Trigger/tender points (upper quarter)

Dr. A is a physician who was initially referred to me by her personal trainer.  She had been working out with him for several months but had begun to progressively feel discomfort (pain) in her shoulders and neck.  It finally got to the point where she couldn’t continue exercising.

Dr. A is a rheumatologist and has been practicing for many years.  She was very easy to work with and easily understood everything I was explaining to her.

My initial precautionary tests:  transverse alar ligament test, vertebral artery compression test, and cervical compression/decompression were all negative.   Dr. A had not reported any other symptoms that suggested brachial plexus involvement or multiple crush syndrome, so I moved on to assessing AROM.   All motions, flexion, extension, L&R lateral flexion, and L&R rotation were limited, but this appeared to be due to discomfort, not muscle tightness.  Her posture did not demonstrate any significant upper or lower-cross characteristics.  The PROM testing revealed no hard end-feels. She was complaining of tenderness and tightness and indicating the exact location of each point, even before we tested RROM.

I started to question whether or not this set of symptoms was actually more related to muscle strains from weight lifting too much too soon, or weight lifting with improper technique.  As I began performing myofascial release and cross-fiber gliding/trigger point release techniques, Dr. A acknowledged every tender point as soon as I used any hand/finger pressure at all. Almost all her tender points were located posteriorly, in the trapezius, levator scapula, and rotator cuff muscles; infraspinatus, supraspinatus, teres minor, and subscapularis.

Because pressure seemed to aggravate the tender points, I switched to a modified strain-counter-strain technique (Chaitow) known as integrated neuromuscular inhibition technique (INIT).  What is unique about this technique is that it includes PNF type stretches following the SCS. (To be sure, we shouldn’t be stretching muscles that are already overstretched, and many of her trigger/tender points were in muscles that are typically overstretched.  But, neither her ROM testing nor her postural assessment suggested muscle length imbalances.)

The way I utilized the INIT was to palpate the tender point with enough pressure to elicit a pain response.  This was done to accurately determine the location of the tender point and to create a baseline of discomfort.  As soon as Dr. A responded to a particular tender point, I positionally manipulated the length of the muscle where the tender point was located so that the length of the muscle became shorter than its normal resting length.  As I manipulated her position, I asked her to tell me if or when the discomfort was reduced by 50%, or more.  Most of the time, the pain diminished completely, when I found the correct position.

I held the SCS position for 90 seconds, exaggerating it slightly if the pain seemed to be returning during the 90 second SCS maneuver.  At the end of the 90 second period, I eased her back into a neutral position and utilized the ‘stretching during therapy’ technique to both stretch and test for any remaining discomfort. I assisted Mary in utilizing a ‘reciprocal inhibition’ form of stretching, or more accurately ‘releasing’, for each muscle/group being treated.  My assistance was only supplying the resistance for the post isometric contraction.  At no time did we create any external manual force (manually increasing muscle length) to accomplish the stretch.

If there was any remaining pain, I repeated the procedure.  I performed this protocol on the previously listed muscle groups in both upper quarters.  Mary’s pain was diminished significantly (but not completely) and her ROMs were WNL at the end of the session.  We decided to reschedule to see if we could achieve a pain-free result.

At our next session, Mary reported feeling pretty good for a few days after the initial session, but the tender points returned after 3 or 4 days at the office.  We decided to stop her weight lifting exercises for a while, to see if it was aggravating the tender points.

The tender point pain had diminished compared to that in her initial session, so we thought we were on the right track.   We then repeated the same protocol we had utilized during the first session, achieving similar results.  I then helped Mary learn how to accomplish the PNF stretches, utilizing a single-person technique, which she could accomplish at home.

Our initial work together began several years ago.  Since that time, Dr. A has returned to my office whenever the physical demands of her practice, or her active lifestyle, have resulted in active, painful trigger/tender points.  From the time we began working together, Dr. A has referred more than two dozen patients to my office.

Thank you! Dr. A.

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