When we hear the mention of a “tight” muscle, many of us think of something being physically shorter than it should be. This is not always the case, and the tight description can sometimes take on a bit of a confusing description. When muscles are “tight,” they are not only in their shortened state, but they may have a reduced protein content, increased connective tissue (not a good thing), and even a thickened inner layer of muscle tissue or two. In addition to this, the fascia that surrounds the muscle may be compromised. Fascia covers just about everything within the confines of our body and serves numerous purposes from allowing muscle tissue to glide freely to helping compartmentalize our body. This helps our body’s defense department play “damage control” and helps keep an active infection contained so we can fight it off easier. If the fascia becomes damaged, it may not allow that free-flowing glide to occur, and motion may become limited or even lost. So, how exactly do we go about fixing this?
Soft Tissue Mobilization
The main goals of soft tissue mobilization (STM for short) are to gain range of motion, increase functional motion, and increase the overall quality of the affected tissue. When we begin soft tissue work, we are usually addressing trigger points which fall into two categories; active and latent. A trigger point is best described as an irritable spot that can be felt by touch, is sensitive when pressed on, and lives in a muscle that is “tight.” The active variant of a trigger point is one that produces symptoms, including local tenderness, pain, and even referral of that pain to various other locations. A latent trigger point will only produce pain when it is pressed on, but they may cause many of the same muscle restrictions that their active “brothers in arms” do as well.
A diagram of referral from two trigger points in a muscle in the forearm. Trigger point designated by red X and each dot is where an individual felt pain from that point.
Many of you may have experienced a trigger point when doing foam rolling, other variants of self-releases, or are just pressing on sore muscle and are well aware of the discomfort associated with placing pressure over one of these little guys. When a trigger point forms, there is a neurological change associated with the muscle that brings along an increased sensitivity to pressure and a stimulation of the nerve fiber thanks to various, complex ion channel interactions within our muscles. This can lead to an increase in muscle pain. Recently, we have been able to capture visible evidence of trigger points on imaging via both high-resolution ultrasound and a variant of MRI.
When a sore spot is found, many times a clinician may have you contract that muscle just to ensure work will be done in the proper area and usually to conform to the orientation of the mobilization that is needed. Now there are enough techniques for addressing these trigger points to write a textbook on (and they have been), but we will tackle just a few of the big ones that you may see in our clinic or ones like it. The first one is called Trigger Point Therapy Release where the clinician will press vertically and perpendicular to the fibers of the trigger point which is theorized to cause some elongation of the tissue as well as a neurological reflex reaction causing the trigger point to “release.”
One other common technique we work with is known as an Active Release Technique, where the goal is to treat and facilitate tissue remodeling of fascia, ligaments/tendons, and muscles. The muscle is shortened, the therapist palpates a “taut band” trigger point, and the muscle is lengthened. While the muscle is being “lengthened” to generate a shearing force, the therapist moves their hands parallel to the muscle fibers with pressure in a direction going closer to the center of the body. The pressure is maintained throughout the stretch while the client actively lengthens the tissue being treated. This is one of the more aggressive techniques that we use, but when paired with other soft tissue work, all of these techniques have their place, and we utilize each in its own way to get you back on the course quicker.
Now to the second point of the article (pun very much intended), dry needling also known as Intramuscular Manual Therapy. In 2009, the American Physical Therapy Association (APTA) recognized and concluded that dry needling is within the scope of PT practice and numerous other nations preceded this decision. This decision has often been debated (and especially in North Carolina), but with a quick Google of Henry V. NC Acupuncture Licensing Board, you can see the updates on this.
The term “dry needling” comes from the fact that a PT is using a “dry” needle or not injecting any solution/medication into the trigger point but instead just inserting a needle into the trigger point without any medications. Now, as far as the difference between dry needling and acupuncture it boils down to dry needling being based on a more Western medicine approach specifically targeting trigger points whereas acupuncture will stick to an Eastern medicine basis without targeting trigger points.
The jury is somewhat out on the exact mechanism for why exactly a needle entering a trigger point causes a nervous system “reset,” but current evidence shows that when a needle breaches a trigger point, a response known as a “local twitch” will occur. This twitch response has been shown to cause an immediate decrease in the concentration of pain-related chemicals in the areas and may cause a rebalancing of the chemicals in that environment. Now, with this reset comes a bit of an after-effect where some clients may experience some immediate (and even up to 48/72 hours) soreness which is usually achy in nature and not at all uncommon.
Dry needling will often cause a referral pattern of the pain patterns that patients attribute to their original pain complaint (see diagram at the beginning if you need a refresher) and can help us as clinicians in our diagnosis as to whether a problem is primarily muscle vs. joint or neurological in nature.
With all of these factors involved, it should go without saying that dry needling takes a high level of training from not only an accuracy basis but also a safety front as there is an inherent risk with inserting needles into one’s body. This tactic should not be performed unless the individual has proper training and certification.
Hopefully, this article has been helpful and provided you with a good insight into some of the techniques that we use to help expedite your return to the course or just to pain-free life. Check out our Physical Therapy page and always feel free to shoot us an email at [email protected] if you have any questions.
Western Carolina University
Physical Therapy Intern, Summer 2017