Trigger Points

Trigger points are a hot topic these days. A lot of people have heard of them, although not too many people know what they are or, in all honesty, much else. But they still talk about them and say they have them and they hurt. We’ll take a look at what they are, how they form, discuss what problems they bring and ones they are symptoms of, and how to get rid of them.

Trigger Point Background

In the early 1940’s Dr. Janet Travell coined the term “trigger point” to describe tiny, painful, palpable “knots” in skeletal muscle and the fascia surrounding it and the radiating pain associated with the trigger point. Not everyone in the medical community subscribes to the theory of trigger points, particularly among conventional doctors.

However, there seems to be some ebb-and-flow acceptance within that community as further studies are conducted. The main delays in acceptance seem to surround the amount of specific scientific evidence in studies and data-specific diagnosis of myofascial trigger point pain syndrome.

Yet several medical specialties (orthopedics, family practice, physical and rehab medicine) are taught and use trigger point theory in practice.  Also, most practitioners in the manual therapy professions of osteopathy, chiropractic, massage therapy, physical therapy are familiar with trigger points. The current “bible” on trigger points is Dr. Travell’s book, “Myofascial Pain and Dysfunction: The Trigger Point Manual”.

What Are Trigger Points?

skeletal muscle structure

Fig 1 (click to expand)

Trigger points or TPs are accumulated bunches of chronically contracted muscle fibers. A look at the anatomy of muscle is necessary to visualize what’s going on, here. The figure to the right is an exploded view of a muscle. To give you an idea of how amazing skeletal muscle is, consider that trigger points start by contraction taking place at the cellular level. Of course, we have no actual sensation of cellular contraction. It’s the accumulated contraction of many hundreds or even thousands of individual cells that we are able to feel internally and palpate with our fingers.

Contraction takes place within the sarcomere (noted in the lower right corner of the figure) by the ratcheting of myofilaments actin and myosin against each other.

sarcomere

Fig. 2 (click to expand)

In the next figure, take a look at the closeup of the sarcomere to see where we are. Notice a single sarcomere is that portion of the myofibril between two so-called Z lines. The contractile fibers, actin and myosin, live within each sarcomere.

sarcomere exploded

Fig. 3 (click to enlarge)

Figure 3 describes a single sarcomere (portion between Z discs) with its contractile fibers in relaxed (above) and fully contracted (below) conditions. Notice the difference between the location of the Z discs in the top and bottom depictions. As actin and myosin contract, they pull the Z discs in toward the center, or M line.

Now that we can see how a single cell contracts, let’s put it all together in this four-minute animated video I chose from the Internet by Mr. Michiel Akkerman, whom I have no affiliation with.

Problems Arising From Trigger Points

Specific problems with trigger points are somewhat arguable when discussing them from a scientific viewpoint. However, the most popular consensus agrees that pain is the most problematic. Some opinions are that trigger points are the most common cause of pain occurring in the musculoskeletal system.

The difficulty lies in the number of professionals who are not knowledgeable enough about trigger points to be able to diagnose and treat them appropriately. TPs do not show on Xrays, CT scans, or MRIs.

Pain

Three types of pain have been found relating to trigger points. The lowest amplitude pain seems to stem from what are considered Latent TPs. A person may have latent TPs for weeks, months, or even years without knowing until the person happens to come across it arbitrarily. When pressed, the pain is localized and dull or achy. If the TP is not compressed, the pain disappears. Latent TPs may become active, although no one can say with certainty how or why. Some camps say that poor health, nutrition, injury or re-injury, inflammation, or infection can be the trigger that does it.

Another pain associated with trigger points is the sharp, debilitating pain from Active TPs. These do not seem to require pressure from an external source to send noxious afferent pain signals to the brain. They literally emanate pain signals constantly, unrelentingly. Most people do not seek medical help for latent trigger points, but the pain from active trigger points is sufficient to motivate people to seek help.

The third type of pain commonly seen with trigger points, or, more specifically, active trigger points, is that of referred pain. Active trigger points cause pain local to the point itself and surrounding tissue. However, they also cause pain to appear elsewhere in the body depending on where the trigger is located.

scalene trigger points

Fig. 4 – Scalene TP Referral map

Myofascial trigger point referred pain is well mapped and documented into referral patterns. These maps are handy for narrowing down the prospect of locating pain sources. Advantage is gained in looking at TP referral pattern maps because the practitioner can use the map in either direction. If an active TP can be located, it may be seen on a map and its referral pattern discovered. Similarly, if the referral area is known, the source trigger point may be traced using the map, shortening assessment time and getting treatment started as soon as possible.

Figure 4 shows an example of a referral pain map from trigger points located in the scalene muscles in the neck. The darker red areas highlight places where pain intensity is highest or strongest. It can be seen that TPs in the scalenes (marked by “x”‘s) may refer pain across the shoulder and down the outside of the arm, with the strongest sensations of pain appearing in one or all of the more dense red patches on the front and back of the upper arm, thumb and forefinger, over the breast and along the junction at the inside edge of the shoulder blade and back.

Intensity of referred pain runs the slalom from dull ache to debilitating, and depends on any number of factors as well as the individual and the individual’s tolerance to noxious stimuli.

Muscle Weakness

Another problem arising from trigger points is that they may weaken and neurally inhibit the muscles or portion of the muscles in which they live. Furthermore, they may cause the muscle or sections of fibers to become chronically contracted. This is different from a muscle spasm. In a spasm, the entire muscle is triggered to violently contract. Trigger points contract only those fibers in which fiber the contracture takes place.

Muscle weakness, particularly weakness in major movement muscles, set the body up for compensatory strain patterns to take place in order to keep the body functioning. And strain patterns may eventually cause facilitation or hypertonicity in secondary, agonist/antagonist muscles or other muscles in the kinetic movement chain.

Along with weakness may come a host of other nerve-related symptoms, such as tingling or numbness, changing temperature sensation, and “ghost” symptoms of a cardiac nature. In fact, by some professions, trigger points are considered to be great pain mimickers. According to the National Association of Myofascial Trigger Point Therapists, “…trigger points may actually be causing the painful symptoms attributed to…” arthritis and bulging discs, as well.

Limited Range of Motion

In combination with muscle weakness, range of motion problems develop with trigger points. When a muscle or portion of one becomes chronically stiff, tight and/or painful, arms and legs lose their extensibility and the neck may lose its ability to move. Functional muscle movement patterns may also become distorted.

Chronic pain patterns also have a way of causing the brain to look for compensatory movement patterns so as not to perpetuate the noxious afferent signals from the dysfunctional muscle and fascia. This starts a vicious pain-spasm-pain phenomenon, compounding the original problem by producing a self-feeding loop.

Other Symptoms and False Diagnoses

Trigger points may cause symptoms and physiological reactions such as sweating, tearing of eyes, goosebumps, dizziness, earaches, sinus congestion, nausea, heartburn, headaches, jaw pain, low back pain, symptoms of carpal tunnel syndrome, golf and tennis elbow, and many kinds of joint pain mistakenly blamed on arthritis, tendinitis, bursitis, or ligament injury.

The NAMTPT gives this list of many misdiagnoses attributable to TPs:

  • Back pain
  • Headaches
  • Neck pain
  • Rotator cuff (shoulder) pain
  • Jaw pain (TMJD)
  • Tennis elbow
  • Carpal tunnel syndrome
  • Hand and arm pain
  • Repetitive Strain Injuries
  • Pelvic pain
  • Hip pain
  • Sciatic pain
  • Leg and knee pain
  • Plantar fascitis
  • Tendinitis/tendinopathy
  • Bursitis
  • Arthritis
  • Disc pain (bulge/rupture/herniation) and radiculopathy
  • Frozen shoulder
  • Fibromyalgia

Skepticism

Some professionals, particularly in the conventional medicine area, are adamantly opposed to the whole theory of the trigger point, as pointed out early on this page. Part of the difficulty is that there is no conventional branch of medicine specializing in or working with dysfunctional muscle and fascia. The science isn’t there. Those of us in the complementary medicine camp wonder why, aside from the money to be made from pharmaceuticals, the science isn’t there. It is said that there’s not enough evidence, but is that because the evidence isn’t there or because they haven’t done enough studies?

I feel that the reason there hasn’t been enough pursuit into the study of muscle dysfunction and pain is because pain itself doesn’t actually exist. The perception of pain is a sensation the human brain comes up with to allow us to recognize the electrical impulses from sensory receptacles throughout the body to the brain as something the brain wants to avoid. Input for all senses is interpreted in much the same way. Since pain itself cannot be accurately measured and is somewhat different in every individual, this fails the typical scientific requirement for qualitative research. Thus, the medical community, both conventional and complementary, decided to use the individual’s perception of pain on a scale relative to that individual as their gauge to help manage pain.

Resolving Trigger Points

Trigger points can be resolved by self-massage, and this is probably the simplest and least expensive way to go. With Internet access so available these days, basic trigger points and pain referral patterns may be found online. You may also be able to find instructions online on how to proceed once you learn where to go. Or you may be able to treat yourself using your own intuition. Many people do precisely that.

Going to someone with experience in Trigger Point Therapy gives you the advantage of not having to research myotomes, dermatomes, and specific muscles and muscle movements in order to start looking for a trigger point. If you choose to go this route, be sure you interview the person you would like to see and ask if they have both education and experience in one of the Trigger Point or Neuromuscular therapies.

To Self-Treat:

Locate the “knot” you’re looking for. Try this website to help you find trigger points. Manchester-Bedford Myoskeletal LLC is not affiliated with that website, its owners, or site builders, and makes no guarantee or recommendation for that website or advice on it. The link may be broken or misdirected. It is simply placed here for reader’s convenience. You may be able to find other trigger point locators online.

To be sure you have the trigger point, press the knot in the most tender spot. If it is an active point, you may be able to reproduce the referral pain when you press it correctly. Do not allow the knot to shift beneath your pressure. The easiest way to do that is to trap the knot between your pressure and a bone or joint, or press it between two fingers.

Apply gentle pressure to the knot. From here, two schools of thought exist in how to treat. Static pressure and frictional massage.

Static pressure procedure: Hold the knot trapped for up to 30 seconds or until you feel it release (“pop” or “squash”), whichever comes first. If you do not feel the knot release within 30 seconds, either (1) you do not have the most tender spot trapped; (2) you’re using too much or too little pressure, or; (3) you do not have an actual trigger point. A fourth possibility is that the dysfunctional tissue has a long history. When this is the case, you may try the frictional massage procedure OR it may simply take a significantly longer number of treatments to dissolve.

Frictional massage procedure: Use your finger, thumb, or tool to press into the knot from the side and slide across the knot in one direction only, dragging the skin along. If you slide across skin, it will hurt more and become aggravated itself, or it will become chafed and red, resulting in damage to the skin. Use a pace of about 1 stroke across the knot per second for about one minute, then stop. Do not work a trigger point any longer than one minute. Repeat this procedure 6 to 12 times per day until the knot dissolves.

After treating using either procedure, use moist heat on the area worked for 5 minutes. Be sure the heat is not too high.

After the moist heat application, move the affected muscle without additional weight. For instance, if you worked a muscle in the right side neck flexors, slowly stretch the flexor by extending your neck, laterally flexing and rotating it. If you worked a bicep, stretch that muscle by extending your arm at the elbow first, then, with a locked elbow, extend the entire arm at the shoulder so that you feel a good stretch in the bicep.

Note: Trigger Point Therapy as a modality is not offered at Manchester-Bedford Myoskeletal.