Stop blaming muscles for chronic pain!
by Core Physical Therapy, December 19, 2015
Look deeper to find the driver of your constant sore muscles.
By: Jason Kart, PT, DPT, CMPT
I’ve debated about writing this post for a very long time. There is a long and deep seated belief that muscles are the primary cause of injury and postural imbalance. So ingrained is this idea, it almost seems like gospel to the many patients, therapists, and doctors around the country. There are countless tools, strategies, classes that all address muscular tightness, myofascial restrictions/ adhesions, length issues, and tendon breakdown. Patients and therapists use everything from massage techniques to foam rollers, metal tools, and specialized techniques aimed at releasing muscles to free you from your pain.
This concept of muscles being a primary problem as been repeated so many times, it is almost sacrilegious to suggest otherwise. Patients and practitioners have spent thousands of hours treating muscles. On the surface, this logically makes sense: “My muscles hurt, you are telling me my muscles are tight, we have to treat the muscles.” But it is all too often I see patients get caught same trap: it’s been six months and they still have to use these techniques to get some sort of relief, or their chosen technique stopped working altogether. They bounce from practitioner to practitioner constantly treating soft-tissue problems only to be met with temporary relief. “If I don’t get a massage weekly, my back really pays for it” I’m going to challenge this institution with some science and a little common sense.
I recently was tapped to be the attending physical therapist for a large sneaker company’s winter athletic competition. I worked with the young group of exercise enthusiasts from all over the country and Canada. All were between the ages of 21 and 28, extremely fit, conditioned, and dedicated to health. These fine people were marathon runners, Cross-fitters, personal trainers etc… There were quite a few patients with mild to moderate low back pain, IT band pain with running, Achilles tendinitis, and mild rotator cuff pain. Almost all of them had been instructed back home to get a massage, roll their IT bands, or to go under some form of specialized muscle treatment technique. All of the athletes I saw had been treating their injury for at least six weeks or more; one patient has been battling IT band problems for two years!
I’m going to stop here for a moment and just say that I am not bashing these muscle and fascial techniques for those that choose to practice or utilize them. I think massage and the other soft-tissue techniques are all helpful and do have a benefit. I believe that they can help induce tissue healing by providing a better environment for the tissue to make positive change. My feeling is that they are just misplaced in the treatment plan. One particular interaction I had with a personal trainer from New York illustrated my point exactly:
Me: How long have you had IT band problems? Was there any event that caused this?
Athlete: Roughly 2 years, and it just came on by itself. I’ve been seeing a physical therapist and chiropractor on and off over that time.
Me: What have they been doing for you?
Athlete: My physical therapist has been doing this muscular release technique across the quadriceps, hamstrings and glute muscles. It provides relief when he does it. My chiropractor has also been using ultrasound, electric stimulation, and is prescribed medical massage, and uses these metal tools to help loosen the IT band.
Me: But you are still dealing with this. So let me ask you,… you go to the gym and workout regularly,… you get sore and fatigued for about 24 hours, but then you’re better, right?
Me: So, what makes these problem tissues different? Why are they behaving abnormally? If you’re young, fit, healthy; shouldn’t you be healing? Everything else heals, correct? So what is the driving force behind this tissue not healing the way it’s supposed?
Athlete: I guess I never really thought of it like that.
What many people don’t realize is that muscles are made to be beat on. They are very capable of stretching, absorbing load and producing force. They are highly vascularized and capable of regenerating quickly. Absent of an actual direct trauma; high velocity strain from sports, a fall, direct impact of some sort, muscles don’t just decide to breakdown. They don’t make the decision to be weaker. They don’t just up and become short. And if they do become short, they are very easy to stretch with a little bit of effort. These athletes are perfect examples of why treating soft-tissue as the primary issue is entirely wrong. They are extremely capable of healing, conscientious of their activity levels, and they are conditioned to withstand force, but somehow. certain tissues of their bodies are not doing their job and are being highly resistant to treatment. This makes zero sense.
What I found next was truly amazing. For the patients with back pain and IT band problems, when I took a look at their hip range of motion, almost all of them had a noticeable lack of internal rotation and extension on the painful side. Why does this matter? The hip joint has a distinct pattern of loss when it becomes stuck, and it starts with the loss of internal rotation and extension. This has nothing to do with the muscles but the actual joint itself. This can start a cascading effect of compensation other places, namely the lumbar spine.
If the athlete is losing hip range of motion, they have to gain it somewhere else. When they push off the affected side while running, if the hip joint doesn’t move, it is very likely that the lower lumbar spine will move excessively backwards to make up the difference. This compensation can only last for so long. Over time this will cause irritability at the lumbar spine as it is much less capable of tolerating excessive amounts of force. The joints and discs within the spine will start to become irritable and produce inflammation. Right next-door are the nerves that control,… you guessed it,… The muscles!
That muscle tightness that you’re feeling? That’s because there are now less muscle fibers working to do the job that you are asking them to do. If 25 to 50% of the muscle fibers have stopped working in that particular muscle because there nerves are not giving them a good signal, the remaining working muscle fibers take on the extra load. This is leading them to breakdown faster and constantly having to heal giving you a tightness sensation. But often, patients mistake tightness as a length problem.
Here is how we bring it full circle. If there is a joint dysfunction at the hip causing compensation at the lumbar spine, the nerves will start to shut down because of the inflammation causing their signal to essentially lessen. The muscles those nerves control will start to atrophy or not fire correctly leading to weakness/instability. Weaker muscles break down faster and don’t stabilize their joints very well. When the hip muscles become dysfunctional, IT band problems, patellofemoral pain issues, hip bursitis, lumbar joint and disc issues are not far behind. Each of these tissue then have to absorb excessive force since they less protection from the hip stabilizers. They are constantly ground down and the body’s natural healing can’t keep up. Once the need for compensation is taken away by addressing the joint not doing its job, the better your body can heal because it is not constantly behind the 8 ball.
I understand it gets hard to make the jump I’m proposing, and its much more complex. It’s a very easy to think that if you’re muscles hurt by not treat the muscles? It seems logical, it’s an easy sell, and hey, who wouldn’t like a massage? But remember, the muscles are really just speakers on a stereo system. Their output largely depends on the stereo and the wires that send the signals. Unless you crank up the volume too high and blowout the speaker, it’s usually a wiring problem. If you are trying to fix the speaker, you aren’t addressing the wiring problem and you won’t get to root of the problem.
If you’re finding yourself battling soft-tissue problems that just don’t seem to heal, find a manually certified physical therapist to take a look at the joint mechanics above and below the area of your problem. Once those are the drivers behind your pain have been addressed, the soft-tissue techniques will help stimulate that healing, but now you’ll get better faster and stay that way.
Jason Kart, PT, DPT, CMPT is the owner of Core Physical Therapy in Chicago and is a manually certified physical therapist through the North American Institute of Orthopedic Manual Therapy. Learn more at www.coreptclinics.com.