Trigger Point Therapy for Low Back Pain!
Lower back pain is by far the most common ailment suffered by golfers of all ages. Based on data collected at the Titleist Performance Institute from over 31,000 golfers, 28.1% of all players deal with lower back pain after every round. Lower back pain is also the most common complaint seen among professional golfers on all tours (data suggest over 23% play with lower back pain). To understand the cause of lower back pain, it requires a thorough investigation of what I call the “Body-Swing Connection”. Let’s take a closer look.
The lower back is rarely the original cause of the pain! It may be the current source of the pain, but it’s rarely the cause of the pain. More often than not, abnormal motions or forces coming from adjacent or distant areas of the body force the lower back to do excessive work until it completely breaks down. In other words, the lumbar spine is usually the area that is being unnecessarily overworked to the point of injury. It is basically the over-used and over-abused worker who just goes it breaks.
In my experience, the lack of mobility seen in the ankles, hips, thoracic spine and shoulders of many golfers forces the lower back to carry all of these excessive loads and is the primary cause for most back injuries.
When the lower back finally does break down, you can typically expect one of the following conditions to occur:
- Muscle Strain or Ligamentous Sprain - A muscle strain or “pulled muscle” as well as an injured ligament will usually resolve itself in 2-4 weeks with plain old rest and recovery. However, there can be some residual muscle stiffness, fascial restrictions, joint fixations or movement alterations that may need to be addressed using Trigger Point Therapy techniques. Sprains or strains are the most common form of lower back injury we see. Symptoms may range from a minor ache to a sharp debilitating pain. Most sprains and strains are localized in the lower back region, meaning pain does not radiate into the butt or leg. The chemical inflammation around the injury is usually sore to the touch and the pain usually subsides with rest.
- Disc Injury - The lumbar intervertebral disc acts as a spacer between adjacent vertebrae to help absorb compressive forces and create space for the spinal nerves to exit the spinal column. Imagine the disc as a jelly filled doughnut. If excessive or abnormal stressors are placed on the disc, tears can occur. When this happens, the force of the jelly against that tear can cause a bulge in a portion of the doughnut leading to a “bulged disc.” In more severe cases, the jelly can actually exit through the doughnut wall leading to a “ruptured disc.” The discs are also susceptible to degenerative changes over time. To continue the analogy, imagine the jelly inside of the doughnut drying up. Any of these disc problems can leave the spinal nerves vulnerable to irritation or compression resulting in dysfunction and pain. Most disc pathologies create radiating pain into the buttocks or the leg (think sciatica) due to the irritation of spinal nerves. Sitting for prolonged periods of time, bending forward into a slouched position, or lifting heavy objects can all exacerbate disc symptoms and pain. Hip flexor muscles actually are attached to the transverse processes of the lumbar spine and the discs! If these hip flexor muscles are stuck in a shortened position due to over-use and/or excessive shortening due to excessive sitting then myofascial trigger points occur and cause these muscles to become stuck in a shortened position. These shorten muscles will actually cause subluxation of the lumbar vertebra and pull these disc out. Thus causing bulging discs! All because the muscles are dysfunctional. Restore these muscle to full function and length and over time the bulging disc will return to its normal position without surgery! How do you know if you have hip flexors stuck in the shorten position. Sit up, if you find you are slow to straighten your back, it is not necessarily your back muscles are weak, but your hip flexors are stuck! Trigger point therapy is the best and fastest methods of fixing hip flexor muscles stuck in a shortened position due to trigger points.
- Altered Joint Mechanics or Motor Control - Interestingly, the brain can completely change the lumbar spine’s ability to move just by changing which muscles are firing or by altering the sequence of when muscles fire. This can occur in the absence of any visible injury. These altered motor control or joint mechanics can begin as a protective mechanism, but can lead to chronic problems over time. Most experts believe over 80% of all chronic lower back problems begin this way and are caused by trigger points that result in muscles that cannot lengthen without intervention from a trigger point therapist..
- Degenerative Arthritis - Just like all joints, with over-use, abuse, or even lack of use, spinal joints can become arthritic. Bone spurs and osteophytes act like stalactites and stalagmites inside a cave closing in on the opening for the spinal nerves. With time, these bony outgrowths can fuse joints, irritate nerves and create general inflammation in the area. Stenosis, the narrowing of the canal or cave that houses the spinal nerves is a very common problem with arthritic changes. Most arthritic problems in the spine create sharp pain with certain movements. The resulting inflammation can then cause chronic dull pain over time. Many problems with painful joints that doctors attribute to degenerative arthritis are actually dysfunctional muscles that are replete with trigger points in the muscles that act near or on the joint. Trigger Point therapy often releases the shorten muscles that stretching only makes worse and the arthritis pain vanishes!
- Bone Fracture - Stress fractures and pedicle fractures (spondylosis) are common problems seen in the lumbar spines of rotational athletes. This occurs due to the rapid extension and rotation of the spine, causing adjacent vertebrae to collide into each other at their end range of motion. This action places high forces on the posterior portions of the vertebrae and can lead to these types of fractures. Injuries of this sort can lead to deep dull pain and instability in the spine.
So the questions are:
- How do I prevent the lower back from getting injured?
- How do I treat the injury once it occurs?
Let’s start by talking about prevention. The best way to prevent lower back injuries in golf is to attack the problem head on with three main offensives:
- Normalize Movement Patterns
- Optimize Swing Mechanics
- Incorporate Recovery Techniques
- Normalize Movement Patterns
The first line of defense against lower back pain is to create optimal movement patterns in the areas directly above and below the lumbar spine - the hips and thoracic spine. The golf swing requires great rotational mobility to develop and transfer energy to the club. That mobility should come from the joints in the body that are designed to rotate, the hips and the thoracic spine. If you study the anatomy of the lumbar spine, you will see that the spinal joints, called facets, are orientated to allow flexion and extension, not rotation. If the lower back is forced to be a primary rotator due to a lack of hip and thoracic mobility, it's only a matter of time before an injury will occur in the lumbar spine. It is important to remember that the hips and thoracic spine do not operate in isolation. Abnormal motion in the ankle can cause poor hip motor control. And poor motion in the shoulder can cause poor thoracic spine motor control. Therefore, we can’t neglect the ankle or shoulder joints in our assessments.
So in order to unravel the mystery of why someone has lower back pain, we must first evaluate the movement patterns of all the surrounding areas. At Indy Myopain Relief Center, we work with your trainers, golf instructors and evaluate your range of motion analyses and perpetuating conditions, identifying any of altered movement patterns and make a true starting evaluation. Once the dysfunction has been identified, we attack all mobility restrictions first, by treating the trigger points found in the dysfunctional muscles. Once treated and have restored the stability required to normalize motor control. When the areas above and below the lumbar spine are functioning properly, the lumbar spine can gain some much-needed rest. Once normal movement patterns are optimized, a solid conditioning program is the best form of prevention. We encourage all players to build a solid base of strength and to maintain proper mobility in order to keep their lower back healthy for a lifetime.
Incorporate Recovery Techniques
The first form of preventative action that should be encouraged is incorporating recovery techniques into a player’s normal after-round routine. Recovery techniques will help reduce inflammation, restore normative motor control and repair muscle and joint damage sustained during the round. Basic forms of recovery include the following:
Hot and cold therapy - This includes ice packs, cold plunges, heating pads, hot packs, hot tubs, sauna, steam rooms, etc. All of these methods can help make a difference after a round. Experimentation with alternative methods may be necessary to find the best combination for each player. I find that most muscle pain responds to moist heat
Massage - This is one of the best ways to reduce soreness, flush inflammation and revitalize the soft tissue.
Nutritional Support - There are many nutrients that can help reduce soreness, repair muscle damage and control inflammation. After four or five hours of playing golf, the body is in a slightly depleted and catabolic (tissue destructive) state. At this time, it is critical to eat the right type of foods to help facilitate recovery of muscles, tendons and ligaments. A player can feel dramatically better the next day by simply adding a post round recovery shake or incorporating proper dietary recommendations. We encourage players to immediately replenish their carbohydrates to help reduce soreness and to add some protein to help repair muscle and tendon damage. Drinking plenty of water is also a great recovery technique. Dehydration after a round can lead to next day soreness and muscle fatigue.
Sleep - One of the most important recovery techniques that I can’t stress enough is a minimum of eight hours of sleep. This is when the body repairs and rebuilds. Without that necessary sleep, most players will wake up sore.
Recovery Exercise - Many exercises can help aid recovery. Stretching is a great example of an exercise that can help re-establish normal motor control after a round.
Now let’s shift our attention to some actions that can be taken if, unfortunately, you already have a lower back injury. The major types of injuries and options available for treatment. Remember, the preventative actions discussed above should also be incorporated into the treatments below.
Treatment of muscle strains should focus on controlling the initial inflammation and restoring proper muscle, joint and ligamentous function. Typical treatment protocols include some combination of the following:
Manual Therapy – Trigger Point Therapy, Extracorporeal Shock Wave Therapy, Myofascial Acoustic Wave Therapy, Extracorporeal Pulse Activation Therapy, Myofascial Release, Massage, Chiropractic physical therapy, osteopathy, and other manual therapy techniques can be extremely effective in reducing the recovery time for muscle strains and ligamentous sprains. These options help promote muscle lengthening and proper blood flow in the lower back (to help with healing), loosen tight lower back muscles, maintain proper joint mechanics, and aid in the release of endorphins, the body’s natural painkillers. All of these things promote accelerated healing in the lower back.
Cold Therapy (Cryotherapy) - The application of cold packs over the injured area can dramatically help numb the tissues and may relieve muscle spasms or associated inflammation. Cold can be applied using an ice or gel cold pack, cold plunge pools, cryotherapy chambers (which use liquid nitrogen to cool the room) or topical sprays (such as ethyl chloride) that cool by evaporation. Do not apply cold to tissues with an already reduced blood supply (for example, when the arteries are narrowed by peripheral arterial disease).
Electrical Stimulation in combination with Trigger Point Therapy - Electrical stimulation via electrodes placed on the skin has been used to help speed recovery for years. Electrical stimulation with Trigger Point Therapy can increase nervous system activity and stimulate fluid circulation resulting in reduced inflammation. One form of electrical stimulation called transcutaneous electrical nerve stimulation (TENS) uses a low current that will cause muscles to contract slightly. When TENS is coupled with Trigger Point Therapy results in trigger points releasing faster and more completely. The device produces a tingling sensation but is not painful.
Heat Therapy - Heat increases blood flow and can temporarily decrease joint stiffness, pain, and muscle spasms. Hot packs, infrared heat, paraffin baths, and hydrotherapy provide surface heat. High-frequency sound waves (ultrasound) can also be used to generate heat in deep tissues.
Acupuncture - This involves treating various points on the body using several methods such as the insertion of thin needles, application of heat, applying pressure or laser light therapy. Traditional acupuncture involves needle insertion, moxibustion (burning of a Chinese herb) and cupping therapy. This is a fundamental component of traditional Chinese Medicine that has been used for over 5,000 years. It is further believed the stimulation of specific acupuncture points corrects imbalances in the flow of Qi (chi) through channels known as meridians. By balancing the body’s qi, healing is accelerated. Acupuncture should be done by a certified acupuncturist and with sterile needles.
Dry Needling – Is the practice first introduced by doctors Janet Travell and David Simons. Dry needling first begins by locating taut bands of muscles and then precisely locating the trigger point nodule within the taut band, then accurately and precisely inserting a dry, sterile needle into it repeatedly until the taut band relaxes. The skill that is lacking in most dry needle therapists is the ability to locate the taut bands. This practice is best done by Trigger Point Therapists, Physical Therapists with advanced training and others. Physicians that inject muscles with lidocaine and cortisone are injecting muscles and on rare occasion locate the trigger point. With a skilled therapist, dry needling is highly effective and almost essential when tiny muscles in small spaces develop trigger points such as the front of the neck and pelvic floor muscles. However, dry needling performed by a skilled therapist is a highly effective treatment. Most trigger points can be released using manual and acoustic compression therapy and is not invasive. Indy Myopain Relieve Center does not perform dry needling but would refer our clients to a Clinic in Bethesda, MD.
Rest & Recovery - Often, muscle strains just need a few days of TLC. However, we do not mean someone should remain 100% bedridden. Reduction of workload, not lifting heavy objects, time off from strenuous activities, improvement in workplace ergonomics and modification of poor sleeping habits can usually do the trick. The body has an amazing ability to heal sprains and strains as long as you stop aggravating it. Just remember, light activities such as walking can be very beneficial in accelerating the recovery process.
Anti-inflammatory Medication - Local inflammation that may exacerbate pain can be reduced with the aid of anti-inflammatory medication such as ibuprofen or NSAIDs. Just remember, these medications only reduce the inflammation and do not fix any potential muscle or ligamentous damage that may lie below the inflammation. Recent studies are showing that NSAIDs, Cortisone and narcotics actually inhibit nitric oxide and other methods the body uses to mobilize you body’s own repair mechanisms and certainly should not be used following trigger point therapy. Be warned, chronic use of NSAIDs can become part of the problem and not part of the solution.
Muscle Relaxants - If muscle spasms are present (which are often associated with muscular strains) these drugs may relieve some of the pain associated with the muscle spasms or help you sleep at night but they too are reported to inhibit the body’s ability to heal itself.
Do not wait for the pain to subside, contact Indy Myopain Relief Center right away. Our therapies are most effective when the pain is at its crescendo. We can often relieve the pain in minutes and teach you how to fix your own pain. Once the pain has subsided, we must investigate why the injury occurred in the first place. In other words, there is usually some underlying altered movement pattern that caused the sprain or strain to happen. We go back to our range of motion screens to make sure the original cause of the problem has been addressed as well as the resulting sprain and strain.
Disc Injuries (Non-Surgical Options)
As we discussed earlier, the intervertebral disc resembles a jelly filled doughnut. All of the treatment options below focus on reducing the irritation or compression to the spinal nerves created by the abnormal displacement of the jelly. Here are the most common options:
Conservative Rehabilitation - The first line of treatment should always involve a 6 to 12 week trial of trigger point therapy and/or Extracorporeal Shock Wave Therapy. The goals of these types of treatment are to:
- Reduce the inflammation
- Restore normal stability, motor control and motion in the lumbar spine
- Improve mobility in the surrounding joints (hips and thoracic spine)
- Educate the patient on techniques to prevent further episodes such as ergonomics, sleeping positions, proper lifting and carrying techniques, recovery options, etc.
- Supply the patient with an exercise routine to prevent re-injury
Most patients will feel some sort of relief right away. Many successful rehabilitation programs include a combination of many conservative techniques.
Epidural Injections or Medrol Dose Pack –The anti-inflammatory of cortisone actually inhibits healing but is still very popular with physicians. Physicians will say that approximately 50% of the time, an epidural steroid injection will give pain relief that may last from one week up to one year. Most physiatrists recommend a maximum of three epidural injections per calendar year (at least two weeks apart). Recent studies have shown better results with just the pain reliever injection and not cortisone.