Beyond The Trigger Point Hype
This is a trigger point, but there is more to it than the medical definition: a hyper-irritable spot in fascia surrounding musculoskeletal tissue - muscle belly, attachments or the fascia itself
They can be identified by palpation, pain patterns or loss of strength and range of motion.
Because there is an impact to the soft tissue or is linked to musculoskeletal pain, They can be reset and released for pain reduction, increased range of motion and prevention of injury. The release feels like a small twitch in the muscle, but no contraction. unlike spasms, they do not involve the whole muscle.
They are NOT caused by trauma, inflammation, degeneration or infection – but they can develop as the body protects itself from these things.
There is a nervous system involvement – but they cannot be explained through a neurological examination.
Soft Tissue and Pain Treatments
How Understanding Pain Can Benefit Therapy
"Soft Tissue Release is only part of the equation, but if you don’t achieve it – full recovery may not be possible!"
Pain is usually the natural consequence of tissue injury resulting is one of the biggest reasons why manual therapy and therapeutic intervention can be critical to a successful recover. In general, as the healing process commences, the pain and tenderness associated with the injury will resolve. Unfortunately, some individuals experience pain without an obvious injury or suffer protracted pain that persists for months or years after the initial insult. This pain condition is usually neuropathic in nature and accounts for large numbers of patients presenting to pain clinics with chronic, non–malignant pain.
What they do not consider, in the attempts to control, improve or ‘get rid of it,’ Pain is the nervous system functioning properly to sound an alarm regarding tissue injury or potential injury which may be related to ongoing structural or imbalance in the body. The idea that neuropathic pain from the peripheral (PNS) or central nervous system (CNS) malfunctioning can become the single greatest gift in resolving the cause of the pain.
Acute pain and chronic pain differ in their etiology, pathophysiology, diagnosis and treatment. Acute pain is self–limiting and serves a protective biological function by acting as a warning of on–going tissue damage.
Chronic pain, on the other hand, serves no protective biological function. Rather than being the symptom of a disease process, chronic pain is itself a disease process. Nociceptive pain is mediated by receptors (messages are transferred to PNS) and fibers which are in skin, bone, connective tissue, muscle and viscera. It affects the sensitivity of any of these structures.
Nociceptive pain can be somatic or visceral in nature. Somatic pain tends to be well localized, constant pain that is described as sharp, aching, throbbing, or gnawing. Visceral pain, on the other hand, tends to be vague in distribution, paroxysmal in nature and is usually described as deep, aching, squeezing and colicky in nature. It affects the ability of the muscle to ‘act,’ and in turn affect the physiology of the musculoskeletal structure (i.e. Knots, adhesions, contractures). This failure of the receptors in the body becomes the primary location for trigger points.
Neuropathic pain, in contrast to nociceptive pain, is described as "burning", "electric", "tingling", and "shooting" in nature. It can be continuous or paroxysmal. Whereas nociceptive pain is caused by the stimulation of peripheral receptors due to introduction of biochemical compounds produced by the body, neuropathic pain is produced by damage to, or pathological changes in the peripheral or central nervous systems.
The mechanisms involved in neuropathic pain are complex and involve both pathologic impact to peripheral and central nervous system phenomenon. The underlying dysfunction may involve deafferentation within the peripheral nervous system (e.g. neuropathy), deafferentation within the central nervous system (e.g. post–thalamic stroke) or an imbalance between the two (e.g. phantom limb pain).
Following a peripheral nerve injury (e.g. crush, stretch, or axotomy) sensitization occurs which is characterized by spontaneous activity of the neuron, a lowered threshold for activation and increased response to a given stimulus – PAIN arrives. Following nerve injury nerve fiber can develop new receptors and sensitivity (slowly 1mm/month), which may help to explain the mechanism of sympathetically maintained pain and then subsequent decrease without treatment.
Following a peripheral nerve injury, anatomical and neuro–chemical changes can occur within the central nervous system (CNS) that can persist long after the injury has healed. The "CNS plasticity" may play an important role in the evolution of chronic, neuropathic pain. As is the case in the periphery, sensitization of neurons can occur following peripheral tissue damage and this is characterized by an increased spontaneous activity, a decreased threshold and an increased responsivity to afferent input, and cell death – MORE PAIN arrives.
So now you’re wondering what you can do – if anything – to reduce sensitivity, manage pain or reduce chronic conditions and live normally. Early recognition and aggressive management of neuropathic pain is critical to successful outcome. Often multiple treatment modalities are needed and should be provided by an interdisciplinary management team. Numerous treatment modalities available include systemic medication, physical modalities (e.g. physical rehabilitation), psychological modalities (e.g. behavior modification, relaxation training), and various surgical techniques (as a last resort). It should be noted that caution is warranted regarding the use of invasive techniques. Such approaches may produce deafferentation and exacerbate the underlying neuropathic mechanisms.
Manual Therapy Impact
Why therapeutic treatment of muscles works
Neuromuscular Therapy (NMT) is an approach to soft tissue release and manual therapy that involves quasi-static pressure that is applied to soft tissue to stimulate skeletal striated issues (i.e. Adhesions, Trigger Points).
You cannot strengthen a muscle that has a trigger point, because the muscle is already physiologically contracted. attempts to strengthen a muscle with trigger points will only cause the trigger point to worsen.
*Devin Starlaynt, MD author of Fibromyalgia and chronic myofascial Pain: A Survivor’s guide
Through applied knowledge of Anatomy and Physiology, Kinesiology, Trigger Point physiology and trigger point development – i.e. Ergonomic or biopsychosocial influences, neuromuscular therapy treatments are designed to address postural distortion (i.e. Rolfing focuses on poor posture), Functional Muscle dysfunction (Corrective exercise re-trains biomechanical challenges), movement and psychological impairments to movement (i.e. Somatic retraining and PNF – Proprioceptive Neuromuscular Facilitation stretch). Both Nerve Compression syndrome or congestion and ischemia deal with the musculoskeletal impact on other areas of the body: nerves, veins and arteries. Remember, when normal distribution and circulation is impaired all systems become impacted.
Because Myotherapy incorporates trigger point therapy, manipulation of soft tissue through massage, dry needling, and joint mobilization it has become an allied health discipline throughout the world. Therapists with this expertise will also use stretching, nutritional support, exercise, posture, heat and cold therapy as well as ultrasound and TENS (Transcutaneous Electrical Nerve Stimulation) to achieve the return to normal balanced activity they seek. Pain reduction is an off-shoot of the successful procedures.
Why is Soft Tissue Ignored?
Muscles as a system in the body, is not ‘owned or claimed’ by any Medical Specialty. Soft tissue treatments are taught in medical school – because they are generally NOT life-threatening. Muscles tissue is the largest organ in the body. Tissue complexity is well documented, and there are multitudes of ‘dysfunction,’ beyond Trigger Points and Myofascial Pain Syndrome where the “primary target of these activities creates the wear and tear of daily activities.” These show up as Repetitive Stress Injuries (RSI) and Cumulative Trauma Disorders (CDT), but nevertheless it is the bones, joints, bursae and nerves on which the medical community focuses.
Where Physical Therapists and Chiropractors are involved with joint dysfunction, biomechanics, and exercise therapy, they often emphasize these things at the expense of soft-tissue or muscles. They simply over-simplify muscle pain as a “sensory disorder,” which can easily affect people with apparently perfect bodies, posture and fitness levels. There is a lot of wasted time ‘treating’ patients, through various methods when a little pressure on key muscles or lengthening of the muscle itself will provide relief. Muscles release in and of itself cannot be expected to occur in a single session – although occasionally it may feel like that.
Massage Therapists in generally know surprisingly little about myofascial pain syndrome, because the training varies for every practitioner. When they become pre-occupied with symmetry and structure, then the ability to give relief may be hard to find. Outside of Neuromuscular therapists, common skilled treatment of Trigger Points and Myofascial Pain is very rare, but look for these individuals who have spent time and effort to begin to understand treatment and management of pain and you’re going in the right direction.
Myofascial Pain vs. Fibromyalgia
As a last point on the complexity of muscle pain, there is a common mistake in comparing Myofascial Pain and Fibromyalgia. Although unexplained FM might be a more clearly neurological disease, while MPS may be more of a problem of muscle tissue. They have related sets of unexplained symptoms, and they may be two sides of the same coin, with overlapping parts on an undefined spectrum of sensory malfunction, or different stages of the same process.
Do NOT confuse “tender points” of fibromyalgia with ‘trigger points’ in muscles – they are not even close. Whatever the similarities of these two causes or labels, therapeutic approaches for MPS seem to be helpful for some FM patients as well. Although pure FM cases seem to be mostly immune to manual therapy.
Muscles, Trigger Points and Referred Pain
In addition to minor aches and pains, muscle pain is often the cause of unusual symptoms in strange locations. For example, people diagnosed with Carpal Tunnel syndrome are experiencing pain caused by congestion of the nerves in the Armpit or Neck (brachial plexus).
Sciatica: often described as shooting pain in the buttocks and legs, this is caused by muscular tension of the piriformis or other gluteal muscles – which in turn irritates the sciatic nerve. Many other ‘trigger point problems’ are mistaken for some “kind of nerve problem.”
Chronic Jaw Pain (TMJ), Toothaches, earaches, Sinus Headaches, Ringing in the Ears (tinnitus), Dizziness and Allergies: these may ALL be symptoms of trigger points in the muscles around the jaw, face, head and neck. There are several large nerves (i.e. Trigeminal Nerve in the cheek near the TMJ, Occipital Nerves at the base of the skull) which when impacted created these types of issues due to muscle tension and dysfunction caused by trigger points.
Migraines or Headaches in general: Since there are over 300 types of headaches, let us just say that some muscle, somewhere in the neck can contribute to headaches given enough tension. There are obvious headaches that affect the Sternocleidomastoid (SCM) around the eyes, ears and back of the head. Then there are less obvious muscles like the Occipitals that just simply block or congest the blood flow to the brain enough to cause tension. There is no way to predict the pattern of a headache from one trigger point, because they may cause secondary sights with the muscles that they touch. Isolating and treating the group of muscles involved in any trigger point situation may take several attempts – it all depends on the client.
Trigger points have many strange “features,” and behaviors. Some people deal with trigger point pain better (i.e. Less resistant to) than others. It helps to have a competent therapist, who understands the discomfort around the treatments – most people who have had trigger point treatment will NOT over do the impact to the nervous system (or overstress the clients comfort level). Some discomfort should be expected. Because of their medical obscurity and confusion with many other problems, the trigger point discussion or diagnosis is often the last thing to be considered. Despite their clinical importance and many distinctive characteristics, muscle pain is NEVER the first problem people look at.
A diagnosis of Trigger Points or Myofascial Pain means that the primary source of your symptoms is from trigger points. Often trigger points are present secondary to other sources of pain: like arthritis or bulging discs. Trigger points may cause the painful symptoms attributed to these conditions. Here is a list of diagnoses which may be Trigger Point origins:
- Back Pain (lower, middle and upper)
- Neck pain/stiffness
- Rotator Cuff/shoulder pain
- Jaw Pain (TMJD)
- Tennis/Golfer’s Elbow
- Carpal Tunnel Syndrome
- Thoracic Outlet Syndrome
- Frozen Shoulder/Adhesive Capsulitis
- Repetitive Strain/Stress Injuries
- Pelvic Pain
- Hip Pain
- Sciatic Pain
- Knee Pain
- Ankle Pain/weakness
- Plantar Fasciitis
- Achille Tendonitis
- Disc Pain (bulge/rupture/herniation) or Radiculopathy
“Many researchers agree that acute trauma or repetitive micro-trauma may lead to the development of a trigger point. Lack of exercise, prolonged poor posture, vitamin deficiencies, sleep disturbance and joint problems may all predispose to the development of micro-traumas.” *David J. Alvarez, D.O. and Pamela G. Rockwell, D.O for American Family Physician
How Trigger Points are Formed
Far from damage to muscle and connective tissue, trigger points can arise from every day use. Although it takes about 7-10 years to constantly place enough stress for them to form, it can happen because of:
1) Repetitive overuse at home or work in activities like work at the computer, cell phone or gardening. These are using the same body parts hundreds of times daily without rest.
2) Sustained loading or stress like heavy lifting, wearing body armor, sustained tension when extending muscles (like reaching to pull things down or moving patients in bed).
3) Habitually poor posture or a sedentary lifestyle, that deconditions the body – or pushes people to overstrain their tired muscles after a week at work. Poorly designed furniture may also contribute.
4) Muscle clenching and tension do to mental/emotional stress.
5) Direct injuries from a blow, strain, break, twist or tear – car accidents and falls are critical situations to deal with immediately after they occur.
6) Inactivity for long periods in exceptional positions, or prolonged rest (i.e. Couch surfing) may also compromise the way the muscles respond.
The only way to deal with trigger points is with a skilled practitioner. There are no commonly available lab tests or imaging studies that can confirm the diagnosis. Myofascial pain can be regionalized or general. Trigger points can be Active (causing pain to touch) or Latent (impacting movement and pre-disposing to injury) and are only noticeable when someone touches them. Treating Trigger Points individually can be simple – get a massage or manual therapy that identified and releases them. You just must get them all primary, secondary, and active – and then leave the latent ones for the next time.
Treating myofascial pain syndrome or the source of the trigger points and pain may be more complicated. Since trigger points are a contraction mechanism of the locked muscles, getting the release is only the first step. Once trigger points are released the muscles need to be moved throughout the full range of motion.
Soreness and ‘post-workout’ fatigue may be common after a trigger point session. However, with 24-48 hrs. rest the muscle will return to a normal one, if work-load balance remains abnormally high