Trigger Points

I recently attended a continuing education webinar on lumbar spine pain syndromes. I was a bit surprised that in 12 hours of lecture, the presenter didn’t even mention trigger points and (as it’s more technically known) myofascial pain. As a health care practitioner who deals with pain generated from trigger points on multiple patients every day I’m in my office, it seemed like a pretty glaring omission.

As common as pain from trigger points, and other myofascial “tender points” is, they have yet to garner much attention from a lot of health care providers in the approximately 60 years since the pioneering research into them occurred.

I suspect that at least part of the reason for them being largely ignored is that there’s no lab test nor imaging for documenting them, and the treatment for them is time-consuming and physically-challenging. These factors lead to relatively low insurance reimbursement for the work involved, and unfortunately low-interest in them clinically.

A trigger point is a “knot” of soft tissue contraction that may refer pain, tingling, numbness, and/or other symptoms some distance from the point itself. Similarly, myofascial tender points are also knots in the soft tissue, but they only produce local pain when pressure is applied to them.

The referred symptoms from trigger points can often mimic other problems. When I was doing my internship in chiropractic school, a patient came in for some back and neck complaints and mentioned that he was very concerned about his liver. He had been having cramping pain over his liver for a few months, but despite multiple lab tests, imaging procedures, etc., no abnormalities could be found. Even so, the symptoms had him convinced that something was definitely wrong and he, of course, was quite distressed about it. Given the rather thorough liver workup he’d had, I wondered if his symptoms might be some type of referral.

In the process of working on his back complaints, I found a tight area of contraction and when I pressed on it, he exclaimed that it shot pain straight to where he’d been feeling the liver symptoms. After a few minutes employing massage and soft tissue methods, the point released and his liver symptoms were gone (and stayed gone for the months I kept in contact with him during my internship). Obviously, if someone has pain over the liver, it’s important to evaluate the organ and rule out serious pathology, but this case illustrates how much a trigger point can seem like something else and get missed entirely by health care providers.

In my experience, trigger points and tender points commonly produce a wide variety of symptoms that often get mistaken for something else. For example, trigger points in the piriformis muscle produce symptoms that mimic sciatica. Trigger points in the scalene muscles in the front of the neck can cause symptoms similar to a cervical disc protrusion or a heart attack. Tender points in the patellar tendon create symptoms that often get blamed on degenerative arthritis. Points in the neck and upper back commonly produce headaches in various locations.

Again, it is very important to rule out more serious causes for symptoms, but also evaluating for trigger points and tender points, and addressing them if found, can make a huge difference in the effectiveness of treatment and in the speed of recovery.

Once a trigger point or tender point is identified, treatment can take various forms. In my experience, there is often underlying joint dysfunction that is stimulating the formation of the points, and correcting that with chiropractic techniques will usually make the trigger/tender point much easier to treat.

Trigger and tender points may also form in response to things like emotional stress, overuse or underuse (from being very sedentary) of the involved muscles, smoking, chronic dehydration, excessive sugar intake, and exposure to allergens and/or toxins.

Once underlying causes for the points have been addressed, deep massage and stretching are usually quite effective. Other treatments commonly used include ultrasound and electrical stimulation, but I think deep massage is usually more effective in most cases. Applying heat is sometimes helpful, as trigger points tend to reduce in intensity with increased circulation (and worsen with reduced circulation).

For more resistant points, “dry needling” (inserting a needle into the point) or trigger point injections with various medications may be helpful in getting the points to release and for getting symptom relief.

Trigger points and tender points can occur pretty much anywhere. While the referral areas for trigger points can vary, points in particular muscles do have somewhat predictable referral zones. If you’re wondering if the symptoms you’re experiencing might be from trigger points, there’s numerous guides to point locations and their typical referral patterns online. Simply Google terms like “trigger point referral patterns” or “trigger point referred pain” with the areas of your symptoms and you’ll find quite a few illustrations as to where your symptoms might be coming from.

Until next time…

George F. Best, D.C.