Myofascial Barriers to Peak Athletic Performance -- Part I

Abstract

Introduction

At this point, a compelling question needs to be asked: "If myofascial ailments are believed to be so prevalent, then why is valid and reliable epidemiologic information so hard to come by?" Much of the data on this topic has been published under a diverse assortment of names. This diversity of terms has done more to confuse and confound doctors. In effect, two doctors would be unaware that they were looking at the same clinical entity by virtue of the different names being applied to it. To this day, as a result of this historical confusion of terms, many physicians are wholly unfamiliar with myofascial disorders. Similarly, myofascial disorders are foreign to those scholars and athletes actively involved in sport.

Myofascial trigger points can be broadly classified into two categories: latent and active. Latent myofascial trigger points are clinically silent for pain, causing muscular stiffness, weakness, and restricted range of motion.

Active myofascial trigger points share all the attributes of their latent counterpart except for the fact that they actively produce pain. According to Travell and Simons1, latent myofascial phenomena are "far more common than active ones."

Much has been written on the pain generated by myofascial disorders. Myofascial pain is unique in that it is typically referred or projected to a distant region of the body. Knowledge of the referred pain and the distinctive patterns that they exhibit is useful in locating the pain-producing trigger point. This is facilitated since each muscle and their trigger points refer pain in consistent and distinctive patterns.

Latent, as well as active myofascial trigger point phenomena arise as a result of acute overload, overwork fatigue, direct trauma, and by chilling.1 These same mechanisms can transform latent trigger points into active, pain-referring trigger points. Travell and Simons1 have noted that the "signs and symptoms of myofascial trigger point activity long outlast the precipitating event." When a muscle is injured or overworked and adequate rest is not given, the muscle simply "learns" how to avoid further insult. This is accomplished by limiting the forces it generates and by staying taut enough to limit its ability to lengthen through passive stretch. Much of the "dysfunction" that occurs is believed to be modulated by muscle spindles and nociception.

Little has been written on the more ubiquitous but latent myofascial disorders. Since latent trigger points are not painful, they receive very little attention, both in clinical practice and in the research literature. This, I believe, will change as we learn more about how latent myofascial trigger points effect athletic performance.

The dysfunctions that characterize latent myofascial trigger points are limited range of motion and weakness. Herein lies their significance in the realm of sport. An athlete, in order to perform at maximum efficiency and effectiveness, must possess exceptional flexibility and strength. High performance athletes understand the value of strength and flexibility in achieving greatness.

An athlete's fitness level relates directly and positively to his performance. It is the wise athlete who recognizes this and trains for the appropriate fitness level. Fitness has three dimensions to it: strength, flexibility and endurance. Muscles harboring latent myofascial trigger point phenomena are known to lack strength and flexibility.1 It is conceivable that they lack an endurance component as well. Individual or groups of muscles such as these can be said to lack an adequate level of fitness necessary to perform optimally.

When an athlete's overall fitness is appropriate for his sport and level of competition, he will perform well. If this same athlete is harboring a latent myofascial trigger point in a key muscle or muscle group, then he will not perform as well as he might otherwise. Latent myofascial trigger points in key muscles may hamper the athlete's performance. These latent trigger points present themselves as myofascial barriers to peak athletic performance.

Discussion

Six sessions of spray and stretch were required to take the trigger point from an active state to a latent state. At that point the patient experienced left groin "weakness" in the absence of pain. Repeated attempts by the patient to jog or skate resulted in weakness and feelings of "tiredness" and fatigue in the left groin. An additional 12 treatments returned him to jogging, tennis, golf, and skating. Today, this athlete is fully recovered and happily pursuing a career as an attorney, while playing adult league hockey in the evenings.

This example is typical of an injury seen by sports chiropractors and sports physicians alike. What it illustrates is the phenomena of myofascial pain and dysfunction playing a role in sports injury and as a barrier to sports participation. The initial injury led to the pain and dysfunction, but what if there is no specific history of injury? What if an otherwise normal athlete is not performing as expected?

References

1. Travell JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol 1, Baltimore, Williams & Wilkins, 1983.

2. Travell JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol 2, Baltimore, Williams & Wilkins, 1992.

Andrew S. Bonci, B.A., D.C.
Tuckahoe, New York

Myofascial Barriers to Peak Athletic Performance -- Part II

In essence, this golfer was describing the symptoms of a weak grip of his left hand. Typically, this was pain-free, but it was accompanied by pain following repetitive and forceful use at the practice range. Travell and Simons1,2 described the myofascial trigger points of the hand extensors and the brachioradialis muscles as causing a painful, weak grip. Examination of this patient revealed latent trigger point phenomena in the extensor carpi ulnaris and extensor carpi radialis brevis muscles. Evidently trigger points in these muscles caused the left hand to "loosen" its grip on the club resulting in rotation of the club head during impact.

Treatment of this problem consisted of spray and stretch of the effected muscles as described by Travell and Simons1,2 The habitual slicing problem was resolved after five treatments that were supplemented with self-directed stretching and strengthening exercise for the wrist.

This example depicts latent myofascial trigger points that act as barriers to athletic performance. Exactly how this problem manifested itself is difficult to say. There was no specific injury that resulted in the "weak wrist-golf slice" problem. There was no indication that gripping the club too firmly precipitated the problem in the first place; it only appears to be the result of a weak grip. The question that needs to be asked next is, "How do myofascial barriers to peak athletic performance develop in seemingly normal athletes?" The answer lies in the manner in which sport techniques are performed.

Most of us learn to play sports by watching others. We imitate our teachers, friends, and sports idols. We copy our idols' techniques in a hope that we can taste the greatness that they so skillfully display. This is the method that most of us use to learn how to play sports, but it is not always the best way. Hay3 refers to this method of learning sport technique as "copying the champion." The problem with this method of learning, as Hay3 points out, is that the champion has succeeded in spite of having a technique that is far removed from the optimum (emphasis mine). Faulty biomechanical execution of sport skills appear to predispose and precipitate an athlete to injury. A sport technique becomes faulty when small muscles are used to perform the tasks best suited for large muscles.

A 19-year-old baseball player complained of left shoulder and neck pain of recent onset. The pain was the final link in a chain that had begun months earlier with a feeling of "weakness" and "slowness" when batting. These feelings of weakness and slowness while batting got progressively worse to where he could not swing his bat with enough speed or force to be an effective hitter.

Examination of this athlete revealed active trigger points in the left levator scapulae and left, middle trapezius muscles. Spray and stretch as described by Travell and Simons1,2 resolved the pain in three treatments. The dysfunction (i.e., weak, slow feeling) resolved after an additional five treatments of spray and stretch. This regime was supplemented with a strength and flexibility routine for the area.

All was fine with this athlete for a period of two weeks, then the problem started to return as before; a sensation of weakness and slowness when batting. Before pain became a problem, it was decided to analyze the technique he used for batting. He, like most of us, received no formal training in the biomechanics of sport techniques. He subsequently learned how to bat by watching others and being coached to "swing level," "make contact," and "hit the ball -- don't try to kill it." Instructive words they are not.

Watching this teen batter revealed that he, quite literally, hit with his shoulder. He relied on the small muscles of his left shoulder to lift his arm and draw the bat up through the oncoming pitch. This action would, and in his case eventually did, overload the small superficial muscles of the shoulder girdle. I retrained him to use the large, superficial muscles of the back that are more powerful to accomplish his batting swing. By learning how to substitute the latissimus dorsi and the middle and posterior deltoid muscles in place of the levator scapulae and middle trapezius, he was ale to shift the load of his batting swing from the smaller, weaker muscles to the larger stronger muscles. The loading demands now assumed by the larger muscles with ease were the same forces responsible for the overloading of the smaller muscles.

In this example, there is no precipitating injury to account for pain and dysfunction. The dysfunction of a slow, weak batting motion is indicative of latent myofascial phenomena. For this athlete, trigger points in the levator scapulae and the middle trapezius were the "Myofascial Barriers to Peak Athletic Performance" that were due to faulty biomechanical technique. But, how does this occur?

Faulty biomechanics of sport technique occur through a process of muscle substitution. An athlete, during the process of learning to perform a gross motor skill, uses muscles that he can exert more control over. The muscles that are better controlled are those muscles with smaller motor units.4 Indeed, the muscles with smaller motor units (i.e., fewer muscle fibers served by a single nerve) exhibit the best control and coordination. In the beginning stages of learning most sport skills, control of that skill is valued over that of its powerful execution. After all, who wants you to bat for their team if you can't control your swing enough to make contact with the ball? And so we learn, powerful execution without control won't get you on the team.

As an athlete becomes increasingly more proficient at his sport, he will demand a higher level of performance from himself. This step up in performance usually takes place in the form of increases in speed and power. There are typically no changes made in technique. Since the technique the athlete uses stays the same, it follows that the muscles being used to perform the skill also remain the same. An athlete such as this is increasing the likelihood of overloading his smaller, more controllable muscles as he attempts to achieve a higher level of performance.

It is acute overload and overload fatigue of the small muscles used in sport biomechanical technique that develop into myofascial trigger point phenomena. The overload may develop insidiously and without pain. Their presence may only contribute sensations of "weakness," "slowness," and "tiredness." The overload of these muscles may develop quickly and present as pain in addition to weakness and restricted range of motion. In any case, faulty biomechanics of sport techniques predispose athletes to "Myofascial Barriers to Peak Performance."

The diagnosis of myofascial barriers to peak athletic performance is made clinically as described by Travell and Simons.1,2 In addition to a clinical workup, field observation of the athlete must be made to identify the mechanical faults in his sports technique. This can be done most effectively with a videotape camera. The videotaping of an athlete enhances the process of retraining an athlete because he can objectively see his faults during the playback.

Treatment of myofascial barriers to peak athletic performance should begin with trigger point therapy as described by Travell and Simons.1,2 Alterations in the athlete's sport technique should be made with an attempt to use large and powerful muscles in place of small and weak ones. This regime of treatment should not be concluded without instituting a sport specific strength and conditioning program for the athlete. Adequate treatment will ultimately serve as the best form of prevention. For performance, prevention, and treatment to be effective for the athlete, he must develop strength and conditioning appropriate for his sport and be coached on the proper biomechanical technique for his sport.

Conclusion

This information can be very valuable to both the sports and chiropractic communities. The sports community can further benefit from the services and expertise of sports-minded chiropractors. Athletes, in addition to receiving quality injury care, will have an opportunity to better understand how their sports performances suffer and how they can improve them.

The chiropractic profession, and sports chiropractors, in particular, can move to the forefront of the sports world. While many physicians' services are limited to rehabilitation, the sports chiropractor will have the skills to take an athlete above and beyond the preinjury performance level. A way should be paved to include qualitative sport biomechanical analysis and the teaching of sound sports skills into the practice of sports chiropractic.

If chiropractic is to be a force in the 21st century, then it must innovate and shape the 21st century. It has no better opportunity than in American and international sports.

Part II of Dr. Bonci's "Myofascial Barriers to Peak Athletic Performance" will appear in the January 1, 1993 issue.

References

1. Travell JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 1, Baltimore, Williams & Wilkins, 1983.

2. Travell JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 2. Baltimore, William & Wilkins, 1992.

3. Hay JG: The Biomechanics of Sports Techniques, ed 3. Englewood Cliffs, NJ., Prentice-Hall, Inc., 1985.

4. Fox EL, Bowers RW, Foss ML: The Physiological Basis of Physical Education and Athletics, ed 4. Dubuque, Iowa, William C. Brown Publishers, 1988.

Andrew S. Bonci, B.A., D.C.
Tuckahoe, New York