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1) Pain from muscle spasm. This follows a severe strain or sprain, or a fracture. A spasm of the muscle triggers a vicious chain of pain and contraction, pain and contraction, which can continue for days. The chain can be broken by ethyl chloride spray, ice massage or, when dealing with a spasm in the back, a hot pack. Then the muscle can be exercised with a gentle limbering motion. Oral pain-killers or tranquilizers do very little to relieve the pain of muscle spasms.
2) Pain from muscle tension. This occurs when a muscle remains contracted beyond the momentary need to perform a task. This sets up a constant, nagging pain, often in the neck, back or head. A so-called "tension headache" is an example of this type of pain. Tranquilizers alleviate it, but to avoid long-term use of tranquilizers, exercise of the muscles involved must be performed.
3) Pain from muscle deficiency. Weak or stiff muscles cause this by not carrying their load. For example, weak abdominal muscles often cause pain in the lower back muscles. Or an athlete with a stiff or weak quadriceps muscle may experience intense knee pain. This kind of pain can be dealt with only through therapeutic exercises designed specifically to correct the deficiency involved.
4) Pain from triggerpoints. For the layman-athlete this could be the most significant revelation in Kraus' book. "The most neglected of all causes of muscle pain, triggerpoints are small hard nodules in muscle that literally trigger pain and spasm," he writes. "They have been biopsied and shown to be areas of degenerated muscle tissue." This phenomenon has been known since the late 19th century. Max Lange, a German orthopedic surgeon, did the classic work describing the distribution, origin and pathology of triggerpoints in 1931, and many researchers have since studied them. Yet, Kraus says, "Most physicians are completely unaware of the existence of triggerpoints and their significance."
The commonest cause of tennis elbow, according to Kraus, is triggerpoints that develop from the repeated shocks to forearm muscles caused by a faulty racket swing. Because triggerpoints usually occur at a point where a muscle is attached to a tendon or a bone, they are also probably to blame for a majority of sore arms and shoulders suffered by baseball pitchers, Kraus believes. Runner's knee is frequently caused by triggerpoints, as are various pains in the neck, calves, back and the occipital region of the head. In fact, President Kennedy's back problem was caused in part by triggerpoints.
Nevertheless, says Kraus, triggerpoint therapy has been slow gaining acceptance. Says Kraus, "Back in 1931 when Lange published his book on the subject, he predicted that 20 years would pass before the medical profession recognized their significance. He was an optimist. Even today few standard medical works discuss them." Kraus points out that Taber's Cyclopedic Medical Dictionary, 12th edition, 1970, a standard reference book, doesn't mention triggerpoints. There is, however, an entry in Taber's, defining tennis elbow as "an obscure, insidious, distressing complaint," for which treatment is as follows: "In mild cases, immobilization by a splint or adhesive strapping, supplemented by heat or diathermy. In long continued cases, surgical intervention may be indicated."
Dr. Nagler doesn't share Kraus' pessimism about the progress of triggerpoint therapy. "I would not agree with him that few doctors are using it," he says. "I would say triggerpoints have widespread acceptance. One reason the treatment isn't practiced more is that it's a lot of work for the physician. It's easier to send the patient to X-ray and other labs than to search for triggerpoints."
The treatment of triggerpoints involves a relatively simple, though tedious and, for the patient, uncomfortable, technique—something Kraus calls "mechanical destruction." Once the triggerpoint is located through methodical manual probing by the physician—followed at each successful probe by the patient's wincing—it can then be destroyed through injection and needling with a hypodermic syringe filled with lidocaine, an anesthetic. (Should a patient be sensitive to lidocaine, then a saline solution matching the salt content of the blood is substituted.) The needle is moved in a circle; as the sore spots are touched, lidocaine is injected. The combination of needling and injection eventually breaks up the triggerpoint. Three to four days after the injection, Kraus applies electric muscle stimulation and ethyl chloride spray, and then directs the patient in gentle exercise of the affected muscle.
Kraus points out that triggerpoints are more commonly found in people with an endocrine imbalance, such as women in menopause, or those suffering from hypothyroidism or Addison's disease. However, he warns that triggerpoints often occur in athletes in top condition—and Kraus himself is no exception.
All his life, Kraus has been an expert rock and mountain climber, a nimble and powerful man in superb physical condition. Yet he, too, has been a triggerpoint victim. "Once while mountain climbing I had to chin myself with one hand over an overhang in order to avoid a terrible fall," he says. "As I pulled myself up, I felt something tear in my right shoulder. It hurt. However, I not only climbed farther that day, but for the following three weeks as well. Eventually I knew from the pain that a triggerpoint had developed in the shoulder blade muscle. I tried pressure, heat, cold and electrotherapy. None of these methods worked. Then I had the triggerpoint needled and injected. That eliminated it."