Sunday, July 26, 2020

Do You Need To Treat Your Trigger Points?

A common comment I get from patients is that they have "trigger points" in their muscles. Either they have been told by someone else treating them or they have read somewhere that "trigger points" are sore, painful areas in their muscles.

Trigger points are often assumed to be specific areas of tenderness in a muscle which can cause generalized musculoskeletal pain when over stimulated. It is believed that most of this occurs because of muscle overuse, muscle trauma (or injury) or even psychological stress.

Trigger points are also thought to arise from sustained repetitive activities like working on a computer/ phone all day or lifting heavy objects at home or work.

Trigger points feel like a lump or knots just under the skin. When pressing on trigger points, most people don't feel any pain or discomfort although there are others may feel pain.

If you google "trigger point therapy" the following shows up (see picture above). Many physiotherapy clinics and other healthcare professionals advertise and make money by claiming to be able to treat your trigger points.

I have also had some of my patients that me that some health practitioners they see say that trigger points are distinct areas of localized inflammation. However published evidence suggest otherwise.

Patients with chronic tension-typed headaches were matched with a healthy control group that had no such trigger points in the trapezius muscle.

Samples after needles were inserted into the patients at rest, 15 and 30 minutes after static exercise (10% of maximal force). All samples were coded and analyzed blindly.

The researchers found no difference in resting concentration of inflammatory mediators or metabolites between patients with tender trigger points and non tender controls. There was also no change after exercise.

The researchers suggest that the trigger points are not sites on ongoing inflammation.

Now you know. Trigger points are not sites of inflammation. You do not have to treat it. Getting rid of trigger points may not solve the problem.


Ashina M, Stallknecht B et al (2003). Tender Points Are Not Sites Of Ongoing Inflammation- In Vivo Evidence In Patients With Chronic Tension-type Headache. Cephalalgia. 23(2): 109-116. DOI: 10.1046/j.1468-2982.2003.00520.x

Sunday, July 19, 2020

Lots Of Recreational Runners Take Drugs To Run

Not the kind of drugs that that elite athletes use like growth hormone or erythropoietin, but common off the counter ones like Ibuprofen. 

Don't believe what I'm writing? Consider the following patients I treated recently. I had a runner who runs ultras and another newbie runner who just started running during the circuit breaker/ lockdown because he couldn't go to the gym. Both had a combination of mild injuries and muscle soreness and instead of taking a break they both gulped down a couple of Ibuprofen tablets and occasionally stronger non steroidal anti-inflammatory drugs (NSAIDs) so they can keep running and training.

Here's what I read. 46% of runners recruited (total 109 runners) recruited during the 2016 London Marathon registration planned to take an NSAID during the race.  Of those 109 runners returning for data collection, 34% had already taken an NSAID on the morning of the race while more than half the runners completing the study (16 out of 28 runners) had taken an NSAID.

Only 13 of the 28 runners (13) correctly stated the risks of taking NSAIDs while only 10 runners (35%) knew the correct safe dose.

NSAIDs while helpful with masking your pain while exercising can cause stomach ulcers, acute kidney injuries and also a risk of strokes and heart attacks (depending on dosage  and how long they are taken).

Under duress of a long distance endurance event, risks may increase. Reduce blood flow and motility in the stomach make tummy problems common even without NSAID use. Muscle damage from racing may increase protein in the blood which can lead to acute kidney damage. This may be worsened by NSAID use. Hyponatremia can also be heightened by use of NSAIDs.

Researchers in UK, surveyed 806 runners in the Parkrun there to find out about usage in a diverse group of runners. A third of  these runners raced marathon distances or higher. Almost 90% of the runners surveyed used NSAIDs (most used Ibuprofen, which does not require prescription by a doctor).

More than half the Parkrun runners took NSAIDs before a run or a race.The longer the run, the more likely they were to take NSAIDs before or during the run. One in ten runners took them during a run and more than 65% took them after a run.

33% of the ultra runners compared to 17.5% of marathon runners took NSAIDs during the event. This is of concern a the longer events already put extra stress on their stomach and kidneys as it is.

Those who do not log longer distances used NSAIDS so that they can keep exercising with pre-existing pain, ongoing medical issues or current injuries. Those who ran further (>40km a week) were more interested in reducing inflammation, soreness, pain and performance enhancement/ improvement.

Almost half the surveyed runners used NSAIDs without any advice from a healthcare professional thought almost all said they would read the advice if it was provided to them.

I, too have taken NSAIDs on the night before and the day of a race. Tried it twice, although I thought they didn't make much of a difference to my performance. Hence, I didn't take them after.

If you're using NSAIDs to run through pain and injury to meet your training/ racing targets, it is counterproductive to the long term health benefits of running especially since NSAIDS can affect healing and recovery. Using NSAIDS occasionally before or after your weekly run is definitely less risky compared to frequent, regular usage during demanding training. Needless to say, they should be avoided while your body is under sustained physiological stress during races.


Rosenbloom CJ, Morley FL et al (2020). Oral Non-steroidal Anti-inflammatory Drug Use In Recreational Runners Participating In Parkrun UK: Prevalence Of Use And Awareness Of Risk. Int J Pharm Pract. DOI: 10.1111/ijpp.12646

Whatmough S, Mears S et al (2017). The Use Of Non-steroidal Anti-inflammatories (NSAIDs) At The 2016 London Marathon. BJSM. 51:409. DOI: 10.1136/bjsports-2016-097372.317

Sunday, July 12, 2020

Do Heavy School Bags Cause Back Pain In Children?

I had a nine year old girl come to our clinic to see me this week complaining of neck pain. Her grandmother who brought her thought it may be related to her very heavy school bag that caused it. That along with the extra time on screens during home based learning recently during the circuit breaker.

After examining the little girl, I explained to her grandmother that what she thought may not be true.

You would have seen plenty of advertisements on the internet suggesting you buy your child an ergonomic bag pack for your child to avoid back and neck pain. However, when I searched the literature, there were no convincing proof in the last 20 years between heavy school bags and posture/ back pain among the young.

Many of you would have seen a young child with a big school bag on their shoulders. You would have read about it in the papers. There are many articles available online regarding this topic too. Many of the articles quoted above suggest that your child should not carry more than 20 percent of their body weight. After searching, I found out that this figure is taken from an article by Dockrell et al in 2013).

The most recent evidence published was from a systematic review in 2018 conducted by a team of Australian Physiotherapy researchers. They examined 69 eligible studies with a total of more than 72,600 children.

Many of the articles were rated as either having a moderate to high risk of bias due to high attrition rates, mixed testing methods, confounding factors and poor prognosis. As a result, most of the articles did not find an association between school bag characteristics and low back pain even though there were mixed sample sizes, different school bag weight and different definitions of back pain.

The authors suggested that due to variables in school bags, measuring instruments and timing of data collection, there were no straight "yes" or "no" answers. Hence, no strong conclusions can be formed.

An older systematic review in 2008 examined 10 qualified trials with more than 17,000 children/ teens on neck, upper back and shoulder pain. The authors found that static postures, depression, stress, psychosomatic symptoms, age and gender (girls had higher reports of pain than boys, especially those who were depressed (Prins et al, 2008).

If I may digress here, even among adult research there was insufficient evidence for association between spinal curves (e.g. scoliosis) and all other health related outcomes. This includes low back pain, disc herniation, neck pain, fractures, headaches, symptomatic degenerative lumbar disc disease and thoracic pain (Christensen et al, 2008).

Perhaps many of us (including all the online articles you read) after seeing a child hunched forward with a heavy school bag while walking home assume that heavy back packs causes neck and/or low back pain.

This may have fueled further beliefs among doctors, physiotherapists, other clinicians and the general public that heavy back packs can cause neck/ back pain.

Personally, I do get concerned whenever I see a young child carrying a heavy back pack even if the evidence does not suggest that it will hurt them permanently.

As my wife says (quoting Tom Myers), children have very elastic connective tissue and they are very resilient. Unless your child is perpetually carrying a super heavy school bag, it probably will not affect their necks and backs permanently.


Dockrell S, Simms C et al (2013). Schoolbag Weight Limit: Can It Be Defined? J Sch Health 83: 368-377.

Prins Y, Crous L et al (2008). A Systematic Review Of Posture And Psychosocial Factors As Contributors To Upper Quadrant Musculoskeletal Pain In Children And Adolescents. Phy Theory Pract. 24: 221-242. DOI: 10/1080/09593980701704089

Yamato TP, Maher CG et al (2018). Do Schoolbags Cause Back Pain In Children And Adolescents? A Systematic Review. BJSM. 52: 1241-1245. DOI: 10.1136/bjsports-2017-09827.

Sunday, July 5, 2020

Iliotibial Band Pain In Runners

The ITB originates from the TFL
I had a patient this week that was suffering from Iliotibial band (ITB) pain and he was so fed up with the pain that he was considering getting a steroidcortisone injection to get rid of the pain. He sent me an article he'd found for me to ask for my opinion.

Having previously suffered from Iliotibial band or ITB syndrome myself before, I'll naturally read any article I'd come across about the ITB.
The ITB over the Vastus Lateralis muscle
The article itself wasn't so interesting even though the authors got a good result after their intervention. The authors concluded that a steroidcortisone injection was effective in reducing ITB pain in runners in the first two weeks of treatment.

I'm not a fan at all when it comes to injecting steroid (or cortisone) to treat any sporting injuries. I written previously that often the cause of the problem is from the hip. For best results, you treat the cause of the problem.

As I've written previously, if you're an athlete or exercising regularly, you definitely do not want a steroidcortisone injection since there is a very high chance of degenerative changes in the surrounding area of the steroid injection. You can read about how my patient tore his forearm flexor tendon after repeated steroid injections.

Anyway, what intrigued me about this article was the small sample size and how long it took to recruit the runners (it took two whole years). The authors managed to recruit 45 runners but only 18 fulfilled the criteria and finished the study.

There was an attempt to have a longer follow up period, but there was too much variability in the second phase treatment of the condition. Their return to running, distance ran, rehabilitation program, change in footwear and use of orthotics etc.

Most of the eligible runners did not want to stop running during the 2-week intervention period. Exactly what I said about athletes (not wanting to rest) in my interview which you can see here. This shows the challenge of recruiting runners for research.

How about you? If you were recruited for a running research and asked to stop running for 2 weeks for the sake of research, would you comply? I'd like to hear your views.


Gunther P and Schwellung MP (2004). Local Corticosteroid Injection In Iliotibial Band Friction Syndrome In Runners: A Randomised Controlled Trial. BJSM. 38(3): 269-272. DOI: 10.1136/bjsm.2003.000283.