Mysterious Patellar Pain
Pain is all too often ignored in the human body. I suffered with patella tendinosis for close to 15 years of my life. Every time I would squat, run, or jump it felt like I had razor blades in my knees just cutting my tendons away. After many doctor visits when I was young, my mother was told I have the bone structure of a healthy young boy and they see no reason I should be in pain. So I squatted, ran, and jumped and the razor blades continued to cut away and cut away, and I just accepted the pain as part of who I am, what my body was, and part of this crazy thing we call life. I now have two surgically repaired knees as a result.
About 10 years ago I had enough. The pain was so debilitating I would often break down and cry. I felt slighted by life. Why couldn’t I be a cook, or own a casino? Why did I choose a profession that required me to squat, run, and jump everyday, to be continuously reminded of this horrible pain. I would see athletes in the gym not want to squat, or run very hard because they didn’t like it. I envied that they could do what I wanted so badly to do with no pain, and was confused as to why they didn’t want to do it. I had no respect for them. Soon, I reached my tipping point and started to call practitioners.
Not a single one of them could explain my pain, and in some cases people just referred me to someone else without an examination. Then I called massage therapists. I left 10-12 voice mails about my condition and didn’t receive a single call back. Finally, I got ahold of a gentleman who said it sounds like I have trigger points. I asked him what they were and he said it’s a bundle of nerves that refer pain into joints and tissue.
“Can you work on me,” I asked?
“Yeah, but it would be really time-consuming and boring, you’d be better off getting a book and doing it yourself.”
Two things struck me as odd. First, why didn’t this guy want to take my money? And two, how did he know that I’m a life long learner and that doing health related tasks myself is my preferred method of choice?
So I bought the book he recommended and started to learn.
The first term I came across was referred pain. Referred pain is the symptom, not the problem. Imagine if your shower is leaking. You would expect a plumber to come in and work on the shower right? With referred pain, it would be more like the plumber coming in and working on your electric panel, finding a short circuiting wire, fix it, and then the shower stops leaking. Western medicine studies disease, not health, so they are conditioned to focus on the symptom and treat it with a pill, a shot, a knife, or a referral. If your elbow hurts, the doctor will treat the elbow, if your back hurts, we must treat the back. When it comes to soft tissue or joint pain this is completely incorrect 99% of the time.
Ever since learning about referred pain and trigger points in 2008, I became addicted to finding new ways of taking pain away in the human body. I would hunt for trigger points and see how they would react under pressure and what I started to realize is they really have a mind of their own. Everyone who lifts heavy, or plays sports knows they should foam roll, and mobilize, but where people fail is the application of it. Since 2012 I logged over 9,545 hours of soft tissue, and mobility practice, and worked on everyone from normal everyday folks, to competitive CrossFitters, to regular CrossFitters, to Professional Athletes, and Doctors. I’ve seen cases that take me 45 minutes to fix, and I’ve seen cases that take me 3 months to fix. In this time, I have come down to three certainties that I would like to share with you, and one opinion.
- Most back pain (about 99%) is butt pain, or butt dysfunction.
- All shoulder pain does not come from, or originate in the shoulder.
- All knee pain is quad pain!
- In my opinion, joint pain should almost never be remedied by going to a doctor (unless something is torn, or has been dislocated).
It’s 2016, No Longer the Ice Ages
Before we get to the meat, I’d like to share a little aperitif with you. I stopped icing injuries, and irritations from training over 11 years ago? Why? Because it wasn’t doing anything! When I first started out as a strength coach I would research tirelessly for close to 3 hours a night. Now, after 16 years, I acquire information in three ways:
- I research myself.
- The information comes to me through other people (i.e. I’ll get an email from someone entitled “What do you think about this?”
- I’m presented with a problem and I have to find the answer quick!
In 2005 an athlete of mine had sprained his ankle badly during a game on Saturday. Scouts from the Chicago Bears were coming to watch him practice Thursday and he didn’t feel he would be ready. As I scoured the internet looking for answers I came across Dick Hartzel’s book called “Don’t Ice That Ankle!” When I received the book on Tuesday, my athlete still couldn’t run. After 2 hours of using Coach Hartzel’s techniques, 80% of his sprint capacity had been restored. He practiced Wednesday, no tape, no brace, just a compression sleeve, and was 100% by Thursday’s practice. I was amazed and confused. Why, if ice is supposed to help heal, does it take so long for an iced ankle to heal compared to not using ice? Digging deeper, here is what I found.
In 2012, a study in the British Journal of Sports Medicine showed that there is no clinical evidence ice improves the healing of muscle strains. Consequently, there was also a study published in the 2013 Journal of Strength and Condition Research showing that icing can actually hinder recovery from eccentric muscle work. In another 2013 study involving eleven 20-year-old male baseball players, topical cooling caused a significant increase in muscle damage markers during recovery from eccentric exercise. All of the pictures you see of athletes jumping in ice baths post workout, or post game seem silly now doesn’t it? In all honesty it should be illegal. A 20 million dollar a year athlete doing damage to his body willingly! I can tell you still don’t believe me though, so lets continue.
A research study published in 2012 by the Journal of Sports Medicine showed that in 25 separate studies, 75% of them reported a decrease in muscular strength following icing. There was also evidence from six studies that cooling adversely affected speed, power and agility-based running tasks. So when Jimmy, the high school running back bangs his knee, gets a pile of ice thrown on it, and then returns to the game like a champ, we are asking for further injury to the area.
Icing is really just a great placebo effect. It is great at decreasing pain no doubt, but in the process we are not letting our body heal correctly. When an injury occurs, the body’s repair mechanism comes in the form of inflammation which contains all of the healing components. Why do we want to decrease the availability of these healing components by using ice and shunning inflammation? Why do we think our wisdom is greater than 4 million years of evolution? In my opinion, the only time ice should be permitted is post-operation when inflammation needs to be controlled due to the invasive process of surgery. All other injuries should be heated to increase circulation and nerve conductivity (researchers believe ice slows down nerve impulses), mobilized in a somewhat pain-free manner, and continuously massaged to prevent the formation of scar tissue and help move the inflammation in to the lymph nodes.
We also find out in THIS article that peripheral blood perfusion can be reduced while icing which means that blood vessels constrict and shut off blood flow that brings in healing cells. Depending on the duration of the icing, it can take up to several hours for the blood vessels to open back up again. This can in effect cause the damaged tissue to die, and permanently damage the nerve. I don’t know about you guys, but I like my nerves alive, not dead.
There is a gigantic difference between speculation and experimentation. I have had nothing but phenomenal results treating injuries, sore muscles, and joints, as well as post-op patients with heat, movement, and foam rolling (or steam rolling which we will get to in a bit). I rehabilitated two blown out knees with no ice. If my inflammation ever got out of control due to aggressive training, I used Curcumin to bring it back down and lived to train another day. Speculate all you want, find blogs or research articles claiming ices effectiveness if this information is getting you all riled up (I’ve read and re-read the entire section in Ben Greenfield’s Beyond Training on the effective use of ice and still just don’t agree. Largely due to my lack of success with using it). I know heat, compression, and foam rolling works through almost 11 years of experience. So next time you twist that ankle, bump that elbow, or get a Charlie horse, reach for the ice, but put it in your glass of scotch before you go get a heating pad or compression device.
Change the Way You Think About Pain
“Stress lives in the brain, and therefore people’s experience of chronic pain is that it increases as they become more stressed. The longer you have pain, the better their spinal cord gets at producing danger messages to the brain, even if there is no danger in the tissue.” -Lorimer Moseley, PhD
Back to the book recommendation. The therapist I spoke to on the phone told me to get The Trigger Point Therapy Workbook (1) by Clair Davies. I promptly ordered it, and even more promptly dove into it the second I received it in the mail. I was fascinated by this new world inside of my own body that I never knew existed. I turned directly to the knee pain section, and as I started poking and prodding around I discovered that I had nearly every trigger point active in my quads known to man. Everywhere I pressed shot pain directly into my patellar tendon. It was invigorating and at the same time made we want to vomit. How could I eat healthy, and look healthy, but still have such unhealthy muscle tissue? The answer was elegant, so it would take time for me to answer.
Ida Rolf says, “In any energy system, however complicated, structure (relationship of units of any size in space) is experienced as behavior. Structure is behavior (2).” I challenge you to look around the gym, the mall, the drug store, or even at the beach and count how many different people you see on a structural basis. I realize there are three typical somatotypes in regards to limb length and body composition, but another dimension we need to consider is circumference. For example, a 250 mesomorph will have a similar bone structure and limb ratios, but will vary in circumference depending on if they are a bodybuilder, NBA player, or an obese mother of three. Movements like the squat and deadlift will stress different areas of these people’s bodies – differently.
Gravity, is the most potent, and persistent physical stimulus any human being will experience in his or her lifetime. We compound this stimulus through running, jumping, and weightlifting. We compound this exponentially through activities like CrossFit, powerlifting, Ultra-Marathons and Spartan races. Muscle tissue does not fire correctly 100% of the time even in a predictable, flat-surfaced environment like a gym. Now take something like a tough mudder where the environment is designed to be tricky; the term “Structure is behavior” takes on a whole new meaning.
Trigger Points Revisited
In the book The Talent Code by Daniel Coyle, we get an understanding that in the human body, practice does not make perfect, practice makes permanent. World renowned soft-tissue guru Kelly Starrett has referred to this fact many times in interviews when trying to hammer home a point on why we should choose to move correctly first, before choosing to do anything else. The reason is simple. Incorrect movement creates incorrect angles of pull on the muscular group being recruited. The damage doesn’t stop there though because our muscular system is a web.
To get an image of this, think of a father walking through the mall with his son. Every time his son sees something he likes, he pulls on the same side of his fathers shirt. One or two tugs and the shirt will probably be fine, but after three hours and multiple stores visited, lets say he tugged on the same side of his shirt 50 times. Upon examining the mans shirt, the side that was tugged on will now sit visibly lower than the other side. Inspecting the shirt more closely, you will see an aberrant pattern that developed elsewhere according to the angle the child was pulling at. Having a knee cave in on a heavy squat will not just pull on and damage the knee, it will affect many other sets and sub sets of muscles connected to that knee. (Picture Copyright Ida Rolf).
As these muscular patterns are left untreated they not only develop trigger points, but also start to become “glued” together. A trigger point will affect a muscle by keeping it both tight and weak. A primary trigger point can be sending a signal to a secondary trigger point as well as satellite trigger points as well. This can cause entire groups of tissue (Let’s say vastus medialis, and the adductor complex) to maintain a hard contraction, get stuck together, and now pull inconsistently every time the knee-joint is called upon to move which can cause a significant injury even at light weights. As an example, I treated one bodybuilder who blew out 4 disks doing a bent over row with 135lbs when he was supposed to work up to 315lbs that day. An alarmingly tight left glute was torquing his hip causing his spine to spiral when activated rather than remaining stable. Since the spine distributes weight as well as supporting it, even with a 43% working load this imbalance was something his body was not willing to overcome any more.
All tightness in the human body is first developed through weakness. As these muscles fire incorrectly, and develop trigger points there is a reduction in circulation which leads to an accumulation of metabolic by-products as well as a deprivation of oxygen and nutrients to the affected muscle tissue which eventually leads to atrophy. This becomes a vicious cycle until acted upon by some sort of external pressure being applied to the muscle tissue in a strategic fashion as the metabolic by-products are actually acidic to the nerves. Have a part of your body that refuses to grow no matter how much volume you introduce? I guarantee if you palpate that muscle group there will be pain from pissed off nerves sitting in their own waste.
The tighter these muscles get the more our brain sends a signal for us to get and inclination to stretch. Re-setting the muscle length will only give the perception of a green light that training will be ok today. It may even reduce the pain considerably for a while. Rest assured there will be a point where the pain comes raging back and will persist until you institute a policy of rest for that muscle. This is because we need to think of trigger points as knots in a rope. The harder you pull each end of the rope, the tighter the knot will get. Muscle tissue is elastic, and mainly liquid, the fascia that it is wrapped in is plastic and will snap back to retain its normal length. By stretching haphazardly you are tightening a knot in a wet rubber band which becomes infinitely impossible to get out the tighter you pull. By stretching slower (through yoga practice or other more breath controlled means) you will change the muscle length which will make it feel looser like you accomplished something, but the trigger points will still remain active. Continuous stretching of trigger point laden muscles will actually increase their referral of pain and activity.
Trigger points will also decrease the metabolic capacity of the affected muscle(s). Think about it. If you walk around holding a five-pound weight at a 90 degree angle in your right hand only, which arm will fatigue faster when you do bicep curls later on at the gym? Muscles with trigger points are not afforded the ability to rest even when the muscle is at rest. A muscle with trigger points does not have a fluid ability to extend and is more apt to fatigue antagonistic muscles surrounding the same joint. An article by Dale G. Alexander, PhD called Muscle Energy Technique: An Evaluation and Treatment Model for Somatic Dysfunction it is stated that it has been estimated that restriction of one major joint in the lower extremity can increase the energy expenditure of normal walking by as much as 40% and, if two major joints are restricted in the same extremity by as much as 300%.
Simply put, muscles with trigger points cause a decrease in work capacity due to their inability to extend. Your muscles are working against the external load (barbell) and the tightness of its own muscles. I’m convinced that trigger points mostly develop as a result of the excessive use of barbell only movements. Most people have a dominant arm and leg which frequently takes over during exercise. The utilization of barbell only exercises perpetuates these inconsistencies especially when it’s done in a time derived, fatiguing manner such as CrossFit.
Balance, Daniel Son
Some of the best CrossFit gyms I’ve been to in the world incorporate single arm and single leg work with kettle bells and dumbbells on a weekly basis. Most people feel separating the body propagates weakness because the weights aren’t as heavy, but I’ve found you can maintain and even increase back squat strength while utilizing single leg exercises, but the inverse is not true. Long consistent durations of barbell squatting will not improve single leg strength. The realization that we run on only one leg at a time should be cause enough for all of us to incorporate single leg exercises into our program at least once monthly on the low side. Chris Beardsley wrote a highly detailed article on the split-squat you can find here.
Here’s a case study of what I’m talking about. One week a long time ago, our progression called for a single leg deadlift off of the bench. A gentleman who was a construction worker had just started up with me. He had a background in powerlifting, but at 50 years of age realized he needed to support his body in other ways (mainly cardiovascularly) so he decided to try CrossFit. He performed the exercise with his right foot on the floor and left foot on the bench perfectly, but when he placed his left foot on the floor and right foot on the bench he was wobbling all over the place and couldn’t use more than 75 lbs for 8 repetitions. His top deadlift was 405.
The Rolfing Institute produced an article called The Technique of Connective Tissue Manipulation in 1976 and in it stated, “The consequences of imbalance are surprisingly broad. When the body’s blocks, shifted in various directions out from the vertical axis, are no longer stacked on top of one another, both skeleton, and musculature are forced into an inefficient weight-bearing function….. The function of most muscles is to contract to bring about movement, to release in order to bring about movement, and then to release in order to prepare for new movement. When they consistently take on the weight-bearing function of bone, their fascial envelopes tend to take on the hard and inelastic quality of bone (Fibrosis). Tightness spreads through the fascial network; the body locks up and the joints lose their freedom.”
I realize as athletes we demand a lot of our muscular system. An overhead squat with a broomstick is enough to show most of us just how tightly bound our system is. At 25 years of age I started to realize that even though I was squat snatching and cleaning every week, I needed to start stretching daily in order to maintain my joints range of motion. At age 30 it was foam rolling. I realized that I needed to recover just as hard as I trained. Now, at age 38 I have taken recovery methods one step further into the realm of the macabre as foam “rolling” just doesn’t do it for me anymore.
A Better Model
When I first started to do soft tissue work on myself, my methods of choice were a foam roller, and a softball. At the start, the pain would sometimes be so bad I would have to medicate with Uncle Jack, or Sir Hennessy in order to actually get anything done. I also noticed I had to smash the same tissue every day for long periods of time and this frustrated me to no end. I could feel big and small fibrotic lumps in my legs, as well as long and short fibrotic stands. Muscle is supposed to be soft and pillowy; you could play the harp on my quads for Christ sake. They say if you give a child a hammer, the whole world becomes a nail. I was hitting every square inch with the ball and roller and it was providing temporary relief, but I wanted permanent relief!
How To Know If Your Tissue Is Healthy
Schrödinger’s cat is a thought experiment in which a cat is allegedly trapped in a box with a vile of poison and a meter which detects decaying atoms. Upon the detection of a decaying atom, a hammer is tripped, smashing the vile, killing the cat. However, since we can not physically observe the cat, we must conclude that the cat is simultaneously alive, and dead. Only when one opens the box can we find out if the cat is alive, or dead.
Pressure is our way of opening the box in the human body. I have many people who swear their muscles feel great and they don’t have any pain, yet they all scream in amazement when they apply pressure. The issue becomes that we forget what it feels like to have healthy muscle tissue. Just because your muscles don’t hurt, doesn’t mean something isn’t brewing. This is the time we want to catch injury – before it happens. When trigger points are forming, and tissue is distorting. Pain is a lagging indicator and you usually have a pretty serious issue going on by the time pain does present itself. I have also found out the earlier you catch a trigger point or tight tissue the better. Relief can be brought within 1-3 days, as opposed to 1-3 weeks, and like I said in some really bad cases it took me 3 months to bring relief to a client.
Early warning signs for trigger points can be a dull ache, to a sharp pain, a stalling out lift, or decreased running economy. Having every trigger point known to man in my quads, it was very difficult for me to get past a 5 rep max of 315 on the squat. Every time I pushed harder than that I would get injured. A knee would get sore, my back would get tight, or I would just simply fail to complete the 5 reps. When I cleared up all of the triggers, my numbers improved drastically and it was amazing how effortless squatting felt. This was due to my tissue not working against itself, and actually now contributing to the movement. We need to remember that tight tissue can not fully express its power capabilities. It will reduce the power of the effected limb during strength and power exercises and reduce the work capacity of that limb during endurance exercises.
Steam Rolling and Raking
If you’re squatting over 185 lbs. on a consistent basis, you need to ditch the foam roller. Muscle tissue is very strong and resistant to change. If we are creating fibrotic patterns and trigger points in our muscle tissue, then this is no longer a muscular problem, it becomes a nerve problem as well. The brain needs to maintain order and creates balance in the body, in an imbalanced state. Using even the black high density foam rollers I find to be ineffective after a certain point. Same goes for the rumble roller, and the infamous trigger point performance foam roller which I’ve had a few break on me even.
Besides using the barbell (which we will get to in a moment) the only roller I recommend is the M80 Groove Roller due to its indestructible design and unforgiving hardness. The next step, after getting the right roller, is to learn how to rake your tissue instead of rolling it. I’ve had many people tell me that foam rollers don’t work for them. Besides having the wrong roller, speedily rolling up and down on the right one won’t do much good for you either. A good therapist learns how to “hook” the fascia and rake it along thus ungluing the tissue and breaking it up. The key is to relax your tissue on the roller and drag it slowly which will provide a good enough stimulus for correction.
Steam rolling your tissue will provide an even greater stimulus to help break up the toughest of knots. The key for this working so well is the decreased diameter of the bar, and the ability to provide an external load, or use your bodyweight for pressure. I’ve worked on 90lb. females, and 315lb. NFL lineman and let me tell you, I need to use a little more pressure with the lineman. The more muscle tissue you have, the heavier you need to load the bar. The pain being registered should be between a 6-8 on a pain scale of 10 being the worst pain you have felt your entire life. If you can have a comfortable conversation while steam rolling you are too…….. comfortable. Add more weight to the end of the bar, or apply more bodyweight to get the desired result.
A word of caution. More weight and more pressure does not equate to faster results. If you are in excruciating pain, sweating, and ready to vomit, you need to ease up and go lighter. It is the nerve that releases the muscle, and they get their signal from the brain. Steam rolling on a pain scale of 10 sends your brain into the alarm stage which causes your nervous system to lock up the muscles making the steam rolling ineffective. Another easy way to detect this is if you cannot keep your muscle relaxed while the bar is on it. If you are contracting your tissue in pain, you are essentially shooting a BB at a tank. The pain should be uncomfortable enough to roll for 3-6 minutes at a time before you need a break. Trigger points release in stages and the really bad ones will require deeper and deeper pressure to get rid of completely. Trigger points in the vastus lateralis for instance can feel like they are sitting right on the bone.
Some Finishing Touches
My go to resource on the internet for trigger point location is triggerpoints.net. They cover the entire body from head to toe. We need to understand that trigger points do not just cause pain in the musculature, they can also cause bodily dysfunction as well. Issues like diarrhea, shortness of breath, heart-attack like pain, nausea, enhanced menstrual cramps, painful intercourse, and even sciatica can be the result of trigger points run amuck. A member of mine had three terrible life events happen to him back to back to back within the span of two months and very close to the holidays as well. He woke up with vertigo one day unable to walk, and unable to drive. He was prescribed medicine and bed rest which helped only temporarily. After several days of this band-aid like medical assistance, I convinced his wife to bring him in to see me. His scalenes, traps, rhomboids, pec minor, and sternum were so tight, he may as well been walking around with a noose around his neck. After two days of self applied soft tissue work the vertigo was gone. This brings us to another important understanding.
Trigger Points Can Also Be Caused By Emotions, and/or Emotional Trauma
This gentleman was under so much stress to be strong, and provide for his family that his emotions locked up every last bit of muscle tissue surrounding the heart. This was interesting to me because for the most part I find more women having shoulder, neck, and chest issues because women are more emotional creatures than men. For men I find they have more issues with a tight low back, adductor and knee pain because a mans energy comes primarily from the loins. In a startling situation, most women will jump up, and run away screaming, while men generally turn around looking for someones ass to kick.
As I’m writing this, Chris Beardsley posted a great infographic supporting the point I am going to make next. Soft tissue work is a MARATHON, not a SPRINT. It is about duration, AND frequency, not just frequency. Rolling on a problem area for 30 seconds in my experience is practically worthless. To make permanent, sustained changes to muscle tissue 2 minutes of pressure is the bare minimum. I typically apply pressure for 3-6 minutes in most cases.
The next consideration we want to make is to always roll before you stretch. Steam rolling and raking are a primer for deeper stretching as foam rolling has been shown to increase amounts of hyaluronic acid in the muscle tissue to improve its sliding effects (3). I can feel a huge increase in the pliability of my muscle tissue after a great soft tissue session and an automatic increase in flexibility when I stretch after. Beardsley provides further proof and theoretical mechanisms for this phenomenon here.
The Two P’s
Persistance and patience are your two keys here. If you have a serious problem, something that has been stuck for a while, you may need multiple sessions a day, every day you train, and multiple sessions on your days off as well. If tissue is locked up, not only are you trying to restore its elastic ability, but you also have to retrain how that muscle fires all over again. In 2011 I released a trigger point in my vastus medialis that produced so much soreness along the entire length of the muscle I was reduced to only walking for 10 days. I had a 50% or more reduction in my knee pain as a result though so it was totally worth it. When I resumed squatting and running I could tell the tissue was re-learning every movement like it was the first time. Even though further rolling may be unpleasant it is important for recovery.
In regards to patience all I can say is this. I have rolled certain areas that I knew were stuck in my body every day in the same way for sometimes close to a year with almost no result. I felt like all I was doing was maintaining the pain staying within inches of an injury. Then one day the muscle releases as if someone just waved a magic wand. I can’t explain it but if a muscle is not releasing for you after a few days, weeks or months, and you know you are in the correct spot, and you’re applying the correct pressure, just be patient. The release WILL happen.
- Davies, C. (2004). The trigger point therapy workbook: your self-treatment guide for pain relief. Oakland, CA: New Harbinger Publications.
- Rolf, I. P. (1977). Rolfing: the integration of human structures. Santa Monica, CA: Dennis-Landman.
- Roman, M. (2013). Mathematical analysis of the flow of hyaluronic acid around fascia during manual therapy motion. J Am Osteopath Assoc, 113(8). doi:10.7556/jaoa.2013.021