Jeff Watson LMT, CSP
Trigger Point Therapy . Osteopathic Muscle Energy Technique . Myofascial Release
Trigger Point Therapy
Trigger point therapy is a therapeutic modality discovered by medical doctors that is used to treat muscular pain and dysfunction. Former White House Physician Janet Travell, M.D. along with David Simons, M.D. who together published the Trigger Point Manuals, were the two most prominent physicians in the field. Trigger points are tender points or “knots” that form in muscle tissue causing pain, weakness and limited range of motion. In most cases, trigger points are caused by trauma to or the overuse of muscle fibers. Pain from trigger points while not medically an emergency can be extremely debilitating and exhausting for the person suffering from them. Often the pain from a trigger point is mistakenly called “a pinched nerve” by lay people and even by some medical professionals. Although sometimes quite excruciating, the pain from a trigger point has nothing to do with nerve pathology. Trigger points can be treated by a number of varying techniques. Some of the more commonly used are; massage techniques, stretching with or without intermittent cold stimulation and injection of local anesthetics.
For more in-depth information on Trigger Point Therapy please read the "Myofascial Trigger Point Pain" article below. Health-care professionals may prefer to read the "Diagnosing Myofascial Trigger Point Pain" article which can be found on the Physician's Page.
Osteopathic Muscle Energy Technique
Muscle energy technique was developed in the 1950’s by Fred Mitchell, D.O. as a softer alternative to high velocity thrusting manipulation for joint pain and dysfunction. It uses the patient’s own muscle force or “energy” to slowly move the painful / dysfunctional joint back into proper position. Muscle energy technique often compliments trigger point therapy quite nicely because many times a patient presents with both muscle and joint pain / dysfunction at the same time.
Myofascial release is a type of soft tissue therapy that focuses on realigning deeper layers of muscles and connective tissue. This manipulation technique can be especially helpful for chronic aches and pains due to long-standing postural muscle imbalance.
Myofascial Trigger Point Pain
Myofascial Trigger Point Pain is just a fancy, confusing medical term for pain that is produced from a muscle(s) that is not functioning the way it should. In plain English the “myo” in myofascial means muscle, fascia is a thin tissue that surrounds and permeates muscles. Trigger points are small “knots” in muscles (myofascial tissue) that produce or “trigger” pain. These “knots” or trigger points form in muscle fibers from some kind of overload, overuse or mild trauma.
Trigger points in muscle(s) can produce pain, weakness, limited range of motion and sometimes sensory symptoms of tingling and numbness. Trigger points can develop in any of the over 400 paired muscles in the human body. However the muscles in and around the neck, shoulder, low back and hip regions are the most common sites.
Myofascial trigger point pain is responsible for numerous musculoskeletal symptoms and conditions: tension headaches, T.M.J. dysfunctions, stiff necks, low back pain, tendonitis, peripheral nerve entrapments, joint dysfunctions and most non orthopedic sports injuries. These are just a few of the many, and sometimes confusing, ways in which trigger point pain can present itself.
Trigger point therapy is not new. In fact the basic concept of myofascial trigger point pain has been around in medicine since the 1930’s. Many physicians from all over the world have contributed to the advancement of this medical specialty. Two of the most prominent doctors in the field were former White House Physician Dr. Janet Travell M.D. and Dr. David Simons M.D. Together they published, to date, the most significant manuals on the theory and practice relating to myofascial trigger point pain.
Trigger point therapy in the right hands of a skilled practitioner is a highly effective treatment for myofascial pain. It can take decades to truly master the concepts and techniques of the clinical application of the therapy. Unfortunately to date there has been no regulation for training and or of who can practice it. Many undereducated lay body workers lacking the ability to understand the medical concepts claim to do trigger point therapy. In an effort to seek fame and fortune a enterprising few have even tried to “simplify and rebrand" it.
They in turn pass themselves off as experts, write books and teach their new “easy and improved” (dumbed down) version. Regrettable this leads to distorting Travell and Simons’ original pioneering work, from a extremely effective medical procedure into a pseudoscience side show. The uninformed public seeking relief from the practitioners of these programs often get poor results. Sadly people suffering with myofascial pain can come away thinking that trigger point therapy is ineffectual for their condition when in reality they were treated by a poorly trained therapist.
The muscle(s) affected by trigger points are not physically damaged. They are not “sprained or ruptured,” which can happen with severe muscular trauma (think of a hamstring pull). Instead the pain comes from dysfunction of the microscopic parts of the muscle (sarcomeres) that are responsible for muscle contractions. The pain from trigger points can be just as intense as or even worse than the pain from physically damaged muscles. Trigger point pain is far more common than muscle tissue sprains or ruptures.
Myofascial trigger point pain is also not the same as muscle spasm and cramping. The pain from trigger points is from abnormally short sarcomeres causing some of the fibers in a muscle to be tight and painful. This happens within the affected muscle itself without any influence from your central nervous system. Spasm and cramping is caused by a “spasm” signal sent from your nervous system to cause a muscle to shorten. This is usually a reflexive move by your nervous system to protect a muscle, tendon or joint from possible damage.
Although an initial spasm signal is not painful, it can progress to become a cramp, which can be quite painful. There are many conditions not involving trigger points that can cause muscles to spasm and cramp. However, if myofascial trigger point pain is extremely severe it can also cause the nervous system to send a spasm signal. If the signal is strong enough to become a cramp then an additional layer of pain is added to the myofascial pain.
Trigger points and the pain and dysfunction they produce are often mistakenly called a “pinched nerve” by lay people and even sometimes by medical professionals. This is especially true with trigger point pain in and around the neck and shoulders. Medically there is no such thing as a “pinched nerve.” There are impinged spinal nerve roots from disk pathology or stenosis. There are also entrapped nerves from a tight muscle overlying a nerve. Both of these conditions will produce characteristic neurological pain, numbness or dysfunction that is distinctly different than the more common pain from trigger points.
Unfortunately, myofascial trigger point pain can sometimes be hard to diagnose. This is because of the many different and confusing ways that it can manifest. Additionally to date, there is no quick and easy way to image the condition. M.R.I’s, C.A.T. scans and Diagnostic Ultrasound can’t “see” trigger points because there is no tissue damage involved.
Remember Trigger points are a dysfunction of the contraction process in muscle tissue. The muscle tissue is not damaged as it is with a sprain or rupture. Muscle tissue damage does show up with present day imaging techniques. Physical examination by someone who has the experience and training with myofascial trigger point pain is presently the only way to diagnose the condition.
Because of the present-day inability to image myofascial trigger points, insurance companies and even some doctors don’t recognize it as a real medical condition. Prior to the invention of the x-ray machine in 1895, doctors couldn’t image bone fractures or tumors either. No one today would doubt that these are real medical conditions, plaguing humanity long before x-rays “proved” their existence.
Someday someone will invent a “dynamic” M.R.I. machine that is capable of taking moving images of living tissue. Today’s technology is a limited “static” frame by frame picture process. With a new diagnostic capacity we will be able to see tissue physiology in action. Using this “dynamic” M.R.I. machine, while moving an affected muscle through a full range of motion, will easily allow us to image trigger points.
Nature of Trigger Points
Trigger points are classified as either active (causing pain with muscle use) or latent (no active pain, just limited range of motion). Both active and latent trigger points will feel sore to the touch when pressed on. They can also refer pain away from their location and to the site where you perceive your problem.
If an active trigger point becomes extremely irritated it can produce pain even when you are not using the muscle. Trigger points are always found in a taut band of fibers within the affected muscle. The formation of a taut band always precedes the development of trigger points, and can also by itself cause restricted movement, but no pain.
Normal Taunt Band Latent TrP Active TrP Extremely Active TrP
Muscle → → → →
Limited motion Limited motion, Limited motion Limited motion,
no pain. pain only from and pain with pain with use and
pressing on TrP. use. pain at rest.
More Common → → → → → → → → Less Common
Unlike when muscle damage occurs, you may not be aware of how or when you first develop trigger points. There is often a delayed onset of the symptoms from trigger points. It can take a few hours to several days after the initial event for these to surface. This phenomena can cause confusion when trying to figure out what you did to cause your trigger point pain to develop.
As mentioned above, the pain produced from trigger points is usually referred to a different location distant to where the problem lies. This can also be confusing for the trigger point pain patient. Most of the time the location where you feel your pain is not in the same location where the trigger point causing the pain is “hiding.” Thanks to the pioneering work of Drs. Janet Travell M.D., Seymour Rinzler M.D. and David Simons M.D., there are “pain maps” to help locate the target muscle and it’s trigger point(s) causing the problem.
Unlike severe muscle trauma which always heals with time, trigger points may or may not get better without treatment. Left untreated there are three possible outcomes for an active trigger point. With reduced activity and time (2-4 weeks), some trigger points will go on to recover fully without any intervention. A few trigger points that are not addressed will progress into a chronic condition. Others, and probably the majority, will go "dormant" deceptively calming down to a latent pain free stage only to reactivate at a later time.
Progression of Development
Normal Taut Band Taut Band Taut Band Taut Band
Muscle Onset → with → with → with → with
No TrP Latent TrP Active TrP Extremely Active TrP
ǀ← ← ← ‖ ← ← ← ← Recovery
Latent Pain-Free Threshold
* To date the concept of trigger point development has been observed clinically but remains untested experimentally.
There is no way to precisely predict how a trigger point will respond without treatment. As mentioned above some trigger points can be self-recovering. If the trigger point is “fresh,” and a “first time offender,” involving a single muscle, then there is a reasonable chance that it can recover without therapy. If however the trigger point pain has been active for a while, and is a “repeat offender,” involving multi muscles, it is extremely unlikely to recover without considerable intervention.
The muscle(s) that harbor trigger points can sometimes get “stuck” sustaining the panful dysfunction. This can be due to perpetuating factors separate from the events that initially caused the trigger point(s) to form. Perpetuating factors have to be identified and addressed to insure complete recovery.
Perpetuating factors can be caused by variations in your skeletal symmetry, postural work habits, emotional stress and sometimes nutritional deficiencies. Trigger points can be perpetuated in either an active (painful) or latent (pain free) state, or can shift or cycle back and forth from active to latent.
This process of “cycling” can, as mentioned, be deceptive, in that the painful, active trigger point(s) often calm down to a pain-free latent stage. The patient can mistakenly assume that they are fully recovered. Weeks, months or even years later the trigger point pain can resurface when conditions are right.
This cycle of latent pain-free trigger points activating to a painful state, and then calming down again, can go on for decades. It is because of this tendency of latent/active cycling that you need to continue to follow home therapy instructions beyond the “latent pain free threshold” to ensure full recovery.
Tight muscles from trigger points can in turn cause three distinct secondary painful conditions to occur: joint dysfunctions, peripheral nerve entrapment syndromes, and tendonitis. All three can add confusing and frustrating layers to the musculoskeletal pain you may be experiencing. These three conditions can present with or without the classic trigger point referred pain patterns. This depends on whether or not the trigger point(s) in the involved muscle are active or latent.
Joint dysfunction and the pain it presents is usually the indirect result of trigger points in dysfunctional muscles acting adversely on the way a joint(s) moves. The most common joints to be affected are the joints of the spine. The sacroiliac joint is also a very common joint to undergo joint dysfunction and can contribute significantly to low back pain. However the SI joint can become dysfunctional all on it’s own, and may or may not include a myofascial trigger point component.
Peripheral nerve entrapments can occur when a muscle with an active or latent trigger point(s) shortens and clamps down on a nerve that lies beneath it. This condition can mimic all the same neurological symptoms of a compromised nerve root. Treatment of the trigger point(s) in the involved muscle is necessary for the neurological symptoms to recover.
Tendonitis can arise when a muscle shortened by trigger points puts undue and persistent force on it’s tendon attachment. Over time this causes inflammation and degenerative changes (tendonitis) to occur to the tendon. Trying to simply treat the local tendonitis without simultaneously treating the trigger points is unlikely to lead to lasting, full recovery.
Analgesics (e.g., Tylenol) and anti-inflammatory drugs (e.g., Ibuprofen) usually have marginal effect on myofascial trigger point pain. They do not directly address the dysfunction within the muscle fibers causing the problem. They only help to manage some of the pain perception from the condition. Muscle relaxants (e.g., Valium) also do not affect the cause of myofascial trigger point pain. They limit the nerve impulses to muscles that can cause painful spasm and cramping to occur. Muscle relaxants however can sometimes prove beneficial, if the trigger point pain is so severe that muscle spasm and cramping accompanies your myofascial pain.
The treatment of myofascial trigger point pain and dysfunction and its associated syndromes of joint dysfunction, peripheral nerve entrapment and tendonitis can be accomplished through several methods. Specific manual manipulation techniques, augmented stretching, and injection of local anesthetics are some of the more common options. Augmented stretching involves adding the application of intermittent cold, or by including techniques that induce neural reflexes that enhance the efficacy of the stretch. In the case of early onset pain, most single-muscle myofascial trigger point pain syndromes can be eliminated with just simple stretching.
All myofascial trigger point pain concepts are from the following sources:
Mense S., Simons DG: Muscle Pain Understanding Its Nature, Diagnosis, and Treatment, Lippincott Williams & Wilkins, 2001.
Travell JG, Rinzler SH: The myofascial genesis of pain. Postgrad Med 11:425 – 434, 1952
Travell JG., Simons DG: Myofascial pain and Dysfunction: The Trigger Point Manual, Volume 1. Upper Half of the Body. Ed. 2 Williams & Wilkins, Baltimore, 1999.
Travell & Simons: Myofascial Pain and Dysfunction: The Trigger Point Manual, Volumes 1 & 2, Williams & Wilkins, Baltimore, 1983 & 1992
Mense S., Gerwin RD: Muscle Pain: Understanding the Mechanisms, Springer 2010
Mense S., Gerwin RD: Muscle Pain: Diagnosis and Treatment, Springer 2010
Greenman PE: Principles of Manual Medicine, 2nd ed., Williams & Wilkins 1996