Information about Trigger Points and their Treatment
Compiled by Dr Diana Cross
What are trigger points [TPs]?
A trigger point is simply a small contraction knot in muscle. This knot feels like a pea buried deep in the muscle, and can feel as big as a thumb. It maintains a hard contraction on the muscle fibres connected to it, thus causing a tight band that can also be felt in the muscle. These trigger points in muscles and in the thin wrapping around each muscle [called fascia] are called myofascial trigger points, to distinguish them from trigger points which can occur in other soft tissues such as skin, ligaments and tendons, and also in scar tissue.
Are TPs the same as a muscle spasm or strain or tear?
No, a TP is not the same thing as a muscle spasm. A spasm involves a violent contraction of the whole muscle, whereas a TP is contraction in only a small part of a muscle. A strain or tear involves physical damage to the muscle or tendon fibres, Such damage has not been demonstrated in studies of TPs. [However, such injuries may predispose one to developing TPs there later on.]
Why are they called trigger points?
Pulling the trigger of a gun makes a noise in the gun but it also sends out a bullet that causes pain at a distant target site. Pressing firmly on muscle TPs hurts right where you are pressing, making you jump, wince and pull away. But, more importantly, TPs also send ['refer'] pain or tenderness to some other site, often quite far away. So, for example, a headache may not be caused by a problem in the head itself, but have been sent to the head from a TP on the side of the neck. Never assume the problem is at the place that hurts.
What does this referred pain feel like?
The referred pain caused by TPs is usually steady, dull and aching, often deep. It may occur at rest, or only on movement. It varies from being a low-grade discomfort to being severe and incapacitating.
Are TPs common?
Myofascial trigger points are among the most common, yet poorly recognised and inadequately managed, causes of musculoskeletal pain seen in medical practice. Unfortunately, many general practitioners and orthopaedic surgeons do not know about TPs, and as TPs do not show on XRays or scans, the patient may be told there is nothing wrong with them or that there is nothing that can be done to help fix their pain.
What common conditions are thought to be due to referred pain from TPs?
TPs are known to cause or contribute to headaches, neck and jaw pain, low back pain, the symptoms of carpal tunnel syndrome and tennis elbow, and many kinds of joint pain mistakenly ascribed to arthritis, tendonitis, bursitis, or ligament injury.
What other symptoms may TPs cause?
Apart from pain, TPs may cause numbness, tingling, weakness, or lack of normal range of movement. TPs can also cause earaches, dizziness, sinus congestion, nausea, heartburn, and false heart pain. And they may result in depression if pain has been chronic.
How can one know where the TPs are?
It is important to realize that the TPs themselves do not hurt, [other than when you are actually pressing firmly on them.] In other words, the gun has a silencer on it, so you don't know there is a gun or that it is being fired. You only know that you're wounded. Most patients are surprised when I locate a very painful tight spot in a muscle well away from where they tell me their pain is. They were usually completely unaware that this painful tight spot even existed, let alone that such a small spot could be the cause of all their pain.
So how did I know where to find that spot?
Fortunately, referred pain occurs in predictable patterns, which have been clearly mapped out in The Trigger Point Manual by Simons and Travell. Using their maps I know which areas to search for the TPs that characteristically send pain to the place where you are hurting. I then feel for a tight muscle in that area, feel for tight bands within that muscle, and localize an area within the band which is exquisitely tender and that is the TP. As I press or twang it, the muscle may twitch. As I keep pressure on it, it will cause your usual referred pain, thus confirming that we've got the spot.
Could there be more than one TP causing my problem?
Yes, TPs tend to gang together, so in practice it is common to find more than one TP in the tight muscle, and more than one muscle whose TPs refer pain to the area where you are hurting. All your TPs need to be hunted out and treated before you'll gain full relief of your symptoms. I will show you the relevant TPs for your problem, and after a while you'll become expert at finding them for yourself. .
What causes TPs to develop?
All of us develop tight bands in our muscles as we age, but some people have more than others, for various reasons that are listed in the red box labelled: 'Predisposing factors'. Then, some of these tight bands go on to develop TPs in them, when one or more 'Precipitating factors' arise. For example, a TP may develop following an acute muscular strain such as during a car accident, a fall, a sprain or fracture, or excessive or unusual exercise. Or following chronic overload of the muscles used to maintain posture because of poor sitting, working or sleeping habits, or by repetitive work tasks.
Could poor general health be making my TPs even worse?
Yes, particularly if your pain has been happening awhile, it is very likely that one or more of the following 'Perpetuating factors' is present: 7 Mechanical stresses such as a short leg, flat foot, poor posture, or immobility. 7 Nerve root pressure, eg sciatica. 7 Chronic internal diseases, and some prescription medications. 7 Nutritional deficiencies, especially vitamins C, B-complex and iron. 7 Hormone imbalances [low thyroid hormone levels, premenstrual or menopausal] 7 Infections [bacterial, viral or yeast] 7 Allergies [wheat and dairy in particular] 7 Poor oxygenation of tissues [aggravated by tension, stress, inactivity, poor sleep, smoking ] These factors MUST be detected and corrected if specific treatment of the TPs is to be successful or lasting, so your doctor will spend some time sorting these out with you. Chronic fatigue syndrome and fibromyalgia also predispose one to develop TPs, [in addition to all the other tender spots characteristic of those conditions].
So how long will the pain take to get better?
With TPs of recent onset, significant relief of symptoms often comes in just minutes, and most acute problems can be eliminated within 3 to 10 days. But longer-standing chronic conditions are more complex and less responsive to treatment. None the less, even some of these problems can be cleared [in as little as 6 weeks] IF you persist with treatment AND if you fix the Perpetuating factors referred to above.
How are TPs treated?
TPs can be treated in a number of different ways, depending on the speciality or training of the practitioner. Doctors may use local anaesthetic, saline, or cortisone injections, but acupuncture needling, use of a cold spray whilst stretching the muscle, or specific trigger point massage also works. Some physiotherapists or masseurs have a real knack in treating TPs, and I can guide you as to who they are. However there are good reasons to learn how to apply trigger point massage to yourself. With self-treatment you don't have to wait for an appointment, you can get help whenever you need it, and you don't pay a cent. You can be the expert in knowing how to get rid of your own pain.
How does massage work?
In 3 ways: 7 Massage breaks into the self-sustaining vicious circle that has kept the muscle contracted. 7 It increases the circulation, which has been restricted in the immediate area by the contracted fibres, thus enabling oxygen and nutrients to flow to the spot. 7 It directly stretches the trigger point's knotted muscle fibres.
What's the best way to massage them?
The Trigger Point Therapy Workbook by Clair Davies gives the following guidelines: 1. Use a tool if possible [such as a firm rubber ball] and save your hands. 2. Use deep stroking massage, [a repeated milking action] not static pressure. 3. Massage with short repeated strokes, moving the skin with your fingers, and releasing at the end of each stroke to go back to the starting point. 4. Do the massage stroke in one direction only, whether with the grain of the fibres or across them. 5. Do the massage stroke slowly, no more than one stroke per second. 6. Aim at a pain level of 7 on a scale of 1 to 10. 7. Limit massage to one minute per trigger point. 8. Work a trigger point 6 to 12 times per day, until pressure on it elicits a pain level of only 2 or 3. 9. If you get no relief, you may be working the wrong spot. Is there anything more I need to do after massage has relieved the symptoms? Yes. After massage it is very important to: 7 Apply a hot pack covered with a dampened flannel or towel to the treated area for a few minutes. 7 Then gradually and gently stretch the treated muscle through its full range of movement 3 times, with a pause to deep breathe and consciously relax between each cycle.
What else can I do or avoid to achieve lasting recovery?
- Learn respect for your muscles. They were not designed to be held for long periods in a sustained contraction or in a fixed position. Vary your tasks each day. Lift very carefully.
- Slow your working pace, and take short rests frequently, especially if feeling muscle fatigue.
- Do a daily program of passive stretches that puts the affected muscles through a full range of movement, and repeat the stretches throughout the day. Be like the cat-- it rarely tries to walk after a sleep without first stretching smoothly and slowly.
- Massage any TPs up to a dozen times a day, for a minute at a time, as described above.
- Learn relaxation techniques, [eg yoga, meditation].
- Always watch your posture when sitting, reading, using the computer car or phone. Don't stay too long in any one position.
- Work out what particular postures, movements and activities stir up your TPs. If you don't have to do that activity, then don't. If you do, then modify how its done.[eg use the other hand].
- Avoid getting the muscles cold, by wearing an extra warm layer of clothing, and adjusting heating etc.
- Correct any imbalances in your diet, and take vitamin and mineral supplements as recommended by your doctor.
What about exercise?
Exercise should be regarded as a prescription, and the kind of exercise prescribed depends largely on how active your TPs are at that time. Your physio will give you the details.
- When the TPs are very active and you have pain at rest, then gentle stretches and hot packs are your limit
- Once the TPs are inactivated and constant rest pain fades, then a carefully graded exercise program is needed to increase muscle endurance and strength. This involves muscle lengthening exercises [adding a new exercise on alternate days], before working up to shortening exercises. Post-exercise soreness and stiffness should not last longer than 3 days or the program needs altering.
- Then a regular conditioning program is recommended, at least twice a week, for example swimming or cycling.
Would the TPs get better if I just rested up?
Yes and no. Studies have shown that with a short period of rest and the avoidance of whatever activated the trigger point, the pain symptoms may disappear over a few weeks. This makes people believe their problems have gone away. But, if you examine the muscle properly you will find it is still tight stiff and weak, and still tender when pressed on. In other words, the TPs are still there; they are just lying dormant [latent], and not causing referred pain at that time. The bad news is that they can be very easily reactivated to cause pain again, by acutely overloading the muscle in a new or repetitive task, working or sleeping in an awkward position, chilling the muscle, or during emotional stress, fatigue, or viral infections. How much it takes to reactivate a latent TP will depend on the degree of muscle conditioning, so keeping fit can help reduce the likelihood of this. But the only way to get rid of the TPs for lasting relief is through actively hunting out and treating all the active and latent TPs. Although this involves more effort, its truly worth it in order to escape "the endless replay" of TP pain.
Travell J., Simons D.: Myofascial Pain and
Dysfunction, the trigger point manual, Vol 1 & 2.Williams and
Wilkins 1982 Davies C.
The Trigger Point Therapy Workbook, your self-treatment guide for pain relief. New Harbinger publications 2001
Trigger Point Diagram Cascade for Diagnosis and Management
(Large page download 96k )
By Dr D Cross