In essence, this golfer was describing the symptoms of a weak grip of his left hand. Typically, this was pain-free, but it was accompanied by pain following repetitive and forceful use at the practice range. Travell and Simons1,2 described the myofascial trigger points of the hand extensors and the brachioradialis muscles as causing a painful, weak grip. Examination of this patient revealed latent trigger point phenomena in the extensor carpi ulnaris and extensor carpi radialis brevis muscles. Evidently trigger points in these muscles caused the left hand to "loosen" its grip on the club resulting in rotation of the club head during impact.
Treatment of this problem consisted of spray and stretch of the affected muscles as described by Travell and Simons.1,2 The habitual slicing problem was resolved after five treatments that were supplemented with self-directed stretching and strengthening exercise for the wrist.
This example depicts latent myofascial trigger points that act as barriers to athletic performance. Exactly how this problem manifested itself is difficult to say. There was no specific injury that resulted in the "weak wrist-golf slice" problem. There was no indication that gripping the club too firmly precipitated the problem in the first place; it only appears to be the result of a weak grip. The question that needs to be asked next is, "How do myofascial barriers to peak athletic performance develop in seemingly normal athletes?" The answer lies in the manner in which sport techniques are performed.
Most of us learn to play sports by watching others. We imitate our teachers, friends, and sports idols. We copy our idols' techniques in a hope that we can taste the greatness that they so skillfully display. This is the method that most of us use to learn how to play sports, but it is not always the best way. Hay3 refers to this method of learning sport technique as "copying the champion." The problem with this method of learning, as Hay3 points out, is that the champion has succeeded in spite of having a technique that is far removed from the optimum (emphasis mine). Faulty biomechanical execution of sport skills appear to predispose and precipitate an athlete to injury. A sport technique becomes faulty when small muscles are used to perform the tasks best suited for large muscles.
A 19-year-old baseball player complained of left shoulder and neck pain of recent onset. The pain was the final link in a chain that had begun months earlier with a feeling of "weakness" and "slowness" when batting. These feelings of weakness and slowness while batting got progressively worse to where he could not swing his bat with enough speed or force to be an effective hitter.
Examination of this athlete revealed active trigger points in the left levator scapulae and left, middle trapezius muscles. Spray and stretch as described by Travell and Simons1,2 resolved the pain in three treatments. The dysfunction (i.e., weak, slow feeling) resolved after an additional five treatments of spray and stretch. This regime was supplemented with a strength and flexibility routine for the area.
All was fine with this athlete for a period of two weeks, then the problem started to return as before; a sensation of weakness and slowness when batting. Before pain became a problem, it was decided to analyze the technique he used for batting. He, like most of us, received no formal training in the biomechanics of sport techniques. He subsequently learned how to bat by watching others and being coached to "swing level," "make contact," and "hit the ball -- don't try to kill it." Instructive words they are not.
Watching this teen batter revealed that he, quite literally, hit with his shoulder. He relied on the small muscles of his left shoulder to lift his arm and draw the bat up through the oncoming pitch. This action would, and in his case eventually did, overload the small superficial muscles of the shoulder girdle. I retrained him to use the large, superficial muscles of the back that are more powerful to accomplish his batting swing. By learning how to substitute the latissimus dorsi and the middle and posterior deltoid muscles in place of the levator scapulae and middle trapezius, he was able to shift the load of his batting swing from the smaller, weaker muscles to the larger stronger muscles. The loading demands now assumed by the larger muscles with ease were the same forces responsible for the overloading of the smaller muscles.
In this example, there is no precipitating injury to account for pain and dysfunction. The dysfunction of a slow, weak batting motion is indicative of latent myofascial phenomena. For this athlete, trigger points in the levator scapulae and the middle trapezius were the myofascial barriers to peak athletic performance that were due to faulty biomechanical technique. But, how does this occur?
Faulty biomechanics of sport techniques occur through a process of muscle substitution. An athlete, during the process of learning to perform a gross motor skill, uses muscles that he can exert more control over. The muscles that are better controlled are those muscles with smaller motor units.4 Indeed, the muscles with smaller motor units (i.e., fewer muscle fibers served by a single nerve) exhibit the best control and coordination. In the beginning stages of learning most sport skills, control of that skill is valued over that of its powerful execution. After all, who wants you to bat for their team if you can't control your swing enough to make contact with the ball? And so we learn, powerful execution without control won't get you on the team.
As an athlete becomes increasingly more proficient at his sport, he will demand a higher level of performance from himself. This step up in performance usually takes place in the form of increases in speed and power. There are typically no changes made in technique. Since the technique the athlete uses stays the same, it follows that the muscles being used to perform the skill also remain the same. An athlete such as this is increasing the likelihood of overloading his smaller, more controllable muscles as he attempts to achieve a higher level of performance.
It is acute overload and overload fatigue of the small muscles used in sport biomechanical techniques that develop into myofascial trigger point phenomena. The overload may develop insidiously and without pain. Their presence may only contribute sensations of "weakness," "slowness," and "tiredness." The overload of these muscles may develop quickly and present as pain in addition to weakness and restricted range of motion. In any case, faulty biomechanics of sport techniques predispose athletes to myofascial barriers to peak performance.
The diagnosis of myofascial barriers to peak athletic performance is made clinically as described by Travell and Simons.1,2 In addition to a clinical workup, field observation of the athlete must be made to identify the mechanical faults in his sports technique. This can be done most effectively with a videotape camera. The videotaping of an athlete enhances the process of retraining an athlete because he can objectively see his faults during the playback.
Treatment of myofascial barriers to peak athletic performance should begin with trigger point therapy as described by Travell and Simons.1,2 Alterations in the athlete's sport technique should be made with an attempt to use large and powerful muscles in place of small and weak ones. This regime of treatment should not be concluded without instituting a sport specific strength and conditioning program for the athlete. Adequate treatment will ultimately serve as the best form of prevention. For performance, prevention, and treatment to be effective for athletes, they must develop strength and conditioning appropriate for their sport and be coached on the proper biomechanical techniques.
Conclusion
This new understanding of how myofascial pain and dysfunction relates to sports injuries and sports performance will add a new dimension to sports chiropractic. The work of Travell and Simons1,2 fits well with sport sciences. A better understanding of how improper biomechanics of sport technique can contribute poor performance should be pursued. Studies need to be conducted that more closely examine how high-demand loading of small muscles affects sports performance.
This information can be very valuable to both the sports and chiropractic communities. The sports community can further benefit from the services and expertise of sports-minded chiropractors. Athletes, in addition to receiving quality injury care, will have an opportunity to better understand how their sports performances suffer and how they can improve them.
The chiropractic profession, and sports chiropractors in particular, can move to the forefront of the sports world. While many physicians' services are limited to rehabilitation, the sports chiropractor will have the skills to take an athlete above and beyond the preinjury performance level. A way should be paved to include qualitative sport biomechanical analysis and the teaching of sound sports skills into the practice of sports chiropractic.
If chiropractic is to be a force in the 21st century, then it must innovate and shape the 21st century. It has no better opportunity than in American and international sports.
References
- Travell JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 1, Baltimore, Williams & Wilkins, 1983.
- Travell JG, Simons DG: Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 2. Baltimore, William & Wilkins, 1992.
- Hay JG: The Biomechanics of Sports Techniques, ed 3. Englewood Cliffs, NJ., Prentice-Hall, Inc., 1985.
- Fox EL, Bowers RW, Foss ML: The Physiological Basis of Physical Education and Athletics, ed 4. Dubuque, Iowa, William C. Brown Publishers, 1988.
Andrew S. Bonci, D.C.
Tuckahoe, New York