Sunday, January 22, 2017

What I Do For "Trigger-Point" Upper Back Pain

The following plea for help was recently posted to the TCSD email list:
I'm looking for some advice/knowledge. In November, I suddenly had intense pain in my right upper back, near my shoulder blade. It made it difficult to move or turn my head. After quite a bit of trial and error, some research, and a couple visits to a doctor and masseuse, I figured out it was a "trigger point" of muscles that have a hard time relaxing, and instead stay completely contracted. It was caused by biking, as swimming and running really didn't irritate it at all. I would wait about a week for the pain to go away completely, get on the bike, and be in intense pain again within 24 hours. It eventually led to my entire right arm going numb because the muscles were hitting nerves. So I stopped biking for a little over a month. I got back on for a short trainer ride yesterday, and unfortunately the pain still came back. I'm at my wits end, and am really not sure what to do. I have gotten my bike re-fitted already and have tried muscle relaxants. Massages help immensely, but I can't afford to keep going, and it doesn't seem to be preventing it.

Does anyone have any experience with this type of injury? How can I expedite recovery and/or insure recovery at all? I'm on a budget, so cost-effective recommendations are greatly appreciated!
Please take everything that follows with a grain of salt.  It's simply the results of my own search, and what wound up working for me.  YMMV, and so on.

If you don't presently have this problem, please feel free to jump ahead to the "Cause and Prevention" section.

First, some terminology: "Trigger Point" pain is a catch-all term equivalent to a localized combination of a nerve inflammation and/or muscle spasm.  There may also be muscle damage involved, where the swollen muscle pushes against a nearby nerve.  Or a nerve may be damaged, and the local muscles are overreacting with cramping/spasming.  The central idea is that it manifests as localized point-like pain.

Let's start with finding out what's going on.  There are multiple distinct injuries (including fractures and disc problems) that can result in similar upper back pain.

Assessment #1:
Get a FREE Injury Screening from TCSD sponsors FunctionSmart or Rehab United.  Your medical insurance may cover specific forms of treatment/therapy.  Work with them to find out.  Starting with a good, focused treatment (such as ART), even if only a single session, can serve as a reset button to hasten overall recovery.

Assessment #2:
Go to the gym (or a fitness equipment store) and do a 20-30 minute high-cadence light workout on a recumbent trainer.  Push just hard enough to work up a sweat, but not so hard that you're forcing yourself against the back of the seat.  Keep your arms relaxed.  If you have a power meter available, average anywhere from 120 to no more than 250 watts.

My hope is that this recumbent spin session goes perfectly fine, with no additional upper back discomfort at all.  If so, then recumbent is your bike workout plan for a while.  If not, then stick to swim and run.

Assessment #3:
Go see your Sports MD.  I can't say it often enough: A Sports MD is an athlete's best friend and advisor in all things medical.

I'm not talking about a doctor who does sports.  "Sports MD" is a separate board-certified qualification.  Every local medical system has them.  If possible, try to select a primary physician who is also a Sports MD.

Next, let's get our toolbox together.

Recovery Equipment List:
  • Tennis ball
  • Foam roller
  • Hot/cold pack that has a strap allowing it to be worn on the pain area while moving (like these).
  • Breathable heating pad (not the sealed plastic ones)
  • Epsom salts (optional)

Please notice that pain relievers are not on that list!  I use them only when I have to reduce the pain in order to sleep.  Otherwise, keep all lines of communication with your body wide open.

Another thing not on the list are motorized massagers or pressure-point devices like the "Back Buddy" or "TheraCane".  These can be useful, but it is way too easy for them to make an injury worse.  Only if you are experienced using them as part of your regular workout recovery can they also be used as part of injury recovery.  It's best to avoid them completely if there is any doubt.

Here are the two major things I do to prepare for an injury recovery session.

Preparation #1:
Always be fully hydrated.  Aim for a gallon of water per day when sedentary, especially when injured.  If your pee is yellow, you aren't drinking enough water.  It should be very close to clear.  You should be peeing fairly often, at least once every hour or two.

I can't overemphasize the importance of thorough hydration as part of both the recovery process and also of pain management.  Both the initial injury damage process and the subsequent healing process release byproducts into the blood that can cause their own irritation: Diluting and eliminating them ASAP is the way to go.  Also, pain causes the release of stress hormones such as cortisol, where again dilution and elimination really help: Pain is often a feedback loop, so cleaning things out can actually lessen the pain itself.

So stay hydrated!  (But not overhydrated: Avoid hyponatremia.)

Preparation #2:
Take a hot soaking bath, with salts if you prefer.  Showers don't count.  Or lay on the heating pad in bed and read a book or watch TV for 20 minutes.  The goal is to relax and increase blood flow to the injured area.

Thorough relaxation and increased blood flow are important to recovery, second only to thorough hydration.

Let's get ready to start fixing things.

Recovery Session Start:
What follows should not cause any pain whatsoever, nor should it make any existing pain worse.  If that happens, stop and go see a Sports MD.
  1. You are hydrated.
  2. The injured area (or the entire body) has been warmed.
  3. Initial stretch: Pull an arm across the chest, over the collar bone.  Put the opposite forearm or hand on the elbow and pull in gently (not at all hard).  Hold the stretch for 5-10 seconds, then switch to the other arm.  Repeat 3 more times (each arm pulled twice).
  4. Final stretch: Hug yourself with both arms, hands on the opposite shoulders (or as close as possible).  Exhale completely, pull in slightly, then inhale fully.  If you don't feel a stretch across your upper back, then curl forward until you do.  Hold your breath and stretch for at least 5 seconds. then slowly exhale and relax. Release the hug, letting the arms gently swing to your side.  Restart the hug so the other arm is on top.  Repeat 3 more times.
You should now feel loose and relaxed across the upper back.  Any pain you may have had should not be any worse, and is hopefully reduced.

This preparation is useful not just before injury recovery sessions, but also before going to bed, or whenever the injury is bothering you.

Let's start working the injury area.

Initial Manipulation - Tennis ball wall roll:
If you experience any pain spikes during what follows, then stop immediately and see a Sports MD.

Gently lean your upper back against a wall, with your knees slightly bent, feet placed just wider than shoulder width.  Place the tennis ball between the middle of your back and the wall, at the level of the injury but not on it. You should be leaning with only just enough pressure to keep the tennis ball from falling to the floor.  Do not press hard against the tennis ball!

Lower your arms to your side.  Relax your upper back, neck, shoulders and arms.

Using your legs, move your back so the tennis ball gently rolls all around the injury.  If the tennis ball can't gently roll over the injury itself because the shoulder blade is in the way, pull the arm on that side across the chest at the collar bone (as done in the initial stretch).  Move the tennis ball in a random motion for 1 minute.

Be sure to always keep your upper back and shoulders relaxed: Do not tense up!  The tennis ball may be uncomfortable, but it should never be painful. Pain defeats the whole intent of the manipulation, and may make the injury worse.

Repeat the same motions on the opposite side.  Be sure to always do this gently, matching what was done on the injured side.

Symmetry is important!  Whatever you do near the injury must be repeated on the other side of the body.  Why?  There are several important reasons, the most obvious of which is that your recovery will be complete when both sides feel equally good!

Take a minute break after the other side is done.  Repeat the preparation stretches if desired.

Repeat the tennis ball roll on each side with slightly increased pressure to improve muscle manipulation, but never to the point of pain or major discomfort.  Then stop: It is important to not over-do any part of an active recovery process.

This may be all you can handle for the first few times.  Stopping early is vastly better than overdoing!

You can have as many initial manipulation sessions per day as you like, so long as you rest, hydrate, heat and stretch before each one.

The tennis ball wall roll is awesome. I also use it on my lower back (QLs), glutes and hip flexor.

Time to get hard-core.

Daily Manipulation - Foam Rolling:
Daily foam rolling is the Fountain of Youth!  Well, at least for muscles.  It should be part of your daily routine, injured or not.  Training or not.  Like food and water.

Athletic injuries seldom occur in isolation.  They typically happen when the entire body is under stress, but one part is either more sensitive or is receiving extra stress (due to misuse or overuse). It is important to treat any localized injury as an injury to the entire body.  Foam rolling is the best way I know to help whole-body recovery (with hot tubs running second).

I will not cover the details of foam rolling here.  There are lots of printable instruction guides and video tutorials available online that can be found by searching for "foam roller tutorial".  Find the one you like best.  This video is pretty good, but the audio has issues.

I am more than willing to guide an informal foam rolling session for any folks wanting one.  Post a request to the TCSD email list and we'll make it happen.

Be sure to roll all of the following areas for two minutes each:
  • calves
  • hamstrings
  • quadriceps
  • ITB (outer thigh)
  • adductors (inner thigh)
  • glutes
  • illiac crest
  • lower back (QLs)
  • spine (do crunch over low and mid spine, and self-hug at upper spine)
  • lats (also great for swim recovery)

If you are new to the foam roller you will likely need to take frequent breaks, so plan to spend an hour getting everything rolled out.  If you are a foam rolling master, you may be able to do all the above in just over half an hour.  If you are rolling for less than 30 minutes there is no way you are doing even a minimally adequate job.

Remember what I said about no machines on the recovery equipment list?  Well, I lied.  There is one machine that has proven to be a near-miracle for me:  The HyperIce Vyper mega-vibrating roller.  It lets me get a full rolling session done in under 20 minutes.

While I highly recommend the Vyper, I do not recommend getting it until after you have become a master with the regular foam roller.  What I said about hurting yourself with machines still holds true: Using the Vyper without first mastering the regular foam roller is like riding a race motorcycle without first knowing how to ride a bicycle.  Truth!

And that's about all I do to recover from Trigger-Point upper back pain.

But what about getting along with it during the day?

Between Recovery Sessions:
That's where the wearable hot/cold packs come in.  I take them to work with me and use them as needed.  Hydrate, do a set of upper back stretches, then apply heat.  If that doesn't help enough, follow with cold.

Now lets talk about how it happened in the first place, and how we can avoid it.

Cause and Prevention:
The fundamental cause is poor riding form.

We ride in either or both of two positions: In road position, leaning on locked arms, or in aero position, leaning on our upper forearms.

Both positions transmit front wheel vibration and impacts directly to the shoulders.

Most of us ride with our shoulders relaxed, with the shoulder blades close together.

This means that shock and vibration goes from the road, up the arms, through the shoulders, and on to the shoulder blades, causing the shoulder blades to lever over, forcing their inner edges to pinch the nerves and muscles in the area against the ribs and spine.

Bingo.  Injury and pain.

Keeping this from happening requires making some changes.

Change #1 (Technique):  Ride with the shoulders neutral (front to back).

Change #2 (Technique, road):  Ride with the elbows slightly bent (never locked).

Change #3 (Equipment, road): Use cushioned bar tape and gloves with gel pads.

Change #4 (Equipment, aero): Ensure the aero bar pads are mounted on cantilevers and/or have multi-layer construction that includes gel.  Be sure to replace old pads before they lose their cushioning performance.

If, like me, you ride a road bike with clip-on aero bars, then all the above will apply.

These changes work together to accomplish two simple goals: 1) Reduce the levels of shock and vibration that reach the shoulders, and 2) keep the shoulder blades away from the spine.

A simple ride-time stretch can help reset the shoulder blade position:  Every 10 minutes or so take a moment to push the upper back as far out as it can go, hold the stretch for 5 seconds, then slowly let it go in far as it can go, and finally reset it to a mid position.  Repeat as often as needed.

Bottom-line, if you are stuck in an injury/heal/re-injury cycle, then you haven't fully addressed the cause.  Worry less about the injury and instead focus on eliminating the causes!


How can I tell if I'm OK to ride?
Elbow planks.  Be sure to always have perfect form!  Keep the knees locked.  No lifting the butt into pike, no dropped/sway back.

Breathe smoothly.  Don't struggle!  Quit before your form breaks.  The best way to exit plank is to drop the knees then push back into Child's Pose.

Once you are stable in plank, do the ride-time stretch mentioned above.  Focus on keeping your shoulders neutral.

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