About Trigger Points and Referred Pain
It’s Probably Not an Injury — But it Hurts Like OneTrigger points are microscopic areas of stagnation in muscle fibers. They are very common, cause a mysterious and extensive array of pain and other symptoms, and are a mystery to most practitioners. Even though myofascial trigger points have been researched and documented by physicians since the 1940s, they still have not achieved wide acceptance or understanding in the health community. Unfortunately, they are also responsible for the vast majority of pain complaints that people experience. There are multiple reasons for this lack of attention. In spite of the landmark publication of the 2-volume Trigger Point Manual by two MDs, Janet Travell and David Simons in the 80s and 90s, the science of pain referral is only beginning to be understood with modern advancements in neuroscience, and some medical people are uncomfortable with the “soft science” of pain referral. Recent advances, however have moved the science along dramatically. The clinical evidence is undeniable. Sadly, trigger point therapy is given short shrift in schools where it should be taught as an important core discipline — medical, dental, bodywork, massage, physical therapy schools may mention it briefly, but students are left with a feeling that it’s just another minor modality. And it’s not a trivial matter to practice trigger point therapy competently. The practitioner needs a solid basis in functional anatomy, be very familiar with locating muscles very specifically and must be able to palpate them for tenderness, know their referral patterns, change the length of the muscle, have effective treatment techniques and have access to a range of reference materials. Many practitioners are poorly trained, incorporate “a little” trigger point therapy in their work, are ineffective, and never realize its full potential.
Basic Trigger Point Physiology
Physiologically, trigger points are very small, microscopic encapsulations within specific muscle fibers that develop when a muscle has been placed under chronic or acute stress that overloads the muscle. Toxic chemicals develop near the area where motor nerves join the muscle fiber, and local edema develops which then prevents the capillaries from providing some essential metabolic activity to the area. The result is that nociceptive, or noxious signals get sent back to the central nervous system, and the body doesn’t know how to process this information. The area of the trigger point itself is tender to compression, but the patient wouldn’t know this unless they happen to press on it.Trigger points occur in single muscle fibers, and groups of them tend to cluster in bundles of fibers near the motor endplate, where the motor nerve connects with the muscle. The affected fiber bundle remains in an artificial condition of engagement due to the bio-electric effects of the sensitizing chemicals. These bundles are known as taut fibers and can be clearly palpated as hard, ropy tissues, which harbor tenderness near the center of the fiber. Trigger point physiology can no longer be dismissed by the medical establishment as “soft science”. Researchers are engaged in studies to understand the microcellular processes and compounds that go into trigger point pathophysiology. Of particular note is the work of Dr. Jay P. Shah of the National Institutes of Health, who has been engaged in microdialysis of the chemical environment in the immediate locale of trigger points and has greatly furthered our understanding of referral and the associated phenomena.
A common CNS response in the face of ongoing nociceptive input is for the CNS to up-regulate and get more sensitive – a process that can happen in 15-20 minutes. Soon the patient begins to feel pain in a completely different area, often over joints, sometimes when specific movements are made. This is known as pain referral, and is thought to occur when new synapses are turned on as a protective response. This is due to the CNS perception of potential danger or “injury”.
To the patient, the pain is experienced very vividly and convincingly where it’s felt, not where the trigger point is located – except in the minority of situations in which the trigger point refers more locally.
Perception Determines Treatment – The Illusion of InjuryPain referral is very confusing to untrained practitioners. There is actually no tissue damage other than cellular level imbalances and stagnation – and these can easily be addressed without invasive procedures. However, most practitioners will automatically assume that the pain is due to an actual injury. Imaging results will often confirm that something is not normal in the area of the joint, which unfortunately often means very little. This misinterpretation of pain leads to the well-worn treatments that so often fail or make things worse — icing the area, steroid injections, NSAIDs, and surgery. Statistically, Drs. Travell & Simons cite several studies showing that the vast majority – in excess of 85% – of pain complaints presenting in pain clinics were due to myofascial trigger points and could easily have been addressed had the practitioners been competently trained in these techniques. This is consistent with the results we get in our clinic. There are very few people that we cannot help dramatically. Trigger points can be resolved through a number of different approaches. Generally, the trigger point area has to be mechanically or electrically stimulated and proper metabolism restored, and then the muscle needs to be put through full ROM, eventually without pain. Doing this well is a craft and an art, and relatively few therapists are competent at it. It isn’t enough to simply press on a tender point and move on, because the body’s neurological adaptations over time tend to reduce movement. The system must be re-trained in the experience of pain-free movement, and the positive neuroplastic abilities of the nervous system must be engaged.
Coaching the Body – Treating Trigger Points with Compression and MovementChuck Duff developed Clinical Thai Bodywork, now called Coaching the Body, as a way to use the efficient techniques of traditional Thai massage as tools to treat trigger points. Traditional Thai massage without the clinical framework of CTB does not consider muscles and is not oriented toward dealing with specific pain complaints. The Thai techniques within CTB are guided by in-depth knowledge of trigger point theory, working muscles into shortening and length, and restoration of conscious, pain-free movement. CTB uses treatment configurations in which the practitioner can easily manipulate muscle length, compress tender points and often work antagonist muscle groups as well. Our CTBP Certification program trains practitioners in a repertoire of techniques as well as providing an in-depth education in Travell & Simons-based trigger point therapy. For those of us who practice trigger point therapy at a high level and see lives changed every day, it isn’t “one more modality”. It is an incredible tool for understanding and treating the origins of a large percentage of pain complaints. However, practitioners need enough knowledge, hands-on training and clinical experience to be able to achieve a high-percentage chance at success with a given client.
Confusing Symptoms Lead to Ineffective Treatments for Pain
The world is slow to change. Pain is an area in which our western medical system doesn’t have great success. Many aspects of trigger point-induced symptoms are very confusing for doctors, PTs, chiropractors, massage therapists and others:
- Trigger points send their pain the vast majority of time away from the location of the trigger point itself. This means that it is generally useless to “rub it where it hurts”.
- Referred pain frequently occurs over and in joints, setting medical personnel off on a wild goose chase to discover the source of the “injury”. Shoulder and knee pain are very common examples of this.
- Trigger points cause not only pain but chronic muscle shortening, producing postural distortions which then set up secondary issues.
- Referred sensation is not restricted to pain, but can include tingling, coldness, numbness, weakness, lack of coordination, and jerky movement. It is tempting to explain these phenomena neurologically with theories of nerve impingement at the spine and other areas, but most often this is not the origin of the pain. Typical misdiagnoses might include carpal tunnel syndrome, sciatic nerve impingement, radiculopathy, disc degeneration, and the like.
- Trigger point referral comes and goes in a confusing manner due to the thresholding nature of referred pain.
- Satellite referral is a common occurrence in which muscles refer pain to other muscles, which then cause their own referral — this can go through many levels and even experienced trigger point therapists miss these patterns.
- When a network of myofascial trigger points is left to develop over time, it generally gets worse and becomes a myofascial pain syndrome. This can mimic a host of systemic conditions, including fibromyalgia, auto-immune diseases, infectious diseases and the like.
- Over time, the consistent, ongoing nociceptive input from trigger points can cause the nervous system to enter a chronicity phase, in which pain becomes constant and highly resistant to even the most powerful opiate drugs. At this point, pain is a brain response and is unrelated to the original inputs. This can lead to overall decline in quality of life and eventually death.