Trigger points are tender taut bands in muscle or fascia which, when pressed, often elicit a "jump" or "ouch" response from the patient, and may produce a predictable referred pain pattern to other areas nearby. Some people call them "palpable pain points". They may be active (i.e. produce pain even when not pressed) or latent, (producing tenderness when pressed but not otherwise). They may be primary - the original site of the injury, or secondary , due to the muscle having to over-work because of lax ligaments, for instance. There is a tendency for new tender points to form in the same muscle or neighbouring muscles. 

Trigger point pain may mimic other conditions because of  referred pain. Some examples: Trigger points in the sternocleidomastoid  muscle (the long strap-like muscle that stretches from behind your ear down to the collar bone and turns your head to the other side) can cause pain in the upper teeth leading to unnecessary dental work being done. Trigger points in the pectoralis major can mimic a heart attack or produce breast pain. 

Trigger points can form as a result of injury (such as a muscle strain or fall), or form over-use, posture or poor ergonomics, or when the muscle has to compensate for other structures which are not functioning adequately. 

Trigger points (known as ah shi points) were treated with acupuncture long before western physicians began treating them in the 1940s. Drs. Travell and Simons produced a two volume encyclopedic description of different muscles and their pain patterns and how to treat them with a combination of injections, stretches and cool sprays. Most trigger point charts, pictures and books are based to a greater or lesser degree on those two volumes. 

Trigger Point Treatment Options: 

1. ischemic compression - this involves identifying a tender point, pressing on it with a thumb, finger, ball or other object (such as a theracane) firmly enough to cause discomfort but not severe pain. One then stretches the muscle along its long axis, takes in a deep breath and presses a little firmer. An excellent explanation of this technique can be found on Dr  Kuttner's website. This is not the method we use but it is effective and can be a useful form of self-therapy. Dr Kuttner's site is very informative and he has inexpensive resources available there. 

2. Various myofascial release techniques have been used by physiotherapists and massage therapists and are often effective but may aggravate the pain if administered too vigorously, or if the pain is due to inflamed sensory nerves rather than primarily a muscular problem. 

3. Our preferred non-needle technique is a group of simple, painless, and safe procedures collectively known as the "Pain Neutralization Technique",  which, when effective, works nearly instantly. 

4. Acupuncture or "dry-needling" has been used for centuries to treat trigger points. Modern versions - using a very fine, single-use, pre-packaged, sterile, disposable, solid (not hypodermic) acupuncture needle - include Dr. Chan Gunn's Intramuscular Stimulation (IMS) and Dr Cynthia Gokavi's adaptation, the Gokavi Transverse Technique. IMS or dry-needling are often offered by physiotherapists and pain clinics and do not involve any medications. 

5.Trigger points can also be injected with a hypodermic needle and syringe. With injections one has both the direct needle effect and the ingredient effect. The needle itself does much of the work in releasing the tight band.  Drs. Travell and Simon pioneered the use of local anesthetic injections into trigger points using Procaine. Today Lidocaine is usually the local anesthetic of choice; some physicians mix this with longer-acting local anesthetic such as Bupivicaine (Marcaine) and may add some steroid (cortisone-like medication). There is no evidence that steroids are helpful for this and may be harmful. Longer-acting anaesthetics are said to reduce the post-injection soreness from the needle which some people feel later, but carry greater risk if used in excess doses, or if they get into the bloodstream too quickly. Some alternative practitioners add herbs, vitamins and homeopathic remedies to their injections but we do not advocate this. Some physicians use normal saline without anaesthetic for trigger point injections. This avoids the rare risks associated with the medications but may leave a little more soreness the next day. Dr Greg Siren (at the Myo Clinic and Changepain) uses this method very effectively and has generously taught this to other physicians in BC.

A study was published in Korea in 1997 comparing three groups of patients with trigger point injections, one group with normal saline, one group with local anesthetic, and another group with 5% dextrose (D5W). Each method was effective but, of these, the local anesthetic group did better than saline, and D5W performed the best of the three. This is possibly because of the known benefit of dextrose in relieving neurogenic pain. This is only one study and if repeated elsewhere might produce a different outcome. 

This therapy for neurogenic pain is sometimes referred to as neural prolotherapy, perineural injection therapy (PIT) or the Lyftogt (pronounced "Lift-off") technique after its developer, Dr John Lyftogt of Christchurch, New Zealand. John is a family physician, runner,  and sports medicine doctor who for many years used the trigger point injection methods described so well by Drs Janet Travell and David Simons. He later was trained in traditional prolotherapy. Being an athlete he suffered from chronic achilles tendinopathy and decided to treat himself with prolotherapy by injecting his achilles tendons with concentrated dextrose and local anesthetic. He found this quite painful but found that subcutaneous (just under the skin) injections around the achilles tendons were not painful but in fact eradicated the pain and caused gradual healing. As traditional prolotherapy uses concentrated dextrose (20% or more) he published a number of studies using concentrations of 20-40% dextrose. By 2010 he discovered that isotonic dextrose 5% (D5W) could achieve the same results. After studying the literature on neurogenic pain and the anatomy of skin nerves he discovered that a large number of musculoskeletal pain conditions could be successfully treated by injecting 5% dextrose under the skin next to these sensory skin nerves. These findings were reproduced using 5% mannitol (a sugar-alcohol) in the same manner. John has recently retired from clinical practice in order to devote his time to teaching this method in centres around the world. 

Having developed this from a background in prolotherapy he named the new technique "neural prolotherapy" and continues to use that term even though it is somewhat of a misnomer ( the 'prolo' part of the term refers to 'proliferation' of cells which is part of the healing process but requires higher concentrations of dextrose than the 5% he uses now). Others have called this technique "perineural subcutaneous injections" as that is a more accurate descriptor of the process involved.  It is postulated that dextrose switches off the (TRPV1) nerve receptors involved in neurogenic inflammation but not the nerve endings which transmit other sensation (i.e. one cannot use dextrose to anesthetize the skin for procedures such as stitches). 

The technique involves identifying tender skin nerves and, using a very fine, short (half inch 27 guage or even 32 gauge in sensitive areas like the face) hypodermic needle to inject small amounts (1/2-1ml) of  5% dextrose or 5% mannitol next to the tender nerves. At sites where nerves exit through small holes in the fascia or traverse fibrous tunnels over bones (e.g. the cluneal nerve in the lower back) larger volumes (2-6ml) are injected. 

Hundreds of physicians around the world have accumulated considerable clinical empirical experience with this technique and found it very effective. 

Some examples in our experience: 

1. a lady presented with intense pain in her arm after taking up pickle ball. She was tender over the outside of her elbow (the lateral epicondyle) but also over the skin nerves (branches of the radial and musculocutaneous nerves: lateral and posterior antebrachial and nerve to anconeus) . Each tender point was injected with D5W and she was pain free. She needed 3 treatments over the next two weeks to make this permanent. That is much quicker permanent recovery than with steroids or physiotherapy. 
2. another presented with tennis elbow after already having physiotherapy with limited results and only required one D5W treatment. 
3. an elderly lady fell on the ice and fractured her hip and several ribs. She bled into her chest cavity and required an incision between her ribs to insert a chest tube drain and also had her hip pinned surgically. With excellent orthopaedic surgical care she made a full recovery but presented several months later with intense pain in and around both scars - chest and hip. Injecting D5W into the tender areas around each scar relieved her pain instantly and avoiding the risks of narcotic pain medications. As expected, some of her pain recurred a few days later but was less intense. In all, she required 3 treatments to obtain a permanent relief for something which could have become a chronic condition. Scar neuromas (tender injured skin nerves in scar tissue) often respond well to this treatment. 
4. a mountain biker with a ten-year history of low-back pain was tender over the cluneal and neighbouring cutaneous nerves over the iliac crest of his pelvis. Only two treatments were needed.
5. a patient presented with intense burning pain involving the entire lower limb which came on after an over-vigorous massage for a calf injury. This illustrates how neurogenic pain can spread from the original site of injury. She was tender at multiple sites in her thigh, around the knee and in the lower leg (corresponding to the sensory distributions of the lateral and anterior femoral cutaneous, common peroneal, sural and saphenous nerves). Meticulously each tender point was injected with D5W and much to her surprise she climbed off the examination table pain-free. It is our aim to have the patient pain-free by the end of the visit. If this can be achieved and the pain-relief lasts at least 4 hours after the first treatment the likelihood is good that incremental progressive improvement will be achieved over a few visits. 
6. one had severe pain for decades in her back, chest wall, neck and shoulders after a series of accidents. After each treatment she was pain-free for a few days and progressed enough to be able to resume activities such as sports and enjoying games with her son who had never previously seen her able to do so. 

Usually the pain-relief lasts 4 hours to 4 days initially, occasionally up to 2 weeks. Very occasionally it is permanent after one visit. This is not a realistic expectation. Most people need 6-8 visits to be substantially or completely better. Some need a top-up a few times per year.  Some need more. In some cases one reaches a plateau of about 50% or more reduction in pain overall without permanent complete relief. 

These are success stories. Some people do not tolerate needles. We have patients who do not find this method beneficial and so we look for other alternatives. One can usually tell quite quickly whether or not the method is going to be helpful. We have others who need more treatments (8 or more) or who need a combination of neural and traditional prolotherapy or deeper trigger point injections.  Some people may do better with physiotherapy. 

Anyone who has studied introductory  psychology has heard about Pavlov's dogs and the concept of conditioning. Pavlov observed that dogs salivate when presented with food. This is an unconditioned (or innate, instinctual) response to the stimulus of food. He noted that over time his dogs would salivate when approached by his assistant (not that the assistant was a tasty morsel but that they associated the assistant with dinnertime). He then performed some experiments. He would ring a bell (a neutral stimulus) and the dogs would not salivate. Then he rang the bell while presenting the dogs with food and they would salivate. After some repetitions of this, the dogs would salivate when hearing the bell rung, even when no food was on offer, a conditioned response. This type of classical conditioning is one mechanism whereby physical pain can be produced in response to a stimulus which the unconscious mind associates with a painful experience. 

If you read some of the stories in the books and websites listed under resources in Part 1 you might come across some anecdotes which illustrate this process. I paraphrase:

A Viet Nam veteran who was injured in the leg during an incident involving a helicopter recovered fully from the injury. However, periodically over the years he would suddenly experience intense pain in the previously-injured leg which would last for several days before dissipating. One day his wife commented on the helicopter flying overhead and it dawned on him that every time he heard a helicopter's engine his leg hurt. 

One lady experienced intense pain whenever she drove through a particular town. She eventually realized that the town was en route to the in-laws' home where she often felt the same pain because of the stressful atmosphere. In time she experienced the pain when travelling that route even when not visiting the family. 

Have you every taken an instant dislike to someone whom you have never met before and wondered why? Perhaps he or she reminds you of someone with whom you have previously had a bad experience. Have you ever had memories flood back instantly transporting you in your mind's eye to someplace else in response to a song, fragrance, or scenery? This is because the parts of the brain involved with memory, pleasure and emotion are  very closely associated, and are also connected to the parts of the brain which process the flight and fight response. The limbic system is also closely connected to the thalamus which is the clearing house for the processing of painful stimuli. 

One of the questions I have learned to ask patients with unexplained pain is: "What was going on in your life when it first happened?" This sometimes gives a clue as to the meaning of the pain and how to approach it. 

Here is some info from the TMS Wiki. Please note: Myositis is not a good term for this condition as there is no inflammation present. 

An Introduction to Tension Myositis Syndrome (TMS)(Redirected from An Introduction to TMS)

Have you struggled with chronic pain or another medically unexplained symptom for a long time? Have you tried everything to alleviate your pain, but nothing worked? Have you had doctors tell you they "just can’t find anything wrong?"

Then you may have Tension Myositis Syndrome (TMS). TMS is a condition that causes real physical symptoms that are not due to pathological or structural abnormalities and are not explained by diagnostic tests. In TMS, symptoms are caused by psychological stress. 

You may be at your wits end. However, there is hope. We know this because the authors of this wiki struggled with chronic pain for many years, and that is exactly how we felt: hopeless. We're not doctors so, of course, we can't diagnose you, and everyone is different, but we are here to tell you what worked for us and how it did so without surgery, needles, or drugs. We found relief from pain through TMS.

Contents [hide] 

• 1 What is TMS?
• 2 How TMS Develops
• 3 Treatment
• 4 Medical Evidence
• 5 More Resources

What is TMS?
Tension Myositis Syndrome (TMS), also known as Tension Myoneural Syndrome, is a condition originally described by John E. Sarno, MD, a retired professor of Clinical Rehabilitation Medicine at New York University School of Medicine, and attending physician at the Howard A. Rusk Institute of Rehabilitation Medicine at New York University Medical Center. TMS is a condition that causes real physical symptoms, such as chronic pain, gastrointenstinal issues, and fibromyalgia, that are not due to pathological or structural abnormalities and are not explained by diagnostic tests. In TMS, pain symptoms are caused by mild oxygen deprivation via the autonomic nervous system, as a result of repressed emotions and psycho-social stress. This is not to say that the pain is “all in your head” or that it is not real. TMS symptoms are very much real, and we should know. All of the people who wrote and developed this website had debilitating chronic pain and other symptoms. We know, first hand, what it is like to have back pain, sciatica pain, RSI, fibromyalgia, chronic fatigue syndrome, migraines, irritable bowel syndrome, and a wide array of other symptoms. We visited doctors and were told the same things you probably heard: "you have a degenerative disc disease, a herniated disc, you type too much, it is due to overuse, or that you are just aging." Even though we were told this, when we applied the ideas first promoted by Dr. Sarno we became pain free and regained our lives.

For more info on TMS watch The 20/20 segment on John Sarno and TMS.

How TMS Develops: At the heart of the development of TMS is our desire to be good people, loved by those we care about. This desire leads us to strive for perfection, and to put the needs of others above our own. We will cook a three course family meal after working a 10 hour day, because that is what a good mother would do. We will be the first person to volunteer to work on the weekend, because that is what a good employee would do. We will stay up all night making sure our homework is perfect, because if we don't, we won't get a good job. Our beliefs of what a good and perfect person will do directly influence our behavior on a day-to-day basis. 

But sometimes, as more and more external stress is added and our desire for perfection increases, we develop a very deep seated resentment toward these tasks. There are some nights when you come home from working a double shift and are angry that you have to cook a meal for your family, while your husband has been watching TV all night. Part of us hates telling our friends that we can't go out on Friday night, because we have to read and study for a class the next day. When our newborn baby wakes us up at 3 am for the fourth night in a row, some part of us has rage at the child, for waking us up yet again. These are all normal feelings and emotions to have. However, when a person has an emotion that goes against their belief of what a good and perfect person would do, the only option available to them is to repress that emotion. If we admit that we are angry at our family, our boss, or at doing homework, we fear that we would be considered a bad person and will be rejected by those we love or who we want to respect us. If we are not perfect, we will be unworthy of being loved. So instead of admitting that we are angry at our spouse for never cleaning up or doing the dishes, we repress it deep in our unconscious. 

Another repressed emotion might be guilt. Some of us have to care for a loved one who is injured or aging. Being a caretaker is not an easy task. If we aren't able to provide the necessary care, or the care the person not only desires but may demand of us, we may feel guilt. If we repress that feeling, especially if we are the type of person who wants to please very much, it can cause us TMS pain.

As we continue to repress these emotions, we create an immense amount of emotional tension which only increases as more and more stress is added to our lives. In order to keep you from recognizing that you have these powerful emotions of anger and rage or guilt, your unconscious creates physical symptoms, such as back pain, neck pain, plantar fasciitis, acid reflux, anxiety, depression, Dizziness, and irritable bowel syndrome. These symptoms serve as a way to distract you from the unwanted emotions by having you focus on your back hurting instead of your anger, rage, or guilt. We develop TMS because we are unable to accept and/or process these emotions.

 A few years ago a lady came to the office and said: “Remember that chronic pain I had? It’s gone.”
“What happened? “ she was asked.
“ I read a book.”

The book she had read was Dr. Scott Brady’s Painfree for Life which describes how the unconscious mind can aggravate, perpetuate, or even produce physical pain through the action of the autonomic nervous system, that part of the nervous system which is involved in the ‘fight, flight or freeze’ response to perceived danger.

When we heard her story we read Brady’s book and over a short period of time acquired a number of other books based on the work of Dr. John Sarno, a rehabilitation specialist, who discovered the role of stress or tension in causing back pain, and later extended this concept to a much larger group of functional conditions.  We had known that pain always seems worse when one is frightened and that a lot of chronic pain sufferers had emotional trauma in their backgrounds, but we were not aware that the brain could reproduce or initiate physical pain in the absence of any actual disease process.

 Since then we have had several patients whose pain disappeared or substantially diminished once they became aware of aspects of their personality, past experience, present circumstances, or psychological issues which triggered their pain.

 Please note, I am not speaking here of malingering (faking the pain when you know that nothing is wrong), or of secondary gain (remaining in the sick role when it is to your advantage to do so because you can avoid work or something else unpleasant or obtain sympathy). Even secondary gain can be subconscious – it is well known, for instance, that the best predictor of a swift return to work after a back injury is whether or not the worker enjoys the job.

 We are talking of an entirely subconscious process of real physical pain being produced (or reproduced) by the brain as a distraction, which allows the conscious mind to avoid dealing with intolerable memories or feelings by focusing on the pain instead of those other experiences. We are also talking about physical pain being produced by alterations in muscle tension, posture and blood flow brought on by emotional stress. Of course, we all recognize that stress can produce physical symptoms: sweating, nausea and diarrhea from “nerves” prior to giving a speech or writing an exam, for instance, or a tight jaw or shoulder knots when we are angry or frustrated. The same applies to musculoskeletal pain. Consider for a moment the metaphors we use in every day language: he’s a pain in the neck, she gives me heartburn, this job is full of headaches etc.

 Causes:

 ·      Personality:  you don’t have to have a dreadful trauma in your background or a psychiatric illness for the subconscious mind to produce pain. If you are a perfectionist, a people-pleaser (always trying to please other people and never feeling you completely satisfy them), or having impossibly high standards for yourself, you can set the stage for pain.

·      Past: a past history of abuse, or severe emotional trauma or intolerable memories can be triggers for pain. 50% of people with fibromyalgia, for instance, have post-traumatic stress disorder (PTSD) and victims of assault or childhood abuse frequently develop a variety of chronic pain syndromes.  Old pains long cured can suddenly recur when a subconscious memory is triggered by a sound, sight, aroma, or similar experience.

·      Present: feeling trapped, vulnerable or powerless in the job from hell or an unhappy relationship or other circumstance can produce physiological changes, postures and muscular tension, leading to pain.

·      Psychiatric illness such as depression or anxiety can also produce physical symptoms.

 
Examples from our clinical practice:

 ·      One patient underwent counseling including EMDR by a skilled psychologist. When this was completed not only were her traumatic memories dealt with and her depression lifted, but her fibromyalgia was also gone. 

·      One young lady volunteered that her fibromyalgia resolved when she forgave her mother.

·      Another found that journaling controlled her neck pain which functioned as a barometer for stress.

·      An accomplished student athlete with a two-year history of incapacitating back pain despite multiple investigations, treatments and specialist consults, read up online about the personality traits that contribute to stress-related pain. After viewing some of the websites listed below the pain was gone.

We don’t suggest for a moment that all chronic pain fits into this category but simply that it is worth keeping an open mind about the possibility that stress may pay a large role in chronic pain.

 Over the next few blog entries I hope to outline in simple terms how pain is processed and modified by the nervous system.

 
Stress Illness (Mindbody Syndrome or Psychophysiological Disorder) Resources:

(Disclaimer: we do not have any proprietary interest in any of these resources). 

Books by John Sarno:

“Mind Over Back Pain”

“Healing Back Pain: the Mind-body Connection”

“The Mindbody Prescription: Healing the Body, Healing the Pain “ (also on video)

“The Divided Mind”  this one is the most comprehensive but is quite academic.

 Book and Video Course by Scott Brady: “Pain-free for Life”

 Book by Marc Sopher: “To Be or not to Be – Pain-free”: the simplest and shortest of these books. 

 Book and Online Course by Howard Schubiner:  “Unlearn Your Pain.”             

 Book by David D. Clark “They Can’t Find Anything Wrong.”

 Book by Steven Ray Ozanich “The Great Pain Deception”

 Workbook by David Schecter  “Mindbody Workbook.”

 Book by Nancy Selfridge and Franklynn Petersen  “Freedom from Fibromyalgia”

 Internet resource: www.tmswiki.org : multiple articles and links on this subject. 

 Journal article:

 Abbass, A.   Somatisation : diagnosing it sooner through emotion-focused interviewing   MARCH 2005 / VOL 54, NO 3 · The Journal” of Family Practice


Additional resources:

 Psychotherapy:

Fosha, D, et al “The Healing Power of Emotion”

EFT, Faster EFT, EMDR can all be researched online.

Pain: Management textbook:

Steven Waldman  (editor)  “Pain Management”

Understanding some of the chemistry:

A book by Candace Pert: “Molecules of Emotion “ explains the biochemical process behind emotion and pain. 


"Acute" and "chronic" are two adjectives which are often misunderstood. They have nothing to do with the severity or seriousness of a condition but refer instead to its duration - how long it has been present. Arbitrarily, acute conditions have been present for less than 3 months, chronic for more than 3-6 months. Between 3 and 6 months is a grey area. If you prick you finger, jab yourself in the eye, have a ruptured appendix, sprain your ankle, or have surgery, those give rise to acute pain. The human body is so resilient at healing itself that most injuries are better within 3 months, often sooner. Acute pain is usually due to physical causes. The longer chronic pain has been present the more social, financial and emotional factors contribute to the whole burden of suffering the person experiences. Intervening before a condition becomes chronic is preferable. 

Pain Neutralization Technique (PNT) refers to a group of treatments developed by an acupuncturist/chiropractor in Denver, Dr Stephen Kaufman, for the treatment of a variety of painful conditions. They are simple, painless, effective and safe and do not involve medications or injections. No need for needles! 

Most of the techniques can be explained through understanding how muscular trigger points can be swiftly released by specific pressure points and stretches. No painful deep tissue massage is involved. A few techniques are best understood according to Chinese Medicine concepts. 

After a standard examination of function and range of movement the therapist examines the muscles and soft tissues for tenderness.  The most basic technique involves first identifying a tender trigger point and then applying specific stretches across the muscle or neighbouring muscles which instantly switch off the pain. The release is held for 20 seconds to make it "stick". One then proceeds to the next tender point. Not everybody responds to this treatment but when they do, the technique can be incorporated into the physical examination in such a way that when the exam is completed the pain is gone and function is restored. The presence of muscular pain limits movement because the body tries to protect itself by tensing up. Normal movement is usually restored once the pain is relieved. 

Most people require several visits to prevent it from recurring, especially if they have habitual postures or activities which perpetuate the muscular pain or re-injure the tissue,  but occasionally one treatment is sufficient.

Here are a few examples of the many people who find this helpful:

• a lady came in with a stiff wrist and painful forearm after having her cast removed following treatment for a Colle's fracture of the wrist. I was concerned that a tight cast may have affected her circulation in her arm but when she was examined she was found to have tender muscles at several points in her forearm. PNT was applied to each tender point and within a few minutes her stiffness and pain were gone and her wrist movement had returned to normal. 
• a fit patient who works out regularly at the gym presented with low-back pain and pain across her shoulders. She could only bend her back a few inches and she had a lot of muscular tension in her shoulders. Each tender point was released, several PNT techniques were applied to her lower back and hip muscles, and a few minutes later she could put her hands flat on the floor when bending her back. 
• a lady fell at work on her outstretched hand and came in complaining of wrist pain. In fact, she had tender points in her wrist, forearm, upper arm and shoulder. PNT was applied systematically to each area  and her pain was gone by the end of the visit. 
• a gentleman came in with plantar fasciitis after a walking tour around Europe. He had tenderness in the sole of his foot, heel, and in his calf muscles. PNT was applied across the plantar fascia and calf muscles and his painful limp resolved. Most patients with this condition need trigger point injections, exercises and muscular stretches, or obtain expensive orthotics, but his was one of a number of instances in which PNT alone was sufficient. 

Clearly these techniques cannot cure serious diseases but myofascial pain often responds very quickly. We often start with PNT when treating muscular pain; if it is effective, then no other treatment may be needed. If not, then further testing and other options are available. 

Referred pain is pain felt at a site other than where it originates. Referred pain can be: 

• Visceral
• Dermatomal
• Joint
• Muscular or myofascial
• Sclerotomal
• Related to skin sensory nerves

Visceral pain originates in internal organs but may be felt on the surface or appear to come form another structure such as a muscle or joint. Examples in include angina or heart attack pain which can be felt not only over the front of the chest but in the jaw, teeth, upper back, down the arm or in the throat. Another example is earache which may arise from the tongue, throat, neck or jaw joint (TMJ). Gallbladder pain may be felt in the shoulder blade. Gynecological pain can be felt in the lower back or thighs as well as the lower abdomen. Shoulder pain can be referred from the neck, chest, heart or diaphragm, including infections or bleeding in the abdomen which irritate the diaphragm. This is why when you see a doctor for apparent musculoskeletal pain he or she will likely ask questions intended to rule out some of these conditions. Occasionally, the skin over an affected organ will be affected (the viscero-cutaneous reflex). 

Dermatomal pain arises from an injury or irritation/inflammation of a nerve in the spinal cord (or face) and is felt along the area of the skin which corresponds to the nerve. Shingles is one such example; a disc herniation also produces similar pain which will be felt in the arm (in the case of neck spinal roots) or down the the leg, as in the case of lower back nerves (lumbar and first sacral nerve roots). If the nerve is compressed sufficiently then numbness may occur instead of pain. 

Joint pains can be referred from one joint to a neighbouring one and present a confusing picture. One common example is hip arthritis which is felt in the knee (or vice versa) or lower back degenerative arthritis which can refer to the hip or thigh. A normal joint (e.g. the knee) is painful and the abnormal one (e.g. the hip) is stiff but not painful and in this case the knee pain resolves when the hip is treated. Don't be surprised if your MD wishes to examine the joint above and the joint below the one you are complaining about. Teasing out where the pain is coming from can be difficult when both joints are involved. 

Muscular or myofascial ('myo'=muscles; 'fascial' refers to the thick white connective tissue which envelopes all our muscles, nerves, organs etc) trigger points, when active, can refer pain in particular predictable patterns which can mimic dermatomal patterns or other conditions. For example, trigger points in the scalene muscles and pectorals major can refer down the arm; some neck muscles can give rise to pain in the upper jaw (resembling toothache) or forehead.  Pain patterns arising from specific ligaments have also been mapped out. 

Sclerotomal referred pain arises from  specific spinal segments and tends to be dull, poorly localized and overlaps with other levels. 

Three thousand years ago King Solomon wrote: "...Of making many books there is no end, and much study is a weariness of the flesh" (Ecclesiastes 12:12). Now, I am of the opinion that one can never have too many books. The New York Times reports on a Scandinavian study of plantar fasciitis:



Plantar Fasciitis Relief
By GRETCHEN REYNOLDS
SEPTEMBER 15, 2014
Question:
Can I get relief for plantar fasciitis?

Answer:
If you have stairs or a sturdy box in your home and a backpack, timely relief for plantar fasciitis may be possible, according to a new study of low-tech treatments for the condition.

Plantar fasciitis, the heel pain caused by irritation of the connective tissue on the bottom of the foot, can be lingering and intractable. A recent study of novice runners found that those who developed plantar fasciitis generally required at least five months to recover, and some remained sidelined for a year or more.

Until recently, first-line treatments involved stretching and anti-inflammatory painkillers such as ibuprofen or cortisone. But many scientists now believe that anti-inflammatories are unwarranted, because the condition involves little inflammation. Stretching is still commonly recommended.

But the new study, published in August in the Scandinavian Journal of Medicine & Science in Sports, finds that a single exercise could be even more effective. It requires standing barefoot on the affected leg on a stair or box, with a rolled-up towel resting beneath the toes of the sore foot and the heel extending over the edge of the stair or box. The unaffected leg should hang free, bent slightly at the knee.

Then slowly raise and lower the affected heel to a count of three seconds up, two seconds at the top and three seconds down. In the study, once participants could complete 12 repetitions fairly easily, volunteers donned a backpack stuffed with books to add weight. The volunteers performed eight to 12 repetitions of the exercise every other day.

Other volunteers completed a standard plantar fasciitis stretching regimen, in which they pulled their toes toward their shins 10 times, three times a day.

After three months, those in the exercise group reported vast improvements. Their pain and disability had declined significantly.Those who did standard stretches, on the other hand, showed little improvement after three months, although, with a further nine months of stretching, most reported pain relief.

The upshot, said Michael Skovdal Rathleff, a researcher at Aalborg University in Denmark, who led the study, is that there was “a quicker reduction in pain” with the exercise program, and a reminder of how books, in unexpected ways, can help us heal.

This research is discussed here: 
Strength training better than stretching for plantar fasciitis

Clinical question
Is strength training more effective than stretching for patients with plantar fasciitis?

Bottom line
A regimen of strength training (specifically, heel raises) improves pain and function in patients with plantar fasciitis faster than a typical stretching regimen. Over time, though, patients who stretch will continue to improve and have similar improvement. (LOE = 1b-)

Reference
Rathleff MS, Molgaard CM, Fredberg U, et al. High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scand J Med Sci Sports 2014 (e-publication). doi: 10.1111/sms.12313

Study design
Randomized controlled trial (nonblinded)

Funding
Foundation

Allocation
Uncertain

Setting
Outpatient (specialty)

Synopsis
These Danish researchers recruited 48 consecutive patients referred for physical therapy for the treatment of plantar fasciitis. All patients had heel pain for at least 3 months and had ultrasound-confirmed plantar fascia thickness of at least 4.00 mm. All patients received Tuli's Polar Bears gel heel cups and were then randomized, concealed allocation uncertain, to plantar-specific stretching or strength training. The stretching regimen consisted of crossing the affected heel over the opposite knee and pulling the toes back for 10 seconds, repeated in sets of 10 three times a day. The strength-training group performed heel lifts from a raised platform (eg, a step), with a rolled towel placed under the toes to cause maximum dorsiflexion (see a picture at http://tinyurl.com/plantarstrength). The regimen is progressive and rigorous (see outline below). The Function Foot Index, a measure of self-reported pain, disability, and function ranging from 0 to 230, was used to measure benefit. After 3 months, scores in the strength-training group were 29 points better than in the stretching group (95% CI 6 - 52). However, at 6 months and 12 months the stretching group continued to improve and their scores were not significantly different from the strength-training group’s scores. High-load strength training: Heel raises are performed on a raised platform with a rolled-up towel under the toes to cause maximum dorsiflexion. Raise the heels over 3 seconds, hold for 2 seconds, and then lower over 3 seconds. Complete 3 sets of 12 repetitions every other day using one leg unless 12 cannot be performed. After 2 weeks, increase the load by wearing a backpack filled with books, reduce the repetitions to 10 per set, and increase to 4 sets After 2 more weeks, increase the load again (add more books to your backpack) and perform 8 repetitions, 5 sets.

We are sometimes asked whether we practise conventional or alternative medicine, as if there were a fixed dichotomy between them. The fact is, we have always practised mainstream evidence-based medicine but have a growing awareness of its limitations (especially the paucity of some of the evidence upon which we have always relied in using conventional therapy, not to mention the toxicity of many medications), and a cautious openness to those (currently) alternative therapies which have not yet made it into the mainstream. Cautious, because not all that is "natural" is therefore safe, and not all claims are justifiable, but an openness because closed minds never learn anything new. The therapies we offer are generally well-tolerated, safe and effective. We prefer the terms 'integrative' and 'regenerative' to describe what we do, inasmuch as we combine conventional medicine and a limited selection of alternative therapies in the attempt to relieve pain and restore function. We have received some good-natured teasing from our less-adventurous colleagues on occasion and on other occasions have had patients indicate that we were not "alternative" enough for their liking. Hopefully, we are not sailing too close to the wind but steering a sensible course. 

In this blog I hope to write some articles aimed at the general public and therefore not in too technical a style, but also hope that our medical colleagues may find something useful here.