped in half! Double arg!

Muscle strains are particularly common in the thigh and groin in soccer, ultimate, hockey and other fast-moving team sports.

Muscle strains are particularly common in the thigh and groin in soccer, ultimate, hockey and other fast-moving team sports.


Muscle strains are particularly common in the thigh and groin in soccer, ultimate, hockey and other fast-moving team sports.

Muscle strains are particularly common in the thigh and groin in soccer, ultimate, hockey and other fast-moving team sports.


Sometimes an impact or a laceration damages muscle fibres in such a way that the injury is basically like a muscle strain. We won’t discuss this scenario much, because there’s not much medical mystery involved if you were gouged by a hockey skate. We also won’t discuss full muscle ruptures in much detail, because they are so extreme that they are easy to diagnose — even doctors can do it! If you have a doctor who can’t help you with lacerations and contusions, you really need a new doctor.

There will be much (much) more detail below about exactly what a muscle strain is, and its complications, and how to treat it, and so on. But before we get into that, it’s important to determine whether or not you actually have a muscle strain, or some other kind of muscle pain.

Part 2

Diagnosis

How do you know that you’ve got a muscle strain?

Muscle strains and especially muscle ruptures are actually surprisingly rare, compared to other causes of muscle pain. Funny thing about this tutorial: most people who find this document, like most people who think they have strained a muscle, have actually not done any such thing — or (just as common) they strained a muscle once upon a time, but the strain healed long ago and has since become an entirely different problem.

This could be you!

Most people who think they have strained a muscle have actually not done any such thing.

Some of the things that get confused with muscle strains are (and these will all be covered in more detail below):

  • Spasms, cramps, and charlie horses are whole muscle contractions, ranging from uncomfortable to those howling, awful attacks that usually afflict the calves and feet.
  • Nasty muscle knots, technically known as trigger points, are small patches of localized muscle spasm and involve no actual damage to the muscle.
  • Delayed onset muscle soreness, a.k.a. DOMS or PEMS, is that savage muscle soreness we all get after an unfamiliar workout … but it always (really) fades after about three days, guaranteed.
  • Low back pain is a complex phenomenon which routinely gets attributed to muscle strain, when in fact it is very rarely caused by muscle strain. Just about the only time low back pain is ever caused by muscle strain is when you have a sudden, severe onset of pain while trying to move a hide-a-bed down some stairs … or something like that. If you have low back pain, I recommend that you stop reading this article right now and head on over to Save Yourself from Low Back Pain!)

Cramp versus strain example: Multi-muscle cramping catastrophe on a hot summer night

In 2007, I was enjoying my athletic peak and managing, just barely, not to embarrass myself while playing quite a bit with some younger and more talented athletes. One hot night I was running low on electrolytes: too much sweating, not enough salt intake. (Actually, that’s a surprising myth.5) I was playing “goaltie,” a variant of ultimate: a hard-running Frisbee sport with the same intensity and speed as soccer, but with more jumping.

Both calves spasmed on a jump, bringing me down hard. That was nasty, but it was just the start: as soon as I hit the ground, both sets of hamstrings went off as well, and all that was more than enough to make for a good cramping story … but then my abdominals joined the fray, and that gave me an anecdote I’ll be sharing for the rest of my life.

The cramping all hurt, a lot, but I was too surprised and busy to focus on the pain. If you’ve ever had a strong spasm, you know that there’s a powerful instinct and need to elongate the muscles. Stretching is your only hope of relief. But I had a puzzle to solve: just try to stretch the backs of your legs and your abdominal muscles at the same time. It’s an anatomical impossibility.

That’s me in the air at the back. Check out that vertical! It was that kind of jump that triggered a massive wave of spasms …

I jackknifed back and forth so violently that the other players wondered if I was having a seizure, but I was simply on my impossible mission to stretch both sides of my body. If I stretched the legs, the abdominals would bunch up; if I stretched them, the leg muscles tried to kill me. After about three tries each way, I realized it couldn’t be done and that my only hope was compromise: to find the least awful position somewhere between the extremes. It meant that neither muscle group would really be stretched at all — but neither would be allowed to fully contract either. I gasped “cramps! lots of cramps!” so everyone knew I wasn’t actually scissoring … and then waited it out.

Without the power of stretch, the cramps took a long time to fade. It was a long time to endure extremely powerful contractions.

A spasm is capable of injuring muscle. In this case, I was wrenching back and forth, my own muscles in a tug-of-war with each other. These were perfect conditions for injury. Something had to give, and it did — I had mild strains of all the affected muscles, resulting in not just days of soreness but severe soreness for weeks, and a vulnerability to re-injury that was still a problem a full year later.

The spasm here was the strong involuntary contraction of the muscles. The strain was the injury caused by the forces on the muscles.

True muscle strain checklist

Here’s a checklist of the signs and symptoms of a true pulled muscle. If you can say, “Yeah, that’s me,” to all of these, then congratulations: you probably have an actual, certifiable, card-carrying Muscle Strain®.

Did it hit you suddenly during strong stretching or a moment of athletic intensity? Were you lifting something way too danged heavy and/or awkward? In other words, did you have an “oh, shit” moment?

Is the injury fairly recent? A few weeks old at the most? If it’s been a long time, it’s probably not a muscle strain any more — certainly not an acute one!

Do you have just one muscle (or muscle group) that’s both weak and painful to use?

Is there a spot in the muscle that’s especially sensitive? (It may even be little bit deformed — is there a bump or a depression?)

Is the skin flushed and hot? Does it look puffy?

If you “woke up with it,” or the pain came on slowly over several days, or if it’s six months old, or if the pain isn’t consistently in one particular place … then we’ll be talking about other possibilities. If your real problem is actually a painful “muscle knot,” for instance, you might want to take your knots for a nice massage — but massage is mostly pointless for a strain.

The “oh shit” moment: the most essential sign of muscle strain

Muscle strain cannot occur without an “oh shit” moment. (It’s fun to explain oh-shit moments to my patients — it always gets a laugh!) In other words, it hits suddenly: you know that something nasty has happened

END OF FREE INTRODUCTION

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  • Free second tutorial! When you buy this tutorial, you will also get Save Yourself from Trigger Points and Myofascial Pain Syndrome! — a $1995 value. Muscle strain (injury) and muscle pain (knots) are so intertwined and confused that most readers need information about both. I supply both for the price of one: a 2-volume set. You automatically get both when you purchase here.

Volume I Contents


 
TABLE OF CONTENTS

Volume II Contents

And here’s a sneak peak of the Table of Contents for the trigger points tutorial, which is delivered automatically with the muscle pain tutorial (yes, it’s much bigger)…

  1. Minor update Dec 30 '10

    Introduction

  2. Trigger point therapy is not a miracle cure for chronic pain — but it’s close

  3. What exactly are muscle knots?

  4. Why muscle knots matter so much

  5. How can you trust this information about trigger points?

  6. Trigger points are good, hard science

  7. Why are trigger points so neglected?

  8. Does your trigger point therapist have the big red books?

  9. A brief note about the relationship between fibromyalgia and myofascial pain syndrome

  10. Minor update Jun 25 '10

    Trigger points also explain many severe and strange aches and pains

  11. Two typical tales of trigger point treatment

  12. DIAGNOSIS: How can you tell if trigger points are the cause of your problem?

  13. Trigger point diagnosis is not reliable … but it also may not matter that much

  14. Where are the charts and diagrams of trigger point locations in this tutorial?

  15. Quick checklist: classic trigger point symptoms

  16. Slow checklist: a more detailed diagnostic checklist for myofascial pain syndrome

  17. Minor update Feb 03 '11

    Negative checklist: symptoms that are probably not caused by trigger points

  18. If you have trigger points, will your muscles be “tight”?

  19. Identifying your trigger points by feel

  20. “Out of nowhere”: a signature symptom of trigger points

  21. Chasing pain: hurting in all the wrong places

  22. Nerve pain is overdiagnosed

  23. Case study: a story about nerve pain that wasn’t really nerve pain

  24. Morning symptoms: an uncomfortable daily mystery for many people

  25. From the frying pan of injury pain to the fire of trigger point pain

  26. Could it be __________? Several specific problems that trigger points get confused with

  27. Case study: “Bursitis” strikes again!

  28. Predictably unpredictable: trigger point symptoms are erratic by nature

  29. All the noise! Trigger points, joint popping, and crepitus

  30. What are the worst-case scenarios for myofascial pain syndrome?

  31. Worst Case Scenario 1: Being triggery

  32. Worst Case Scenario 2: Rare but extremely severe cases of myofascial pain syndrome

  33. Worst Case Scenario 3: Quick-start trigger points

  34. TRIGGER POINT SCIENCE: The dance of the sarcomeres and the (weird) science of trigger points

  35. What sarcomeres do

  36. One: The vicious cycle (why trigger points are so generally stubborn)

  37. Two: Good pain (why pressing on trigger points hurts like hell but feels like heaven)

  38. Three: The “tightness” problem (why grouchy muscles may not respond to stretching)

  39. Four: Weakness (why muscles with trigger points are weak and should not be challenged with strength training)

  40. Everything we just discussed … in a few bullet points

  41. Triggers for trigger points: what makes patches of sarcomeres go haywire?

  42. The all-powerful acne analogy

  43. The evolution of muscle pain: does muscle “burn out”?

  44. Referred Pain Science (basic)

  45. Referred pain science (advanced)

  46. Other trigger point theories

  47. “The bamboo cage” theory of muscle pain

  48. Case study: an example of getting unstuck and feeling “giddy with joy”

  49. Muscle knots are not inflammatory: the myth of the inflamed myofascial trigger point

  50. Adhesions and contracture: when trigger points freeze in place

  51. Corrected Jul 20 '10

    The science of adhesions: atoms stick to each other

  52. The scar tissue issue — are you scarred for life?

  53. BASIC TRIGGER POINT SELF-TREATMENT: What can you do about garden variety trigger points?

  54. Downloadable quick reference guide

  55. Basic self-massage instructions

  56. How do you know it’s working? Getting a trigger point to “release”

  57. Basic tips and tricks for better, longer-lasting trigger point release

  58. Top 5 mistakes beginners make

  59. What about massage tools?

  60. Can you damage your nerves when self-massaging?

  61. Don’t hesitate to recruit amateur help

  62. A little more perspective on amateur assistance

  63. How to get adequate professional help

  64. Common medications that might make a difference (and might not)

  65. ADVANCED TRIGGER POINT TROUBLESHOOTING: What can you do about severe and persistent trigger points?

  66. A brief detour: why not The Trigger Point Therapy Workbook?

  67. Fundamental limitations of trigger point therapy, and how to take advantage of them

  68. Several more treatment mistakes and problems (that you can fix)

  69. More serious barriers to success

  70. NEW Feb 03 '11  +1

    New evidence that squishing trigger points works at least a little

  71. Upgrade your self-massage technique

  72. Don’t get hung up on anatomy, and be persistent

  73. Focussing on one trouble spot versus “a little bit of everything” — which is the better strategy?

  74. More information about exactly how to rub (moving strokes)

  75. Yet more information about exactly how to rub (pressing and holding)

  76. Using “press and hold” to identify a trigger point release in progress

  77. Identifying your trigger points by feel (once again, as it pertains to treatment)

  78. Referred pain is not a diagnostic feature of trigger points!

  79. Don’t be fooled by “reverse referral”

  80. Beyond the tennis ball: commercial massage tools

  81. Commercial massage tools to avoid

  82. Massage tools: 7 free and cheap and effective tools from objects not originally intended for massage

  83. The sock trick

  84. The bath trick

  85. Introduction to non-massage self-treatments for trigger points

  86. Stretching (executive summary)

  87. Mobilizations: massaging with movement and the Goldilocks zone

  88. Case study: mobilizations prove to be crucial factor in recovery from neck pain that started in the 1970s

  89. Trying to squirm your way out of trigger point pain? Don’t do it! Consider a little more method in your madness

  90. How to take your trigger points to the gym (if you must)

  91. Thermotherapy

  92. Breathing deeply is free, safe, and possibly amazing therapy for trigger points!

  93. An introduction to medicating muscle pain (hint: not a great option)

  94. Anti-inflammatories and Tylenol

  95. Voltaren® Gel, an intriguing new option

  96. Minor update Apr 10 '11

    The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids

  97. Tiny update Jul 07 '10  +1

    The surprising futility of muscle relaxants such as Robax-whatever, Valium and other benzodiazapenes

  98. Combination treatments: why and how to throw everything at it but the kitchen sink

  99. Troubleshooting referred pain: the referred pain field guide

  100. Case study: referred pain causes a “heart attack” and completely fools dozens of professionals

  101. Troubleshooting negative reactions to treatment

  102. PERPETUATING FACTORS: What makes trigger points stubborn?

  103. Troubleshooting “stuck” trigger points — adhesions and contracture

  104. Troubleshooting stress (without meditation or yoga, unless you like that sort of thing)

  105. Troubleshooting posture, ergonomics, and muscle imbalance

  106. Troubleshooting mysterious perpetuating factors

  107. The relationship between trigger points and other physiological disorders and diseases, especially fibromyalgia

  108. Way beyond stubborn: troubleshooting extreme cases

  109. Reality checks: some self-treatments that don’t work at all (or not nearly as well as you would hope)

  110. What if trigger points only partly explain your chronic pain? Several other causes of chronic, undiagnosed pain

  111. Many new sections Sep 23 '10  +1

    MEDICAL FACTORS THAT PERPETUATE PAIN: The effect of statin drugs, nutritional and hormonal deficiencies, infections, and inflammatory diseases

  112. Some usual, unusual, and unique medical disclaimers

  113. Getting tested and treated: the hard way, the easy way, and the right way

  114. Statin (cholesterol-reducing) drugs

  115. Nutritional and hormone deficiencies

  116. Science update May 07 '11

    Vitamin D deficiency

  117. Thyroid hormone deficiency

  118. Iron deficiency (and excess)

  119. Vitamin C deficiency

  120. Vitamin B12 deficiency

  121. Vitamin B1, B2, folate, and magnesium deficiencies

  122. Testosterone deficiency

  123. Estrogen deficiency

  124. Infections

  125. Inflammation

  126. Overall treatment strategy

  127. STRETCHING: Stretching is generally over-rated … but it might be good for trigger points

  128. The anecdotal evidence

  129. NEW Oct 06 '10

    Case study: A cautionary tale of stretching: that time I almost ripped my own head off

  130. The limitations of stretching for trigger points

  131. Muscles with trigger points may already be overstretched

  132. The spray-and-stretch method implies stretch alone may not work

  133. Simons and Mense are keen on stretching

  134. How stretching works if if works

  135. Stretching “conclusions”

  136. Minor update Mar 22 '11

    GETTING HELP: How do you find good therapy for your trigger points?

  137. Minor update Apr 17 '10

    Types of therapists and doctors and their relationship to trigger point therapy

  138. “But I’ve already tried massage therapy …”

  139. Two case studies: highly-trained therapists failing miserably

  140. Worst practices in massage therapy

  141. How to find good trigger point therapy

  142. The Pressure Question: how much is too much?

  143. Minor update May 30 '11

    Pain in three flavours: the good, the bad, and the ugly

  144. Training your therapist

  145. Other kinds of therapies

  146. How about spray and stretch therapy?

  147. How about the Paul St. John Method of Neuromuscular Therapy?

  148. How about transcutaneous electrical nerve stimulation therapy? (TENS or ENS)

  149. Major update Dec 30 '10

    How about ultrasound therapy? (ESWT and “Sonic Relief™”)

  150. How about chiropractic joint adjustment and popping?

  151. How about myofascial release and fascial stretching?

  152. How about trigger point injection therapy?

  153. How about Botox injection therapy?

  154. How about nerve blocks?

  155. Modest expansion Nov 25 '10

    How about Dry Needling and Intramuscular Stimulation (IMS) therapy?

  156. How about acupuncture?

  157. How about Active Release Techniques® (ART)?

  158. Measuring progress in trigger point therapy

  159. Closing Thoughts: How is a lemon like a trigger point?

  160. NEW May 26 '10

    Appendix A: Trigger Point Reference Materials or: Diagrams, Diagrams, Diagrams!

  161. NEW May 26 '10

    Appendix B: The Trigger Point Symptom Checker

  162. NEW May 26 '10

    Appendix C: The Perfect Spots

  1. Spot #1 for pain almost anywhere in the head, face and neck, but especially the side of the head, behind the ear, the temples and forehead

  2. Spot #2 for pain anywhere in the low back, tailbone, lower buttock, abdomen, groin, side of the hip

  3. Spot #3 for pain in the shin, top of the foot, and the big toe

  4. Spot #4 for pain in the upper back (especially inner edge of the shoulder blade), neck, side of the face, upper chest, shoulder, arm, hand

  5. Spot #5 for pain in the elbow, arm, wrist, and hand

  6. Spot #6 for pain in the low back, hip, buttocks (especially immediately under the buttocks), side of the thigh, hamstrings

  7. Spot #7 for pain in the side of the face, jaw, teeth (rarely)

  8. Spot #8 for pain in the lower half of the thigh, knee

  9. Spot #9 for pain anywhere in the chest, upper arm

  10. Spot #10 for pain in the bottom of the foot

  11. Spot #11 for pain anywhere in the upper back, mainly between the shoulder blades

  12. Spot #12 for pain in the lower back, buttocks, hip, hamstrings

  13. Spot #13 for pain in the low back, buttocks, hamstrings

  1. NEW Apr 03 '10

    Appendix D: Trigger Point Therapy Resources

  2. Acknowledgements

  3. Reader Comments

  4. What’s new in the Trigger Points tutorial?

  5. Notes

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Part 2.4

Appendices

Acknowledgements

This document and all of SaveYourself.ca was, for many years, created in my so-called “spare time” and with a lot of assistance from family and friends. Undying thanks to my wife, Kimberly, for countless indulgences large and small, and for being my “editor girlfriend”; to my parents for (possibly blind) faith in me, and much copyediting; and to Mike Gobbi, buddy and digital mentor, for many of the nifty features of this document (hidden and obvious). And thanks to all of the above, and many others, for many (many) answers to “what do you think of this?” emails.

Thanks finally to every reader, client, customer, and big tipper for your curiosity, your faith, and your feedback and suggestions and stores. Without you, all of this would be pointless.

And a few thanks to some health professionals who have been particularly inspiring to me: Dr. Steven Novella, Sam Homola, DC, Dr. Harriet Hall, Simon Singh, and Dr. Stephen Barrett.

Reader Comments

Here is what some readers have said about the muscle strain and pain tutorial over the years. Feedback is always welcome. I focus on the positive in this section, but I want to acknowledge that I certainly do receive some criticisms as well. In many cases I respond by making improvements to the tutorial. However, the vast majority of feedback is enthusiastic. Thanks, everyone!


The internet is a dicey place to spend money ... so many scams. I wanted to let you know how appreciative I am of your eBook on muscle strains. When I got to the stop sign, I had to reflect and realized that the style and quality of what you had written was worth a gamble. Well, paying the twenty bucks and learning what I wanted to learn — and more — was worth every penny. I am now rehabbing my level 1 calf strain with full confidence and feel very well informed moving ahead. Good luck and keep writing — we need all the help we can get out here!

— Craig Adkins, tennis player and professional skiing cameraman, Portland, Oregon


Enjoyed your web site and found the advice extremely helpful having just strained my thigh muscle.

— Paul Farley, West Sussex, England


My strained thigh muscle felt like a broken bone at first, but I'm using your icing method and it’s responding brilliantly.

— Paul Farley, West Sussex, England


I found this article when I was researching how to heal my pulled muscle. I love the mobilization exercises at the end — great for a ‘desk jockey’ like me!

— Juanita Vannay


I read your article on muscle strains, and I was very impressed. You seem to really know your stuff. I wish there was one of you in every state!

— Robin



One more special comment. In the Spring of 2009, I received an incredible endorsement from Jonathon Tomlinson, a GP in Hackney, East London, praising the whole website and every tutorial:

I'm writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.

— Dr. Jonathon Tomlinson, MBBS, DRCOG, MRCGP, MA, The Lawson Practice, London

High praise indeed! Thank you, Dr. Tomlinson — testimonials just don’t get much better than that.


Further Reading

Here are several additional articles of interest:

And here are the articles recommended for those of you who may have muscle knots, as opposed to a muscle strain:

What’s new in this tutorial?

A major feature of my tutorials is that I actively update them as new science and information becomes available. Unlike regular books, and even ebooks — which can be obsolete by the time they are published, and can go years between editions — this tutorial is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 11 major and minor updates worth logging since I started logging carefully in late 2009, and countless more minor tweaks and touch-ups.

New section (Mar 30 '12, section #4.17)No notes. Just a new section. See section #4.17, Prevention: will water and electrolytes make a difference?

Update (Nov 2 '11, section #4.9)Rewritten and expanded with important evidence about how stretching does not prevent strain injuries. See section #4.9, What about stretching? Can it treat or prevent strains?

Minor update (Jul 14 '11, section #2.2)Added a (very) funny clip from the TV show Glee. See section #2.2, True muscle strain checklist.

Major update (Jun 21 '11, section #2.2)Major improvements to the table of contents, and the display of information about updates like this one. Sections now have numbers for easier reference and bookmarking. The structure of the document has really be cleaned up in general, paving the way for efficient conversion to other formats (Kindle, Apple’s iBookstore, etc). Best of all, it is now significantly easier for me to update the tutorial — which will translate into more good content for readers. Care for more detail? Really? Here’s the full announcement. See section #2.2, True muscle strain checklist.

New artwork (Jun 8 '11, section #3.3)Added a nice new diagram of strain severity. See section #3.3, What’s the worst case scenario for your muscle strain?

New section (Mar 12 '11, section #2.1)No notes. Just a new section. See section #2.1, Cramp versus strain example: Multi-muscle cramping catastrophe on a hot summer night.

New section (Jan 18 '11, section #3.4)Some useful new information about how to estimate healing time more accurately. See section #3.4, Healing time is hard to predict.

New section (Oct 5 '10, section #4.13)Another new section and yet more good new evidence about prevention. See section #4.13, Prevention: Warmups work.

New section (Sep 15 '10, section #4.16)New section based on solid new evidence about prevention. See section #4.16, Prevention: can you prevent muscle strains by upgrading your muscle balance?

New cover (Aug 6 '10, section #4.16)At last! This e-book finally has a “cover.” SHOW See section #4.16, Prevention: can you prevent muscle strains by upgrading your muscle balance?

New section (Apr 9 '10, section #4.18)No notes. Just a new section. See section #4.18, Is there anything to the platelet-rich plasma injection hype?

Older updatesListed in a separate document, for anyone who cares to take a look.

Notes

  1. Simons in The Trigger Point Therapy Workbook: Your Self-Treatment Guide for Pain Relief, from the foreword. “Muscle is an orphan organ. No medical speciality claims it. As a consequence, no medical specialty is concerned with promoting funded research into the muscular causes of pain.” BACK TO TEXT
  2. You can get a rough measure of how well-studied a subject is by doing a search for it on PubMed, a large database of citations to medical research. Searching for muscle strain is a bit tricky, because “muscle strain” is mentioned in lots of papers that aren’t really about muscle strain. But if you cleverly search for the terms “muscle strain” only in titles, you will get, as of 4/14/07, only 61 search results, even less than iliotibial band syndrome (another under-studied condition). Compare that to, say, 3000 for adhesive capsulitis (frozen shoulder), or 5900 for carpal tunnel syndrome. BACK TO TEXT
  3. Most doctors are well aware that there are serious shortcomings in the medical management of most musculoskeletal problems, especially chronic pain cases. Dr. Jonathon Tomlinson, an instructor at St. Leonards Hospital in Hoxton, explains that “undergraduate training is focused on hospital orthopedics (broken bones and anything else that’s amenable to surgery) or rheumatology (nasty inflammatory diseases) which comprise a minority of the aches/pains/strains and injuries that people actually suffer from.”

    Medical researchers have done many studies showing that most doctors do not understand aches and pains or heed expert recommendations. A good recent example is a paper in the Archives of Internal Medicine showing that family doctors frequently ignore guidelines for the care of low back pain — see Williams et al.

    More generally, the Journal of Bone and Joint Surgery, and the Journal of the American Osteopathic Association, have both published papers recently showing that physicians simply do not have an adequate understanding of musculoskeletal medicine. In 2002, Freedman et al felt that “It is ... reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate.” Then again in 2005 in JBJS, Matzkin et al concluded that “training in musculoskeletal medicine is inadequate in both medical school and non-orthopaedic residency training programs.” Most recently, in 2006, Stockard et al wrote “82% of allopathic graduates ... failed to demonstrate basic competency in musculoskeletal medicine.”

    BACK TO TEXT
  4. A torn ligament is always called a sprain, whereas a torn muscle is always called a strain. BACK TO TEXT
  5. Was it really the electrolytes? No. That’s what I thought at the time, but a nice myth-busting 2011 experiment comparing crampy runners with their uncramped comrades showed clearly that dehydration was not the culprit. Fun science. See Schwellnus et al. BACK TO TEXT

There are 30 more footnotes in the full version of this book.
I like footnotes, and I try to have fun with them.


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