According to Travell & Simons in their Trigger Point Manual, “In patients with chronic myofascial pain, attention to perpetuating factors often spells the difference between sucessful and failed therapy.” Perpetuating factors in the case of Krystal S. were an important consideration in reducing the need for continued treatment for restless leg syndrome at my Neuromuscular Therapy center near Boston.

Structural asymmetry is one of the most commonly overlooked factors. Krystal has a scoliosis (curvature of the spine), a fusion of L5 to her hip bone (the lowest moveable spinal joint), a pelvic asymmetry (hip bones different sizes) and LLLI (lower limb length inequality). With an asymmetry, the body is out of balance and constantly compensating for it. The muscles get overloaded from working too hard. Trigger Points form and joints become irritated from the tension.

In Krystal’s case, I suspect the fusion in her spine may be a factor because I have to keep going back to treating her lumbar spinal muscles and sacroiliac joint when they become symptomatic. The compression may be causing irritation of the nerves at that joint that serve the deep muscles of the spine, creating Trigger Points that refer to the muscles of her hip and lower extremity. It may also be irritating the L5 fibers of the sciatic nerve.

(Therapist tip: treat deep multifidi, rotatores, and QL muscles, IL and SI ligaments with pressure bars; recommend heel lift and butt lift)

Postural stresses often result from misfitting furniture, poor posture, muscle overuse, immobility or repetitive use. Krystal is small, so she often compensates by sitting with one leg tucked under her. She has uneven hip bones and a scoliosis, so seated posture is stressful for her back muscles. Sitting on her foot causes entrapment of the sciatic nerve by perpetuating Trigger Points in the piriformis muscle.

(Therapist tip: change work station furniture to fit, stretch the piriformis using Active Isolated Stretching specific stretch and protocol)

Prolonged muscle constriction perpetuates Trigger Points. Krystal’s feet don’t reach the floor in an average chair so the back of her thighs are compressed against the edge of the chair seat.

(Therapist tip: use a stool for the feet or put a soft roll under the knees. stretch the hamstrings using Active Isolated Stretching protocol)

Nerve entrapment by the piriformis (piriformis syndrome) and groin muscles is a result of chronic muscle tension. Because of Krystal’s structural and postural stresses, this is a major perpetuating factor.

(Therapist tip: release Trigger Points in piriformis and pectineus muscles, check iliopsoas)

Nutritional inadequacies are important to resolve for lasting pain relief. There are nutrients that are essential for the health of the nerves and muscles, but even an insufficiency of nutrients can aggravate muscle pain syndromes. Krystal’s diet was poor, she didn’t like drinking water and said she didn’t react well to taking vitamins.

(Therapist tip: add B-Complex, C with bioflavanoids, Calcium complex with Vit.D and magnesium and a good natural multi-vitamin)

Systemic and genetic factors that impair muscle metabolism and create inflammation perpetuate Trigger Points. The presence of toxins, pH acidity and poor lymph drainage are not well studied, but I’m finding more and more evidence of muscle pain from these sources. Exercise helps. Krystal didn’t exercise because it hurt, but she needed to exercise to improve muscle health by increasing circulation of blood and lymph and increasing muscle mass.

(Therapist tip: have patient get CRP test, pH testing over several days; allergy, environmental and food sensitivity tests, aerobic exercise or mini trampoline to start. Sometimes they just have to exercise past the pain.)