Let me start off by saying that trigger point therapy has been a fantastic tool for finding muscle knots in my arms, relieving and deactivating those knots through massage, and generally helping me understand a large part of what is going on with my arms. In the process of the trigger point therapy, however, I experienced (and still have) some ulnar compression going on in the nerve of the right hand which manifests itself in numbness in the outside edge of the pinkie (I don’t know whether this is related to the therapy or not) and I have currently greatly reduced trigger point massage to focus on the ulnar issue.

Does this put me off trigger point therapy? No! On the contrary it is one of the best methods I have encountered in understanding my RSI condition (and other painful soft tissue conditions), and potentially fixing it long term.

I am a 15 year sufferer so my condition is most likely a bad case, but what I have found with trigger point therapy is that you can deactivate a lot of the larger trigger points (muscle knots). I have also noticed that I still have many sites of smaller, much deeper tissue that still generate a lot of referred pain. As these are deeper down in the forearm, they are harder to access, massage and deactivate. I am also amazed at how many trigger points that I have found in many areas of the forearms. It is apparent that computer use, repetitive injury and continual adjustments to try to ease the pain when using a computer can lead to muscle knots forming in all kinds of places in the forearm. It’s not much wonder that such conditions are hard to diagnose, treat and recover from.

So in summary, I have currently backed off from trigger point massage due to the ulnar nerve numbness, but I am still 100% bought into this therapy for helping RSI.

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Trigger point therapy, as discussed previously in my post “Does forearm extensor trigger point massage offer a potential cure for RSI?”, is a method of massaging trigger points (muscle knots) that refer their pain elsewhere eg forearm extensors into hands and fingers.

Before starting Trigger Point Massage it is essential to understand the anatomy of the forearm muscles and what they do, where they form muscle knots and where they refer pain to, and as discussed in a previous post, the Trigger Point Therapy Workbook is a great place to start with this understanding.

Weeks 1/2

The first two weeks were mainly spent in a lot of pain, easily finding extremely sore trigger point muscles of the forearm extensor groups. I had exceptionally sore areas in the Extensor Carpal Radialis Longus, Extensor Carpal Radialus Brevis and the Extensor Digitorum. Couldn’t find anything going on in the Extensor Indicis despite having had a history of index finger overuse and pain previously.

Massage was done mainly by supported thumb, and knuckles, 3-4 times a day. Excruciating pain was experienced during massage from many of these trigger point areas, and as such can lead to a reluctance to continue, however I just had to keep saying to myself  “this muscle is sore and it shouldn’t be”, grit my teeth and keep massaging!

Most of this period was spent in continual pain from the massage. It is a recurring theme with trigger point massage. Your arms spend a large portion of time in pain from the massage as well as the RSI condition. So there is very little opportunity to asses any progress. I reckoned, however, that if I am massaging sore tissue then that must be a good thing!

Weeks 3/4

As the sore extensor muscles recovered from their intensive massaging of the previous weeks, the forearm felt less painful, but it was a gradual process. Sometimes taking a day or two off of massage treatments helps, just to give the arms time to recover and to allow you to assess progress. I had massaged out the eye-wateringly sore extensors, but there was some deeper down trigger points in lower muscle  tissues to try to access, as well as a persistent ache at the point where the extensors attach to the elbow. I also found a sore trigger point in my Extensor Carpi Ulnaris, which I subsequently found massaging can lead to a nerve type pain down the outer edge of the hand wrist and  little finger, which wasn’t good, and is something to be wary of. If you are trying trigger point therapy yourself, please be careful not to massage nerves!

I have used my thumb for massaging, but as stated in the Trigger Point Therapy Workbook, extended use of heavy pressure with the thumbs alone can lead to sore thumbs pretty quickly and as such is not advised.  The book recommends the use of balls eg tennis balls (or denser rubber ones) to roll your arm muscles against beside a wall. They also recommend a ‘Knobble’ which is a hardish object that you can grip with a knobbly protrusion which can be used as a pressure point for massage. I have generally just used my hands (knuckles and supported thumb) and a beach pebble (with smooth rounded edges) for massage through a fleece top, and both have worked quite well, although its very tempting to resort to using the thumbs which really should be avoided!

Weeks 5/6

After massaging out most of the extensor trigger point (muscle knots), I still have sensitive tissue areas around the elbow where the extensors attach, and this area is still being worked on. After a suggestion from James of How I Overcame RSI I also checked the inner forearm muscle called the Brachioradialis which is a muscle on the inner side of the arm that attaches to the lower end of the upper arm, and is used to bend the elbow. Under this is a smaller muscle called the Supinator which turns the hand palm side up. Much to my surprise, I found trigger points in both of these especially at the points close to the elbow/lower upper arm. The book suggests that trigger points here can refer pain to the thumb area as well as the inner forearm, but James also indicated that in his experience they also referred pain to much of the forearm too. I also found a small trigger point on the Brachialis (bicep) of the right arm, and have massaged it too. The Trigger Point Therapy book says that this point can refer pain to the thumb.

Progress

Progress is actually a difficult thing to asses on an ongoing basis. As I have mentioned before this is because you are in quite a lot of  pain from the massage for a large part of trigger point therapy. You literally spend a lot of time massaging, and even after the sorest muscles are less sore, there are still a lot of aches around and you are still stressing the forearm muscles with massage. The only real way to assess progress is to take a two/three day halt in proceedings, and see how they are. I’ve done this a couple of times, and yes the arm muscle pain of RSI does seem to be improving, it’s just not gone yet!

I am, however, very encouraged by the less screamingly sore muscles in my forearms, and am tending to focus on secondary areas now. I still feel pain from typing and mouse use, but much less intense than before, which must be a good thing. How sore the pain would be after a more demanding day of computer use is another question altogether though!

There are also other potential areas according to the Trigger Point Workbook that can refer pain to the arms and hands, including the Scalenes (shoulder neck area) and Triceps (back of upper arms), so more investigation of these areas for trigger points is required. I also am doing a lot of deep probing of the forearm extensors and finding a lot of  trigger points down there, which are very hard to reach and even harder to massage on a continual basis. Some of these small painful muscle fibres appear to be narrower than a fingers width and as soon as you get a finger on them to do massage they disappear to the left or right of your massaging finger before you get the opportunity to truly massage them, very frustrating!

I should also add in that I am doing some wrist rotations to work the extensor muscles in a fluid motion using a weight of about 1kg, and am also doing some work with a Powerball in slow motion.

I will continue to update on my progress here as therapy progresses, although I am at this stage very encouraged by Trigger Point Therapy as a potential solution!

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** Post updated with additional material at end on 16 May 2011 **

Trigger Points and RSI

I’m delighted to be given space to say a few things about RSI and trigger points. I battled with RSI for several years before finally overcoming it several months ago and I now have a very small website that details my journey back to full health. What helped me was discovering that trigger points (a.k.a. muscle knots) can be a significant cause for repetitive strain injury. Alan has already posted on the essentials of what I found in an earlier post titled “Does forearm extensor trigger point massage offer a potential cure for RSI?” He talks about an excellent book by Clair Davies and how trigger points can cause referred pain elsewhere. I will try not to be repetitive and just highlight a few points that I would make in addition to Alan’s post.

Trigger Points Refer Pain Elsewhere

What this means is that the pain you feel is not necessarily at the site of the actual problem. Normally, injured tissue is painful at the site where the damage occurs — if I cut myself with a knife, the pain is located at the very site where the skin is pierced. However, with trigger points, we feel pain in places where there is no problem at all. What seems to happen is that the brain gets confused about where the pain stimulus is coming from and we end up feeling pain some distance away from the real source of the problem. In other words, the trigger point (or muscle knots) refers pain to another location. The site of the trigger point itself is often not particularly painful.

This is very important to realise because the danger is that you will end up pointlessly rubbing away or massaging muscles to no avail. For example, I had searing pain along the outside of my forearm (i.e. the upper side) but this was actually caused by a trigger point on the inside forearm (i.e. palm side or inside forearm) near the crease of the elbow. If I massaged the top of my forearm where it hurt, it did nothing to resolve the problem. Not until I started to massage the underside (palm side) of my forearm at a specific spot near the crease of the elbow did the forearm pain go away. If you have the book by Clair Davies, this is described on p116 with the accompanying diagram figure 6.9.

I mention this because I recently had a conversation with a work colleague about trigger points and RSI. He was getting pain in his arms. He was very interested in my success with massage. Unfortunately, I forgot to explain to him about referred pain and he thought you had to simply massage the spots where you feel pain. Thankfully, I later managed to explain to him how trigger points refer pain elsewhere and he’s now purchased a book which is hopefully setting him right.

Another example is that I had a very sharp pain in the front of my right shoulder. I used to rub away at this place because it was so painful. Unbeknownst to me, there was nothing wrong with my shoulder. The real pain came from a trigger point in the infraspinatus which is a muscle round the back over the shoulder blade. Only by treating a trigger point some distance away from the pain did this help. In Davies’ book, this is on pp90-91.

Trigger Points Weaken Muscles

If you have been suffering from trigger points for a long time, the affected muscles can weaken. In the words of my physiotherapist, they “shorten”. So, getting rid of a trigger point (by deep massage) may not be enough. You may also have to rebuild weakened or shortened muscles with targeted exercises. Having suffered from RSI in my forearm for several years, my muscles had become quite weak. I found it difficult to hold an umbrella or a mobile telephone to my ear. Even after the trigger point had been “deactivated” (to use the proper term), I still needed to rebuild strength in my shortened muscles. My physiotherapist told me to use very small weights of 1 kg max and gently hold them in the way I might hold a microphone. I would then gradually rotate my hand and bend my wrists to slowly rebuild the muscles. It’s important not to use weights that are too heavy because the point about computer usage (and other RSI-inducing activities) is that they are “low load” work. You need to rehabilitate the muscle’s ability to cope with low load endurance. By the way, my physiotherapist said that a tin of baked beans serves as a very good alternative to a hand weight! Another alternative is a Powerball which if you spin SLOWLY, can achieve the same effect. I actually used the Powerball more than small weights but I tend not to recommend it so much because there is a danger that users will spin it too quickly and therefore not achieve the “low load” effect.

Massage Immediately after a Session on the Computer

I found it was quite useful to do massage after working on the computer for a short time (say 5 mins). In other words, I deliberately waited until the RSI symptoms had arrived before doing the massage. Typically, I would spend about 5 min on a computer whereupon my arms and shoulder would start to hurt a lot. I would then do the massage because it’s easier to find where the trigger point is when my muscles were raging with pain!

Other Good Books

I recommend The Trigger Point Therapy Workbook by Clair Davies but there are other very good books too. I really like Simeon Niel-Asher’s Concise Book of Trigger Points which has very good colour drawings but I found that it doesn’t contain quite as much detailed information as Davis’ work. Also, some of the trigger points I suffer from are not mentioned, although to be fair, it is a “concise” book. There is also a useful book by Donna and Steven Finando called Trigger Point Therapy for Myofascial Pain. It is not especially well presented but has some useful information that can serve as a supplementary details. It’s not as good as Davies or Niel-Asher but it is certainly an interesting resource.

Okay, well that’s all I would add to the previous post. You can find out more on my website  How I Overcame RSI.  Don’t hesitate to e-mail james@howiovercamersi.co.uk if you have any questions.

James J

Additional Information  16/05/11 (from James J)

One thing I would note is that I don’t think the book by Davies’ covers all of the possible trigger points ( and nor do the books by Niel-Asher or Finando). I am convinced that I found some other trigger points causing pain along the topside (outer side) of my forearm; these points are not mentioned in those books so I may be wrong but I am personally 100% convinced that I had trigger points at those spots. Until I started massaging those spots, I didn’t get much better.

Have a look at the image on the right. you will see that all of additional spots that I found are on the inside part of the forearm. Whenever I pressed them, they would have the characteristic pain of a trigger point i.e. they were exquisitely painful. Quite often, they referred pain elsewhere, although not necessarily to the outside of the forearm. You might want to give it a go. One of the spots, to be fair, is mentioned on page 116 of the book by Davies. It is figure 6.9 for the Brachioradialis. However, the pain pattern shows that only part of the outside forearm is shaded. I think that more of the forearm should be shaded – at least that was my experience. Of particular importance were the parts in the middle region of my inner forearm – see the four red dots placed together.

James J

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The common position for hands hovering above a keyboard is as shown on the right, which I refer to as the ‘claw’. This position elevates the tension in the aforementioned extensor muscles, causing them to become fatigued over prolonged periods of time. Typing whilst the hand/wrists are in this position (another common posture mistake) will further increase the muscle and tendon stresses making the situation worse.

What may not be so obvious is that moving the wrists into a more neutral ‘level’ position (see image) can still create enough continual tension in the forearm extensor muscles. This is not always apparent unless, like me, you already have a bad RSI condition and can notice the pain in already injured muscles.

This is a much better position than the ‘claw’, and the forearm extensors are far less tense. They are however still in tension which may lead to forearm extensor fatigue when held in this manner for long periods of time eg 6-8 hours a day hovering your hands over a keyboard at work.

The final image on the right shows a ‘hanging’ wrist position which, if adopted, places minimal stress on the forearm extensors, (they should in fact be relaxed in this position), and is a good posture to aim for when typing. You can then utilise the weight of your hands and fingers to type, lifting the arms from the shoulders and elbows instead of placing the burden on the forearm extensors and associated tendons.

You don’t even need to be at a keyboard to try out these different wrist angles. Just hold your hands in these positions for 2 minutes and observe the different tensions in the forearm extensor muscles. Start to imagine what it is like for your body to hold this tension for up to 8 hours a day at a computer, and ask yourself whether it may be more beneficial if you changed your posture to one that has far less muscle/tendon tension in it.

Note: In order to successfully utilise the ‘hanging’ wrist position you will most likely need an ergonomic computer set up with a drop down keyboard tray, perhaps even an adjustable position keyboard tray.

Related articles on forearm extensor muscles :

Typing with clawed hands

Forearm Extensor Muscle Overuse and RSI

Does forearm extensor trigger point massage offerer a potential cure for RSI?

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RSI symptoms are very often the result of extremely tight (overused) forearm extensor muscles. These muscles are located in the upper forearm region. They are used to raise the wrist and fingers, which is the primary motion involved in unergonomic keyboard and mouse driven activities such as having the hands bend backwards and fingers raised while hovering over a keyboard ready to type.

The tight and potentially knotted extensor muscles end up being over used, and don’t get the chance to recover. This leaves them in a permanently fatigued state, tightly tensioning the forearm tendons to which the extensor muscles are attached, causing referred pain down the tight tendons into the hands, wrist and fingers.

The forearm extensor muscles consist of five main muscles and are shown colour coded in their approximate position in the image above. The image is meant for indication only, and I recommend you search for a more detailed anatomical diagram for a more accurate placement.

The five forearm extensor muscles are -

1. Extensor carpus radialis longus which attaches to the index finger but controls bending of the wrist towards the thumb as well as bending the wrist back.
2. Extensor carpi radialis brevis which attaches to the middle finger and again controls the raising of the wrist.
3. Extensor digitorum which attaches to all four fingers of the hand but controls the straightening of the 3rd, 4th, 5th fingers.
4. Extensor carpi ulnarus which attaches to the 5th finger and is used to cock the wrist outwards, for example reaching for a far away key on a keyboard.
5. Extensor indicis attaches from not far behind the wrist to the index finger and is the primary control muscle of that finger.

The extensor muscles exist at different depths in the arm and some are hard to precisely locate.

Over use strains along any of these extensor muscles from bad ergonomic practices (like having a clawed wrist at a keyboard) can lead to them developing knots (solid tissue that is scarred). This scarring results in pain (to press on at the location of the knots) but is mainly noticeable as referred pain down the forearms into the back of the hands and fingers – which is a classic RSI symptom. The extensor muscles (apart from the extensor indicis)  attach to various bones around the elbow joint, and some pain symptoms can also be found close in to the attachment points.

You can do a check to see how fatigued your forearm extensor muscles are. Using your left hand to check your right forearm extensor muscles press down firmly with the thumb onto the full area of the various forearm extensor muscles, move the position of the thumb over these muscles and check for pain. Repeat the diagnosis with the left arm extensor muscles and your right thumb.

If you are in any doubt about what these muscles do, press your thumb on your arm as above and raise your wrist up as if you were about to type. Also raise and wiggle your fingers. With your thumb, you should be able to feel the various extensor muscles tightening as your wrist and fingers raise.

If you find the extensor muscles to be in pain with the above procedure then these muscles are fatigued. It also means that ergonomically, you are not using your keyboard properly and are probably typing using the claw, which causes this type of problem. This type of condition is one of the most common mechanisms for RSI pain, but can easily be addressed by changing the way you type.

If you are experiencing pain in these muscles, it is time to try to relieve them which can be done by massage, icing and rest. Consult your doctor or a trained physiotherapist to find out the best techniques which may include ultrasound. You should also read my post about Trigger Point  Therapy on extensor forearm muscles which describes my findings from an excellent book for self help in RSI diagnosis and massage techniques. You may also want to try to find a knowledgeable Trigger Point massage therapist.

It is also time to re-assess your typing technique otherwise you may be placing yourself at risk of an RSI type condition. This may send the forearm extensor muscles into a more permanently fatigued state, from which recovery may be difficult, and in some extreme cases may be impossible.

In my own case, forearm muscle fatigue is the primary mechanism for my RSI pain. Unfortunately for me, I learned of the prevention techniques several years after my symptoms began, when these symptoms had already become more persistent.  I do however still get some much needed temporary pain relief these days from massage of the forearm extensor muscles and tendons, just not very long  lasting , but my injury is after all a long term one.

Related articles on forearm extensor muscles :

Typing with clawed hands

Forearm extensor muscle overuse wrist position and RSI

Does forearm extensor trigger point massage offerer a potential cure for RSI?

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