Dealing with Back Pain: Psoas

Back pain can come from a variety of places.  Did you know that back pain can come from muscles in your abdomen?  One of these muscles is called the psoas (pronounced "SO-az").  It actually connects up with another muscle called the iliacus and together they are called the iliopsoas ("Ill-ee-oh-SO-az'").

The psoas can refer pain to the back, anywhere from the shoulder blades to the buttocks area.  Back pain from the psoas is usually on one side of the spine or the other, unless both the psoas muscles have trigger points, in which case, the pain will not feel like it is confined to one side or the other.  Here are some other places that the psoas can refer to:

• groin 
• upper thigh 
• contributes to scoliosis 
• abdomen 
• genitals 
• stiffness in hips or groin in morning when you get up 
• rotates legs outward 
• can't stand up straight
• stooped posture
• leaning to one side

(Information is from, The Trigger Point Therapy Workbook, by Clair Davies, pp. 151-155.)

The psoas attaches to the bones of the spine, starting at about the height of the last rib. It comes down and forward to attach to the top of the thigh bone.  The iliacus portion of the muscle starts at the front of the hip bones and joins the psoas to attach at the same place on the top of the thigh bone.

Primitive drawing, but it should give you an idea.  The psoas is shown in red, the iliacus in green.  

While the iliacus is a little more accessible, the psoas is buried deep in the abdomen.  But it is possible to work it.

You must use caution.  It is important to stay away from major veins and arteries, so if you feel a pulse when working your psoas, just move over a bit until you do not feel it anymore.

The psoas is actually located under your intestines.  To work it, you need to come in at an angle.  There are a couple of ways to work the psoas.

One is to lie down on your back with your knees bent.  Then let your knees drop to one side.  This will bring the hip opposite your knees up and move your intestines over a little. (Move your knees to the other side to work the other psoas.)

The main trigger points are a couple of inches away from the belly button on either side.  You can start there and look for trigger points about halfway between your belly button and your hip bone.  Bring your hands together with the fingers of each hand on the backs of the fingers of the opposite hand.  Using this tool, push down into your abdomen, searching for trigger points.

Tool for working abdominal trigger points, including the psoas.

You will probably find trigger points in other abdominal muscles, and you can just go ahead and work those while you are at it.  If you want to know for sure if you have located the psoas, you can move your leg up and down.  You should be able to feel the muscle under your fingers as you move it.  Do not work the muscle while moving, however.  Trigger points are much easier to work out when the muscle is relaxed.

A second way to work the psoas, and this is where I am saying use caution, is to use the theracane.  I personally like to do it this way, at least sometimes, because my arms seem to wear out pretty fast when I work my abdomen.  I would advise that you learn how to find the psoas first, using your hands and when you feel like you have a good handle on where it is located, then you can move up to using the theracane.

To work the right psoas, hold the theracane in front of you with the curve on the right, curve facing upward.  Grasp the top of the curve in your right hand and the outermost handle in your left hand.

Holding the theracane.

Let your knees fall to your left side.  Then push the remaining handle into the trigger point.  It is very important to proceed gently and carefully.

Using remaining handle, press into trigger point.  I am standing in this picture to provide a better view how to push in with the theracane, but you would be lying down.  

You can also work the iliacus with a lacrosse ball against the wall or a countertop.  Place the ball just below your hip bone in the front.  You can also work your quadratus lumborum, another contributor to back pain, by placing the ball just above the hip bone.  Working both of these areas will make it easier to work the psoas.

When you work the psoas muscles, be sure to work both of them every time.  And it is a good idea to work your glutes, quads and hamstrings, since they work with the psoas.  If all of the muscles are tight, and you loosen one of them, the others may reflexively tighten even more.  Picture a tug-of-war happening.  As long as both sides are pulling hard on the rope, it stays pretty much in the same place.  But, if one side lets go, the other side will end up falling down because they have still been exerting the same amount of force needed to keep that rope in the same place when the other side is pulling with all of their might.

So, if two muscles (for example) are plagued with trigger points, both muscles will be extremely tight, but that tightness will be tempered by the pull of the other muscle.  When one muscle suddenly has its trigger points released, there is no longer a pull on the other muscle and it is likely to tighten even more, resulting in more pain.  Because of this, it is a good idea to work any muscles that are antagonists (the muscles perform opposite functions) or synergists (the muscles perform a function together) at the same time that you work the original muscle.

Addendum added Oct. 23, 2012: 
I have found another way to work the psoas which I think is easier IF you are able to get down on the floor.  I have been able to get down on the floor lately, and it is easier to access the psoas using this method.

Part 1:
1) I lie face down on the floor with a lacrosse ball placed between me and the floor, about two inches out from my waist.  I take slow, deep, full (abdomen fills also) breaths and let myself fall further into the ball each time I exhale.  After two or three times, I go to step 2. 

2) I lift my head and rest on my elbows and forearms.  At the same time, I pull slightly forward.  I do the same breathing routine.  Then I go to step 3.

3) As I exhale my first deep breath, I lift my leg on the same side the ball is on and I let myself fall into the ball.  I hold my leg in that position until I have done about 3 repetitions.  The leg is lifted from the hip.

Then I repeat on the other side.

Part 2:
Then I turn over onto my back and work two or three trigger points at my bottom rib area and at the top of my pelvis (about waist level).  Using the breathing technique is helpful here also.  I do this on both sides.  Then I roll over gently and get up.

I found this excellent youtube video by tptherapy that shows how to do Part 1:  Trigger Point Weekly Workout #1   There is more on the video, but the part I am referring to is the first few minutes when he shows how to work the psoas with a therapy ball. 

For the second part of what I am describing, check here:  Remove Muscle Knots Yourself (Tennis Ball Release).  This youtube video by Paula Moore is excellent.  She also gives good advice about getting up from working your trigger points.  Don't just sit up.  She will show you how to roll over correctly when getting up.

One more thing:  This video, uploaded by posturedoc, describes a good sleeping position to help prevent back pain. I found it very helpful.  The Best Sleeping Position and How to Get Out of Bed

Hopefully, something here will help you. 

More Trigger Point Tools

Having the right tool can make all the difference. For example, it would not be very effective to use a screwdriver to hammer in a nail, and it would not make much sense to use a hammer on a screw. Sometimes, we can substitute another tool and it will be somewhat effective, like using a knife as a screwdriver, but it will be faster and more efficient to use the right tool. Sometimes, we have tools that are good enough, but a more specialized tool would make it so much easier.

I have introduced you to what I would consider the mainstays of a trigger point tool kit:  the lacrosse ball and the theracane (or backnobber). Today, I will introduce you to a few other tools that can be useful, especially for specific jobs.

Interestingly enough, bouncy balls are great tools for getting to some of the harder to reach muscles. They come in different sizes so you can usually find something that will fit your particular purpose. They are not as durable as lacrosse balls, but they are relatively inexpensive and they will last for quite a while.

Two sizes of bouncy balls and lacrosse ball.  

I have a favorite size that I have been using to massage the muscles in my arm while I am recovering from my elbow injury. There are many narrow muscles in several layers that I am working and this ball is perfect for this. The ball a size up is too big and the ball a size down is too small.  

Using bouncy ball on the outer elbow area.  

Using bouncy ball on inside area of elbow and down the arm.  

 Using the opposite hand, I press and roll the ball into my muscle. I use the heel of my palm to get particularly deep, but I also use the entire palm of my hand, and my four fingers held straight and close together to form one tool. Using this method, I roll the ball around my arm, and as I find trigger points, I work them for a few strokes before continuing on.

Getting in position to use the opposite hand on outer elbow.  The ball is placed between the palm and the opposite elbow. 

I have used a bigger size (the purple and orange ball in the photo above) for my triceps, and it is perfect for that. When I first got off the pain pills and I was starting to venture out into the world again, I went grocery shopping. I took that ball with me, and whenever my elbow started to really ache, I worked my triceps with the ball, and it relieved my pain.  

As part of my physical therapy, I have to wear a splint on my arm for 6 to 8 hours a day to help me stretch my muscles back to where they were before the accident. Often, my arm starts to ache when I wear this, but I can work some trigger points through the back side of it, which is open. I can also take the splint off temporarily, work some trigger points on the inside and put it back on. When I have worn it for several hours, my arm is usually pretty tender all over, and it hurts to move it. I use the ball to work all of the areas that are tender and stiff.  

The difference between the two arms.  I have gained quite a bit of range of motion, but I have some way to go still. My arm usually extends farther after I have had my arm in the hot whirlpool bath for 15 minutes at the physical therapist's office.   

My arm in the splint.  

Sometimes, I can just set the ball on the table, or another hard surface like a book, and roll the exposed part of my arm on the ball.  

Another tool that I have used recently is called the Palm Massager (made by a company called Pressure Positive, available online).  

Palm massager.

This handy tool is held in the palm of the hand. The fingers fit comfortably into grooves molded into the tops of the three "arms" of the tool. Each "arm" has a rounded end. Two of these ends are relatively small, while the remaining end is larger.  

The finger fits in the groove on top of the arm.

This design makes it easy to use quite a bit of pressure without totally trashing your fingers. I have used it for trigger points in the back of the neck, and, lately, I have used it to work my inner elbow. It is good for going deep.  

Using on the back of the neck.  It is even better if you can lean back into it, so that the muscles that you are working are relaxed.  

Late one night, I was using the palm massager on my inner elbow, and I was able to find some places that hurt that I had not been able to reach before. I worked them, and I could see that it was increasing my mobility. I was pretty excited. The next morning, I was dancing and singing: I've been dreaming of an arm that moves... to the tune of, "I've been dreaming of a true love's kiss," from the movie, Enchanted. It has become sort of a theme song for me.  

Another tool is the Knobble (also by Pressure Positive, available online).

The Knobble

This tool looks a lot like a round door knob. It has a rubber-like surface on its side, which helps in gripping the tool. I often like to hold the tool sideways and use the rubberized side for the trigger point therapy.

The Knobble, side view.

The Knobble is great for places that you want to get into deep with minimal effort. I have used it on my arms, my quads (but I decided later that I like the lacrosse ball against the wall better for the quads) and also on my pecs (using the side).

In position to use the Knobble on my arm.  My fingers are held up to show how the Knobble is placed.  They are wrapped around the Knobble when working the trigger points.  

Holding the Knobble sideways to work the pecs.  

I have even used it on the muscles of my head, staying on the gentler, rubber side.

Using the side of the Knobble on my temporalis muscle. 

Experimenting with different tools, you will probably find some that you prefer over others for particular tasks. The more comfortable you are using a tool, the more likely you will be to use it. You will also probably be more effective, giving the right amount of pressure, not too much, not too little.

How "cruel" are your shoes?

I read a story written by comedian Steve Martin some years ago entitled, "Cruel Shoes." In this story, a woman goes to a shoe store to purchase shoes, and is not satisfied with any that are brought out to her by the salesperson until she finds a pair that are so uncomfortable that they contort her feet and make them bleed. When she tries these on, she is finally pleased, and decides to get them.

When I was younger, there were times when I walked all over BYU campus in heels, sometimes spiked, not all of the time, but at least once a week for a school year when we had church services in a building on the opposite side of campus from where we lived. I knew it wasn't good for my feet; however, I have short legs, and I thought wearing high heels made my legs look longer. Besides, I did not want to make myself look weird. So, I kept wearing them and put my feet up to rest when I got home.

In my late thirties to early forties, I noticed that whenever I wore high heels (as opposed to lower heels), my knees started to hurt a lot within 15 minutes. It was so bad that I could not stand, but had to sit down. They kept hurting for a while after I took the heels off. I stuck to low-heeled pumps for several years, until a few years ago, I could not even wear those. The bottom of my foot had started to hurt in addition to the knee pain. It felt like I was walking on the bones, with no cushioning at all. I had to stop wearing dress shoes completely. Also, there was only one style of athletic shoe that did not make my knees hurt, and the last time I went to get another pair, they were discontinued.

Thankfully, it was about that time that I found out about trigger point therapy. I worked the trigger points in my legs to help get rid of the pain. The pain in the knees came from my thighs, and the pain in the foot came from my calves. But the pain was quick to return when I walked for any length of time.

I learned that I have something called Morton's foot (not to be confused with Morton's neuroma), that is, I have a longer second metatarsal (bone behind the second toe) than the first metatarsal. This predisposes me to problems with my feet and indirectly causes pain in the rest of my body. This difference in metatarsal length made it so I was walking on two points of my foot, instead of three--kind of like walking around on an ice skate, but without the high top boot. The muscles farther up my body were working very hard just to keep me standing.

Fortunately, The Trigger Point Therapy Workbook had a fairly simple and inexpensive way to compensate for my foot structure (See p. 243). I cut out an oval or circle of moleskin about an inch-and-a-half in diameter for each foot. I stuck it (it is a peel-and-stick product) on the bottom side of a foam insert that had been cut to fit my shoe, in the area under the first metatarsal.

Foam insert, cut to size. 

Example of piece of moleskin attached to bottom of foam insert. 

I was amazed at the difference this made. I could actually stand tiptoe, something I had not been able to do for a long time. It eliminated my knee and foot pain (as long as I stick with low shoes). Putting the pad under the first metatarsal gives it a little more "length" so that it can hit the ground before the second metatarsal.  The first and fifth metatarsals, and the heel, act as a tripod to bear the weight of the body.

So, if you have ongoing foot pain, knee pain, or back pain, it might be a good idea to take a look at the bones that protrude when you bend your toes. (There is more information on p. 243-245).

To fit yourself with one of these "custom orthotics," flex your big toe upward and feel for the bony part in the center of the fleshy pad below the big toe.

Feel the bone in the fleshy pad below the big toe.  

Trim the circle or oval of moleskin to fit comfortably under that bone, without going under the bone that is further into the foot (the second metatarsal). Check where to place the pad* first (before you peel off the backing), then peel the backing off and stick it to the bottom of the foam insert. Then place the insert in your shoe. Mine usually last a month or two before the insert starts to wear out.

Also, consider the type of shoe that you wear. Clair Davies writes, "Wearing high heels keeps the soleus [this is a large flat muscle that wraps around the back of your calf] muscles shortened, which is a sure way to create and perpetuate trigger points. The ankle instability typically caused by high heels also strains the soleus muscles with each step." (p. 239).  Trigger points in the soleus can cause "deep pain in the sacroiliac area and maintain spasms in the muscles of the low back" (p. 238). It also sends pain to the back of the calf, heel of the foot, and inside ankle.

So, how cruel are your shoes?

_________________________

*I have noticed that some people have a very large difference in length of the first and second metatarsal.  They may need to have a thicker pad to compensate.  Experiment a little bit to see what helps you.

Senses and Sensitivity

Have you ever picked up what you thought was a pitcher full of water (or other drink) and found out that it was actually almost empty? Instead of lifting the pitcher in a well-controlled manner, you may have catapulted it high into the air. You expected it to be heavier, and you automatically made adjustments in the force you used to lift the pitcher. Because you had incorrect information, you used too much force for the weight of the pitcher.

We get information from our basic five senses, but it is not as simple as: I smell, or I don't smell; I hear, or I don't hear; I feel things, or I don't feel things. In reality, there are many nuances to our senses that we might not even be aware of--unless we have a problem, for example, if certain smells give us a headache, particular sounds irritate us, or certain textures feel unpleasant. In addition, there are other less-talked-about "senses" that give us information about our world. For example, our vestibular sense helps us know where we are in space, and among other things helps us keep our balance. Our proprioceptive sense helps us perceive our muscle movement and body position.

So, what if we rarely had the correct information about the weight of an object or how much force we were exerting? We would be experiencing proprioceptive difficulties. This sense helps us to judge how much force to exert and how far to move our muscles. When we put a glass down on a table, we see visually how close we are to the table, but we also sense when we are close to and have touched the table. If our nervous system does not let us know that we have touched the table, we will continue to press down until we feel the table. If we have already reached the table, but our proprioceptive sense does not register that, we will continue to push down until we sense that we have reached the table.

Our proprioceptive sense helps us to know how much force to use, where to place our body, and gives us the ability to put our body where we want it, as fast or as slowly, and with as much control as we need for a given situation. If we have proprioceptive difficulties, these abilities can be greatly reduced.

If we are not receiving enough proprioceptive information, we might exert a lot of force in our movements:  we might stomp when we walk, press very hard down on the paper when we write, or bump and crash into things. Instead of sitting gently into a chair, we might drop into it. On the other hand, if we are receiving too much proprioceptive information, we might be extra cautious in our activities. We might not exert enough force to accomplish the task at hand. In either case our ability to grade our movement might also be affected. Instead of moving smoothly, we might move from low to medium to high with no speeds in between.

Applying this information to trigger point therapy...

1) If you are working your trigger points and you are one who has proprioceptive difficulties, it may be difficult to gauge how much force to use.

As you may have learned by now, when we work our trigger points, it is supposed to "hurt good." If we press too hard, our efforts might backfire and make things worse for a while. If we do not press hard enough, there will be no benefit.  Clair Davies suggested that it should be at about a 7 on a pain scale of 1-10.

When I first started trigger point therapy, I worked my trigger points so that they hurt at a 7. But over time, I found out that it was too hard. I was getting bruises and then I would have to wait until things healed up a bit before I could work those trigger points again. After much trial and error, I decided that I needed to be at about a 5 on a pain scale of 1-10. (As you might have guessed by now, I have proprioceptive difficulties.) I am probably exerting as much pressure as Clair Davies would to get a 7, but I am only registering a 5.

2) Taking this idea a step further, it is possible that many people with proprioceptive difficulties (at least those who are not receiving enough input) have a higher tolerance for pain.

Because they are not reacting as if they have a higher level of pain, they may not be taken seriously when they actually have intense pain.

I am one of those people. I would go to the doctor for some type of pain. Inevitably, the doctor would press here or there and ask if it hurt. Well, it hurt a little, but I hurt everywhere a little. Was it supposed to hurt more than the other places? In fact, sometimes, it actually felt better when they pressed on the spot. Or the doctor might ask me if the pain was like such-and-such, and I would hesitate and have to think about it. Because my reaction was not what they expected, they did not think I had much of a problem. I would leave no better off than I was when I came in. In fact, I was worse off because what I thought was my best possibility for help had just been nullified. I would not come in to the doctor unless I really thought I needed to come in, but I had just been treated as if I had overreacted. Now, I would wait even longer before I would go in again for something.

I have often heard people say, "Oh, you would know it if you were experiencing such-and-such type of pain." Well, I had migraines for many years before I knew they were migraines. While other women were staying home from church or school and offering each other cokes and pain relievers, I kept going, unwittingly making things worse. I did not have enough information.

Pain is exhausting. What if you are in pain, but you really aren't even aware of it? It may have become such a part of your existence that you have become resigned to it.

If we are aware of our proprioceptive difficulties, there are adjustments that we can make to the way we do things and to how much we expect of ourselves. (See the link below for more information.)

Add to that a regular routine of working our trigger points (with the appropriate pressure), and we can lessen our overall pain, be more physically active and hopefully get fewer trigger points. In other words, hopefully, we can reverse the vicious cycle of pain, immobility, trigger points, more pain....

3) If our movements are not smooth and gentle, but are more choppy and abrasive, chances are that we might injure our muscles as we bump into things, stomp our feet and even clench our jaw.

Clenching my jaw is a big one. I know that as soon as I get to sleep, my jaw will clench. This overworks several muscles, including the masseters, which contribute to headaches. I have noticed that if I work some trigger points before I go to bed, all of my muscles seem to be more relaxed, including my jaw.

I have noticed that when I work my trigger points that I feel like I have been oiled. My movements are more fluid and I feel like I have more control over my movement. I am more relaxed, and, I am actually a little more coordinated. (It's pretty motivating, actually.)

4) If we are not receiving enough input, we may overuse our muscles because we do not quit when they get tired.  

This is a big one for me. I also have a personality that likes closure, so between those two characteristics, I can really overdo it. Again, working the trigger points seems to give me more awareness. Instead of beating a dead dog to do things, which is how it usually felt for me--I already felt like my muscles had given all that they could give, even before I started an activity--I was starting out with, well, maybe not a peppy puppy, but at least I felt like I had energy and when I started to get tired, I could tell a difference.

Janet Travell, the doctor who pioneered the research on trigger point therapy, suggested that we mix up our activities during the day. It may be helpful to set a timer for 20 or 30 minutes at a time. It might also be good to post this statement somewhere that you will see it:


Pushing through to finish an activity is not worth being in pain for several hours or days.

It is hard to remember when we are deep in a project what happened the last time we decided to push through. In fact, we might just remember that we finished and may not have made the connection between the pushing through and the symptoms that followed perhaps a few hours later.

So, take a break. Your future self will thank you.

If you think that you or someone you know may have some proprioceptive issues, check out the link below.


If you are interested in learning more about sensory processing difficulties, this site has a good overview.  This link goes directly to a checklist, but there is a lot to explore on the site itself.  http://www.sensory-processing-disorder.com/sensory-processing-disorder-checklist.html

Dealing with Headaches: The Sternocleidomastoids

You might be intimidated by the name, but you needn’t be. The sternocleidomastoids (pronounced STERNO-CLYDE-OH-MAST-OYDS), or SCMs, are muscles that contribute to headaches, especially migraines. Located on the sides of the neck, they are the fleshy muscles that extend from the ear down to the sternum (breastbone) and clavicle (collarbone). 

There are two branches of the SCMs. Both branches attach just below the ear at the top, but the clavicular branch descends and attaches to the clavicle, while the sternal branch attaches to the sternum. 

Side View

Front View

There are better (and more to scale) drawings in The Trigger Point Therapy Workbook.  See pages 51-55 for more information.  

The sternal branch refers pain to 

• the top of the head 
• above the eye  
• front of the ear 
• the side of the head 
• the chin 
• upper neck 
• lower neck.  
• deep eye 
• tongue (when swallowing) 
• jaw (can mimic TMJ) 

(Note:  You don't have to have pain in all of these places in order for the SCM to be the problem...)

Trigger points in the sternal branch can also cause 

• dimmed, blurred, or double vision 
• red eyes
• excessive tears
• runny nose
• drooping eyelid
• twitching eye
• the print to appear as if it is jumping all over the page

And it can mimic trigeminal neuralgia (face pain).


The clavicular branch causes 

• frontal headache
• pain in the ear 
• pain behind the ear. 

It also can refer pain to the opposite side of the forehead, which is kind of unusual; most pain referral is to the same side of the body.

In addition, trigger points in the clavicular branch can cause 

• deep earache 
• toothache 
• dizziness
• nausea 
• fainting 
• unilateral deafness or hearing loss. 

The range of symptoms of the SCMs is really quite incredible. Besides headaches, they can cause: 

• disturbed weight perception 
• cold sweat on forehead 
• excess mucus in sinuses, nose, and throat
• chronic cough 

The SCMs are fairly easy to work. And you can work them practically anywhere.  


Massage these trigger points between your fingers and your thumb. This is one area where using a tool will not work. If you grab the flesh just below your ear, and begin to squeeze, you may be able to discern the two different branches of SCMs. Trigger points can be found anywhere up and down the two branches of the muscle.  Work your way down both branches.  Be sure to work both sides of your neck.  

Massaging the sternocleidomastoids near the top of the muscle.  

Moving further down.  

Working with the opposite hand.  

Following the sternal branch down.  

Trigger Points in the Lower Legs-Working Your Calves

This is from a post that I drafted on October 21st, but I am finally getting it posted.

I've been focusing on working my calves for the past few days, and it is amazing what a ripple effect it has.  I feel more flexible and lighter on my feet.

Trigger points in the lower leg can send pain to the foot, the lower leg and up to the lower back.  If you have had back pain that has not responded to other trigger points, you may want to check your soleus muscle in the back of your lower leg (See p. 239 in the Trigger Point Therapy Workbook.  You can also click on the trigger point map link in the right column of this blog.)

The soleus is a very broad muscle that covers the upper two thirds of the back of the leg.  Much of the soleus is covered by the gastrocnemius which is a very thick muscle that has two branches.  The gastrocs (that is what I will call them--I have no idea if this is a typical term) form the part of the calf that bulges out in the back.  The Tibialis Posterior, Flexor Digitorum Longus and Flexor Hallucis Longus are narrower muscles that are located under the soleus and gastrocs.  (See pp. 234-243 in The Trigger Point Therapy Workbook for diagrams and details.)

It takes a lot of strength to work these muscles because of the thickness of the outer muscles and their location on the back of the leg.

There are several ways to work the lower leg muscles.  It is tempting to use your fingers, but you can soon end up with sore fingers, arms, and shoulders.  Another way is to lie on your back, or sit up, and rest one calf on the knee of the opposite leg.  By sliding the top leg back and forth, you locate the trigger points.  When you find a trigger point, massage it by pressing your leg in a little deeper.  This is effective, but can get quite exhausting, particularly for your quads .

If you are lucky enough to have an older armchair that has solid wood in the arm instead of cardboard, you can sit in the chair, place a lacrosse ball on the chair arm, lift up your leg and move your calf around on top of the ball.  This can also be quite effective.

I have recently come upon an idea that is working well for me, so I will share it with you.

Lie down on the floor next to a bare coffee table or side table.  Place a lacrosse ball on the table and place your calf on top of the ball.  Move your leg around the ball and work trigger points as you find them.

If you need to push a little harder for some of the trigger points, bring your opposite ankle over and rest it on top of the ankle of the leg you are working.   This takes the least effort and is the most effective of the ways I have tried to massage my calves.

Some of you may not be able to get down on the floor to do this.  I know that I would not have been able to get on the floor when I first started doing trigger point therapy.  One idea is to get a lightweight table (like the LACK side tables that IKEA sells for around $10). If your bed has enough room, place the table on one end of the bed and you can do the same procedure while lying on your bed.  You can also place the table in front of a chair and do the procedure that way, but you may not have quite as much leverage.

You may have something else that works for you around your house already.  The idea is to make working your calves as easy as possible.

One note.  The ball may roll off the table from time to time, especially when you are first learning.  It is mildly annoying, but easy enough to put back up.  It is easier to control the ball if you have bare legs, or fairly snug pant legs, since there is a tendency for it to get entangled in your pant leg.

I won't go into detail for each muscle in this post, but just to get an idea of what types of symptoms are caused by or contributed to by your calf muscles:  calf cramps; pain in ankles and calves, on the bottom of the foot, Achilles tendon, back of ankle, in long arch of foot, back of thigh, knee, inner ankle, outer side of heel, heel; hard to straighten knee; deep pain in sacroiliac area; spasms in lower back; hypersensitivity to touch in lower back; pain in jaw, knob of inner ankle; plantar fasciitis pain; low blood pressure; unexpected fainting; posterior compartment syndrome; circulatory problems; pain in metatarsal arch, undersides of toes, under the big toe, head of first metatarsal; numbness underside of big toe; cramps in the bottom of the foot; contribute to hammertoe and claw toe.  (Take a breath here!)

In later posts, we will address some of these more specifically.

Triceps

The triceps have become a special focus for me lately. A week ago, the doctor removed the splint and I have been working on regaining mobility in my left arm. At that time, I could not twist my wrist back and forth. My elbow was at at about a 90° angle, and I could not bend it closer to my body or extend it farther away from my body.

The surgeon told me that I might have my movement back in 3 to 4 weeks. [Update:  Nelson told me that the doctor said 8 to 12 weeks.  I was on meds and did not remember...] I needed to be prepared for the possibility that I won't get my full range of motion back. It has been about one week, and I am pleased with what I have gained so far. Today, I am able to twist my wrist to make my palm face down, and I can twist about halfway in the other direction (palm up). But I have gained only a little bit of movement in my elbow.

I have been occasionally working my trigger points in my arm and it has helped me, especially in gaining the twisting movement toward palm facing up. I found a particularly effective trigger point in the muscles on the outside of the lower half of my forearm that I worked to decrease my pain and increase my flexibility in that area. I have also been careful to not work too much or too hard. My elbow is still fairly swollen, and I need to give it time to heal a little bit before I can do extensive trigger point therapy. I am also still dealing with a fair amount of pain, and it does not take much to overdo it.  

I have wanted to do more research on arms for quite some time. So I guess this is the perfect opportunity for me. I decided to research the muscles that control extending the elbow. This led me to the triceps. 

Triceps

To me, the triceps are somewhat like a spare bedroom or spare closet in the house. They are useful but they don't seem to get much attention. Because they're located on the back of the upper arm, they are not that noticeable. But there are some very important trigger points in this muscle. 

The triceps is actually one muscle that is divided into three bands. The one on the bottom is wider and the two on the top are narrower. Together, they cover the back of the upper arm. 

There are five main trigger points in the triceps.  (For some good diagrams, see pp. 101-102 in The Trigger Point Therapy Workbook.)


Keep in mind that all of these trigger points are located on the back of the upper arm.  

(1) Triceps number one trigger point is a couple of inches down from the armpit on the inside edge of the arm. It refers pain to the back of the shoulder and the outer elbow. But it can also refer pain to the upper trapezius and the base of the neck, making this a potentially important trigger point when dealing with headaches.

(2) Triceps number two trigger point is located just above the elbow a little to the outside. The muscle is quite thin here, so it does not necessarily feel intuitive to search here for trigger points. Its pain pattern is on the back of the forearm and it sometimes reaches down the entire forearm. It is also a source of pain in the outer elbow, or "tennis elbow."

(3) Triceps number three trigger point is centered about halfway up the back of the upper arm. It causes pain in the back of the upper arm. But it can also cause numbness in the thumb side of the forearm and hand if it presses on the radial nerve. This one was so bad I could hardly touch it when I massaged it today.  So, I am massaging close to it until it settles down enough that I can massage directly on it.  

(4) Triceps number four trigger point is also just above the elbow, but it is located about in the middle.  It sends pain to the elbow, and makes your elbow "hypersensitive" to touch.  

(5) Triceps number five trigger point is an inch or two above the elbow on the inside of the upper arm.  It refers pain to the inner elbow.  It can also refer pain to the inner forearm.  This is sometimes called "golfer's elbow."  

All of the triceps trigger points have the potential to do the following:  

• cause pain in the fourth and fifth fingers 
• cause oppressive sense of achiness in back of forearm and in the triceps 
• weaken the elbow 
• limit bending and straightening of elbow 

Fortunately, the triceps trigger points are pretty easy to massage.  The hardest part is knowing where to find them.  Massage them with a lacrosse ball against the wall or on a table top.  

What I've been doing - Part 2

(continued from the last post...) 

I was so glad that I had taken the time to work my shoulder, upper arm, upper back, and pec muscles before going to the Emergency Room (ER). At the ER, they decided to do a CT scan. The technician had me lie down on the bed (trolley?) and asked me if I could bring my arm over my head and rest it on a pillow above me on the bed. I hardly thought that was possible, but he assured me that he would help me and convinced me to try. The ER doctor had confirmed that my shoulder did not appear to be injured. The technician said he would brace my arm as we inched it up and over to where it needed to go.  He carefully placed a hand over each side of my elbow joint. His hands overlapped my lower and upper arms, and kept the angle locked. Each movement was not of separate parts of the arm, but the arm moved as if it were one piece. We moved an inch or so at a time and soon, my arm was lying above me on the bed, and I had experienced no pain.  In fact, for the first little bit, it felt good because my arm was getting a change of position. I couldn't believe that it worked!

I thought about it, and if I had not worked my pecs and my shoulder and upper back muscles, it might not have gone so smoothly. I probably would have succeeded in getting my arm in position for the CT scan, but I suspect it would have been somewhat painful, judging by how much those areas needed to be worked.

Fast forward.

They gave me my diagnosis, informed me that I would have to have surgery, and sent me home with some meds and an estimated surgery date. While I waited, I tried to keep myself relatively pain free.

One night, I was trying to get to sleep, and suddenly my left thumb started to hurt.  It was throbbing.  I was exhausted and not thinking very clearly, but my first thought was that the brachialis (p. 113) refers to the thumb.  I reached over and started to work the brachialis trigger points, which are located in the lower part of the front upper arm (by the biceps). They were sore. Within a few seconds, the pain was subsiding in my thumb, but I continued to work the brachialis until it was substantially softer. The next day, when I went to look things up in my trigger point manual, I saw that brachialis was the most likely muscle to cause pain in the thumb  It made sense. The brachialis had been held in the same position for several days. It was stressed because the bent elbow limited its movement in either direction.

On the first day of the correctly prescribed meds, I felt so much better, but then I got a weak, but very unpleasant headache. I thought, "Oh no!  I'm already taking all of this pain medication.  If that isn't taking care of it, I don't know what I'm going to do!" Then my inner trigger point detective kicked in.

My neck had been through quite a bit lately. Where do most headaches come from? The neck. I had been wearing a sling, and my neck was bearing the weight that my shoulder and arm usually bore. Not only that, it was dead weight, and it had been necessary for me to assume awkward positions to keep from bumping and hurting my arm.

Also, because it hurt my arm so much to sleep lying down, I had been sleeping sitting up in an arm chair with my feet up on a footstool. My neck had been in all kinds of positions. I was often sleeping in a "C" position, with my neck tucked into my chest. This made it harder to breathe, too. The muscles in the back of my neck were being held in an extended position too long, and the muscles in the front of my neck were being held in a shortened position too long. Both conditions create trigger points.

First, I worked my sternocleidomastoids (SCMs) since several of my symptoms appeared to be caused by the SCMs. Then I worked my scalenes and any of the muscles in the back of the neck that I could reach. I was not using very good ergonomics because I was limited to one hand. I tried to make up for this a little bit by taking frequent breaks. I focused on relaxing my working arm and hand each time I took a break. I also worked my right arm's flexor and extensor muscles after each session of neck massage. The headache pretty much disappeared halfway through massaging the SCMs, but I continued until I had got every trigger point that I could reach.

Later, I ended up with a similar headache and I was able to get it under control very quickly, but I realized that I need to do more in the way of prevention. I located a few pillows, including a neck pillow to help support my neck. I arranged things so that I was not sitting with my head thrust forward, or some other awkward angle. This helped a lot.

My sling was causing its own set of problems because of the extra strain it put on my neck. Also, the way that the sling fit my arm actually caused me pain. The straps of the sling attached at the elbow and wrist and I could feel a significant pull in both areas. Ordinarily, that might not be a problem, but my elbow was injured and the extra pull on my elbow made it hurt worse.  I decided to make my own sling and design it with these issues in mind.

I sewed up a 4-5 inch wide, padded strap, with one end folded back on itself about 11 inches and sewn to form a loose loop. I placed the loop over my splint and found that somewhere near the middle was the ideal place for the sling to pull up. I pulled the strap straight up and over my left shoulder, pulled it around my right waist to the front of my body. I was trying to decide what kind of fastener to use, when I noticed that the weight of my injured arm would hold the end of the sling in place, so I left it at that (I probably really shouldn't have been making a sling in my condition, anyway...). Sometimes, I use my arm as the weight and sometimes I tie the end of the sling to the loop part, depending on what I am going to do. The point is that I got a sling that was not hurting my neck or elbow. I was trying to prevent more problems than I already had.

The new sling is much more comfortable and my neck is not being pulled forward.  

The sling goes straight up to my neck, around my back, and to the front.
(Note:  For some unknown reason, my camera takes pictures in mirror mode, so even though it looks like the right arm is in a splint, it is actually my left arm.)