Insane In The Membrane: Anything And Everything's Fair Game

In the last two months, I have been experiencing a shooting pain in my forearm, or more specifically, the brachio-radialis muscle, a group located in the outer region of the forearm directly beneath the brachialis. It started off as a shooting pain only when I did heavy lat pulldowns, but then progressed to occurring every time I did any form of curls, especially barbell and hammers. Of course, like any athlete with a profound faith in his invincibility, I pushed through the pain confident in the fact that somehow, everything would "snap" back into its robust condition. Sadly, that was not the case. One night, it got so bad after training, I couldn't even lift a toothbrush. That's when I knew I had to pay the doc a visit.

The doctor, of course, was touted as the best in his field (orthopaedics, sports injury) and had a rather long line of impatient patients outside his clinic. When my turn was up, he examined my arm rather cursorily with a poke here, a prod there and a request to move my arms this way and that to see if I felt any pain. That entire “professional” inquiry took merely five minutes, upon which he was ready to offer an official diagnosis. He said it was tendonitis and that I had to lay off the weights for a couple of weeks. However, something seemed amiss; apart from the fact that I couldn’t weight train for an indefinite amount of time, which is a fate worse than death! I’ve had tendonitis before and the onset of symptoms was not as gradual as was the case with my forearm.

Tendonitis:
What it is: A sudden onset of inflammation of the tendon/muscle tissue
What causes it: Sudden trauma brought on by unexpected shock to the tendon
How doctors diagnose: Area is tender to light pressure and swelling is often visible. On MRIs, the affected areas show up as white.
How to cure it: Complete cessation of exercises that aggravate the tendon for 1-2 weeks until symptoms subside. Ice packs and friction massage can alleviate the symptoms. Medications include NSAIDS like COX-2 inhibitors (Arcoxia, for one) and in severe cases, injections of corticosteroids might be warranted.
How to prevent: 1. Warm up before exercise. 2. Stretching between sets. 3. Controlling eccentric movements to avoid unnecessary shock to the tendons/joints.

Like any responsible human being, I had to get a reconfirmation of my condition… from Google! After perusing various sites and this forum, my symptoms seemed to fit those that were identified with tendinosis, a form of chronic overuse injury that involved “micro-tears” to the tendons. This was actually worse news for me, considering the condition required an even more long and drawn out treatment than tendonitis. I went to get a second opinion from another doctor and he reaffirmed that my condition was in fact tendinosis and not tendonitis. Of course, this came after another quick but supposedly “thorough” examination of my forearm with a series of pokes and prods.

Tendinosis:
What it is: 1. Chronic overuse injury resulting in micro tears to the tendons. 2. Improper healing response of a tendon resulting in excessive fibrosis.
What causes it: Accumulative micro-tears due to overuse of the tendon/muscle usually from lifting or pulling more load/resistance that it can handle. Furthermore, the tendon may not have the time to heal (lack of rest) or the healing process overcompensates by the production of too much unaligned collagen in the muscle/tendon matrix (fibrosis).
How doctors diagnose: Affected area exhibits pain (level depending on the stage of degeneration, which can range from 1 to 4) when it is contracted with a certain amount of load in a certain stance (eg, hammer curls). Swelling is not present and area is generally not tender to the touch. On the MRI, tendinosis shows up black.
How to cure it: 1-2 weeks of active rest therapy followed by 8-10 weeks of modified activity – initially using the tendons in a limited fashion with minimal loads to stimulate realignment of the collagen matrix and simultaneously allowing the tendon to heal (it takes 8-9 weeks for new collagen to form). Commencement of activities can resume but in a gradual fashion. Hot packs and friction massage can increase blood flow and matrix realignment. As of now, no formal medications exist except for OTC pain killers. NSAIDs and corticosteroid DO NOTHING to improve the situation.
How to prevent: 1. Warm up before exercise. 2. Stretching between sets. 3. Using a lower weight/resistance that allows recruitment of the targeted muscle fibers without placing undue strain on the tendons. 4. Getting enough SLEEP

After a week of cessation from any exercise that aggravated the injury, the application of hot/cold packs, and the reduction of resistant weights used for all upper body exercises, I still felt something was not right. This time, it was more of a logical deduction than a do-the-symptoms-fit-the-crime scenario. First off, the pain I felt was not near the tendons but at the belly of the muscles in my forearm. Secondly, I had been on hGH for six months, which meant my ligaments and tendons were well looked after. Lastly, the weights I lifted were, in fact, noticeably less than when I was cycling last year, so I couldn’t fathom how I was placing more load than my tendons could handle or heal. This time, I contacted a well-renowned physical therapist with a certification in sports medicine (he had worked on Olympic athletes before, also being one himself) and wanted his prognosis. Our initial consult was an hour long, upon which he asked me about my workouts and the way I did them (warm ups, resting, stretching, massaging, etc.). He then gave me a light massage in my forearm to “feel” for anything unusual he might find. That’s when the “Eureka!” moment came.

He had discovered several muscle “knots”, or myofascial trigger points, hiding in my forearm. The knots can form for years before they become symptomatic. They often result from spasms that arise from the lack of stretching or warming up a muscle, which never allows it to fully recover from the post-workout “shock”, so that it never fully relaxes and remain in a contracted state. As time elapses, each workout places an additive effect on the trigger points until they become large or stubborn enough to elicit pain. Sure enough, I have been visiting this therapist for 5 sessions now for deep tissue massages and trigger point injections with lidocaine. I also took his advice to warm up before my workouts and stretch vigorously after each set. I am feeling less pain after each session but the progress is going to be slow (undoing knots that had been neglected for years was going to be a lengthy undertaking). However, the goods news was that although I had to tone down my resistance and avoid exercises that aggravated the trigger points, I could continue to workout at the gym so as to keep my hard earned gains (and my sanity!).

Myofascial Trigger Points:
What it is: Permanently contracted knots of muscle
What causes it: Exact causes have not been fully studied but current findings seem to point to the use of excessive load, improper stretching, and muscle spasms/twitches caused by restless nerves (probably from overtraining). Initially the knots (or trigger points) are painless and undetectable by the sufferer until it becomes severe enough to cause pain with the application of resistance. Left untreated, the knots may, in time, harden with fibrosis.
How doctors diagnose: Affected area exhibits a knot like formation that may be visible to the naked eye. Applying pressure to the knot may elicit pain that can be felt radiating throughout the length of the entire muscle.
How to cure it: Deep tissue massages of the trigger points often help them relax and soften the fibrosis to restore functionality. In severe cases, injections of numbing agents like lidocaine may achieve the same loosening of the trigger points. Trigger points are tricky to cure and the stubborn spots may never be fully cured, but partially restored. Activities that aggravate the knot should be mitigated for several week while therapy is being applied.
How to prevent: 1. Warm up before exercise. 2. Stretching between sets. 3. Strengthening the muscle (especially smaller ones like those in the forearm) to “catch up” with the rest of the body. 4. Getting regular deep tissue massages (1-2 a week) as a preventive measure.

What was the moral of this story? Doctors are not gods. I had to consult with three physicians before I finally uncovered what was really wrong with my arm. It goes to show how the standard of care in the health industry has really gone to the dogs in the name of money (more patients = more revenue). Always find a doctor that is willing to give you his/her time without continually looking at the clock; this is a matter of your health! Also learn to trust your instincts: In the age of information, always do your own researches to understand the doctor’s diagnosis and call him on any discrepancies that may arise.


Till Next Time,
Insane