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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Homedics massager

As you will know from reading this blog, I have had a chronic RSI condition in my forearms for over 14 years. I live with it by avoiding computer use as much as possible. Whilst resigned to having this condition long term,  I am always looking at ways to try to rehabilitate it somehow. Usually when things get more painful I resort to digging out an old, vigorous Homedics massager that I bought in the US. It’s a heavy duty one that is probably more designed for deep tissue massage of the back and neck, however, it can and is used by me to reach deep into the forearm extensor muscles for a relieving massage (although you have to be careful not to overdo it). This usually takes the pain down to background levels, at least temporarily.

The massager is, however, still only treating the symptoms of the RSI. What I really need is to try to strengthen the forearm muscles to an extent where they can resume being normal muscles tissue again (as opposed to the knotted, tense mass that is there right now). I have always drawn a blank as to how to do this.

NSD Power Ball gyroscope

I recently came across a friend with a NSD PowerBall Gyroscope (which I’d seen plenty of advertisements for but hadn’t got round to trying out), and my curiosity got the better of me. Amongst its claims is that it can be used as a “Rehabilitation product bringing gentle non-impact relief  to Carpal Tunnel syndrome (CTS), Repetitive strain injury (RSI), tendinitis, arthritis, and all wrist related ailments. Spinning for just five to seven minutes per day is enough to start your rehab!”.  Lofty claims indeed! I was keen to get my own Power Ball and get started!

The units are actually quite inexpensive (less than £10 for the basic model). The more expensive ones have electronic counters in them so you can count rotations and gyroscope speed RPM, which I decided was superfluous to my requirements. My NSD Power Ball arrived in a few days from Amazon and I ripped the package open with great enthusiasm and interest, as well as much hope!

The theory behind the Power Ball is that spinning the gyroscope inside the ball offers a resistance to motion of the ball. Spinning  the gyroscope is started by means of a short piece of string (or alternatively by means of an additional electric base unit at extra cost). Rotation of the ball with the hand/wrist keeps the gyroscope running and maintains resistance. The gyroscope, when in motion, will actually start to produce a gentle whirring sound. The faster the hand/wrist rotation, the faster the gyroscope spins and the more resistance the ball offers and vice versa. The resistance that you encounter is therefore  controllable in infinite degrees, and can be tailored to your own needs (or degrees of injury) which is useful.

Gripmaster

What I have found thus far (after about 1 week’s use) is that it is a really good way of getting the forearm extensors exercised in an aerobic manner (as opposed to the continuous micro movements that computer keyboard/mouse input dictates, which can lead to RSI conditions). I can honestly say that I have never felt the forearm muscles heat up as much, which is surely a good thing (I can sense blood rushing into them, which will hopefully be good to promote healing).  I am also coupling this with using a medium/low strength Gripmaster hand exerciser, and adding in a few forearm stretches too. I am keeping this routine to 2 to 3 x 10 to 15 minute timeslots each day. I realise that it’s important not to overdo it!

Having had such a long term injury, I am under no illusions as to the uphill battle I face to rehabilitate it, and it’s still too early to assess the long term benefits of using the Power Ball Gyroscope with a forearm extensor RSI injury such as mine, but so far I haven’t needed to use the big massager for forearm extensor pain relief again which is a good sign! I will report back here after more prolonged use to let you know how things are working out. I at least have a little hope to cling on to for now!

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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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The biggest problem with the invention of the mouse, and for that matter all current GUI based computer systems, is that they force a user to do a very repetitive motion that had up until their invention not been done before, ie the repetitive small movement of the index fingers to send a ‘click’ to the computer to say ‘do this’. Sometimes this repetitive task can be very intensive (depending on the application being used). This has over the last 15 years or so led to a large increase in cases of Repetitive Strain Injuries (RSI).

So what alternatives to standard mouse ‘clicking’ exist right now for the computer user? (Note: the following is by no means an exhaustive list)

• keyboard short cuts
• voice recognition software
• foot pedal clicking
• graphics tablet/tablet PC pen “taps”
• software generated clicks
• touch screen monitors

Each of the above have their own set of positive as well as negative points. The following is a brief summary of what I’ve found from my experiences with each of them -

• Keyboard shortcuts -these are quick access (single or combination) keyboard strokes which activate a command without moving (or clicking) a mouse and can greatly reduce the amount of mouse use required to do certain tasks. There are keyboard shortcuts available for most of the operating system versions around including Windows (9x, 2000, XP, Vista), Linux (KDE, Gnome) and Mac, as well as most of the applications that run on these operating systems. I have indeed found many keyboard shortcuts to boost my efficiency when using some software applications. Indeed without these shortcuts I would have been only 50% as productive at my job as I was! However the biggest limitations to keyboard shortcuts are as follows -
  • They are not well publicised, and as such there is a general ignorance out there as to their existence
  • The shortcuts may be common in a certain operating system, but not always transferable from one platform to another.They are rarely common across applications apart from very common tasks eg copy and paste etc.
  • A lot of applications could be more productive if more of their menu commands were available as keyboard shortcuts
  • There is a lack of ability for a user to customise the shortcuts in these applications.
  • You often have to continue to click a button to activate things, eg hit ‘return’ key or mouse click.
  • You still have to use your hands on the keyboard
  • Keyboard short cuts themselves are also repetitive in nature, and can cause RSI conditions in their own right.

• Voice recognition software – In my own experience, voice control software has always had great potential for relief of over-used arm and hand muscles, however, the effort involved in learning how to use the software, ie teaching the software to recognise your voice is a soul destroying and often futile task (I have had a lot of frustration in my numerous attempts!). Unless someone comes up with a version for a low toned, Scottish speaker, I see it as of little practical use to me personally. The last thing you want to do around an office is talk in a loud distinct and clear voice anyway! You will start to get strange looks from your co-workers!
• Foot pedal clicking is certainly a viable option. There are a few foot controlled ‘mice’ out there. Whilst I can’t be enthusiastic about mouse movement control with a foot mouse (my ankles started to hurt when I tried this motion), the clicking action could easily be done by foot, although double click timing could be an issue.

• Graphics tablets/tablet PCs – these input devices give the user an option to use a special pressure sensitive pen to move about a ‘tablet’ surface. This action is akin to holding a pencil whilst writing. This a relatively natural position which we have been used to ever since we learned to write. The clicking action is either controlled by clickable switches on the side of the ‘pen’ or by ‘tapping’ the pen tip against the tablet. This is indeed a complete change from standard mouse clicking action, but still involves many small repetitive movements (mainly wrist based) for clicking, coupled with a tight grip holding onto the pen. I also find the tablet surface (and edge) itself to be a cold and hard surface to rest my hand, wrist and arm upon. They can also take a bit of getting used to. Personally, as an RSI sufferer, I found the wrist motion to control the pen taps to be too painful to use on a regular basis. My injury may well have progressed too much by this stage, and the continual need to grip the pen also didn’t work for me. It may, however, be a viable alternative to a mouse for many other computer users.
• Software generated ‘clicks’ – This method has intrigued me for a long time. There is software available that can be used to generate a mouse click. The trigger for a click is the movement of the mouse followed by the stopping of the movement for a pre-determined time. This is usually indicative of the user hovering the cursor over a button etc that needs a click to activate. The software can be user controlled to send left, right, centre, double etc mouse clicks, which can be an absolute life-saver for some RSI sufferers (myself included). One such piece of software available (for free!) is ‘Point-N-Click‘ by Polital Enterprises. The use of this type of software is great for certain types of common applications eg web surfing. They can of course detect an unintentional mouse movement and send an unintentional ‘click’. This is often not important, but can have implications if, for example, you accidentally send out a mail message to someone prematurely (as I have done). Fortunately, there are sensitivity and delay controls available to tailor the software’s response to your individual needs. ‘Point-N-Click’ also has a built in “take a break” reminder alarm, which is very useful. Even better, the software is currently free, so you can try it out for nothing!
  Alternative mouse click generation software are ‘Nib‘ (formerly free software called mousetool) by Designer Appliances, and ‘Gentle Mouse‘. Neither of them are free, however you can evaluate both with time limited demo versions. Gentle Mouse has the added benefit of not sending clicks until you move the mouse a second time to choose either left or right clicks, the advantage being the reduction in the number of erroneous clicks you send.
• Touch screen monitors – I have not yet experienced a touch screen monitor. They certainly may be a very usable option for an RSI sufferer. I personally still feel that I’d be tapping my fingers against a surface yet again, which for me would still most likely lead to pain. It could, however, be a viable solution for many computer users out there, and looks like a promising development in computer input devices.

As is often the case, there may not be a single solution to combat RSI. It may be more sensible for an individual to choose a few different methods of control, and switch between using them. The key thing is to avoid doing any one repetitive action all of the time.

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Having been an RSI sufferer for the best part of a decade, and having come from an identical background to my colleagues (and no doubt had been prone to thumping keyboards in my time), I fully realised the implications of the use of excessive force as people interacted with their keyboards.

Keyboard thumping (the act of hitting the keyboard keys with exaggerated force or heavy pounding) can be barely noticed by the user, but is usually attributable to them being overly frustrated with the computer/piece of software being used or or emotionally involved with an angry ‘flame’ mail etc. During these times it is not unusual for this anger and stress to build up and be vented in this way. There is really no place for emotional frustration and computer use. Your body needs to be ergonomically positioned, relaxed and fluid when interacting with computers in order to minimise the exposure to RSI causing effects, and not demonstrating emotional reactions like the guy below!

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In reality the keyboard (although it may well be suffering long term wear and tear from such actions) isn’t what’s ultimately paying the price, it’s the user’s health in the form of forearm/wrist/hand tendons/muscles, coupled with joint impact, especially if this behaviour becomes habitual.

The best approach for users when frustration and anger creeps into computer use, is to take a break (mental as well as physical), go cool off somewhere and let the emotions settle down. Rarely are any problems solved by emotional responses to computers or for that matter ‘flame’ emails, and ultimately you need to be aware that you are risking your health if you do. Try to recognise when you exert heavy pressure on keyboards, ask yourself why you are doing it, and if the cause is anger or frustration, go take a break.

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