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What Are Trigger Points? (Excerpt)

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  Perpetuating Factors

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About Trigger Points

Common Trigger Points Example: Trapezius Muscle in BackMuscle is the largest organ in the human body, and accounts for about 50% of its weight. There are approximately 400 muscles (there are individual variations), and any one of those can develop trigger points which can refer pain and cause dysfunction. Symptoms can range from intolerable agonizing pain caused by "active" trigger points, to painless restriction of movement and distortion of posture from "latent" trigger points.1

The answer to "What Are Trigger Points?" is: research it still underway. But many characteristics have been observed for decades by researchers all over the world. With new testing methods and equipment, in the last ten years much has been learned about the physiology of trigger points. And even though not every mechanism is known, patients get better when their trigger points are treated!

More Trigger Point Information

  •  When pressed, trigger points feel like "knots" or tight bands in the muscle, and are usually very tender. Healthy muscles usually do not contain knots or tight bands, are not tender to pressure, and when relaxed, they feel soft and pliable to the touch, not hard and dense, even if you work-out. When trigger points are present, on the microscopic level, part of the muscle fiber is contracted into a small thickened area, and the rest of the fiber is stretched thin. Several of these muscle fiber contractures in the same area are probably what we feel as a "knot" in the muscle. These muscle fibers are not available for use because they are already contracted, which is why you cannot condition (strengthen) a muscle that contains trigger points. The sustained contraction probably leads to the release of sensitizing chemicals, producing the pain that is felt when the trigger point is pressed.3 Eventually some of the structural changes may be irreversible if trigger points are left untreated for long enough. The contractile portions of the fiber in the middle of the knot may separate and retract to each end, leaving an empty portion of the cell in the middle.4

  • Trigger points may refer pain both in the local area and/or to other areas of the body, and common patterns have been well-documented and diagramed. These are called "referral patterns." Approximately 74% of the time trigger points are not located where you feel symptoms, and working on the area you feel symptoms does not give you relief. These referral patterns do not necessarily follow nerve pathways. Pain levels can vary depending on the stress placed on the muscle and any of other the perpetuating factors that keep trigger points activated. Tingling, numbness, or burning sensations are more likely due to nerve entrapments, which may be a result of trigger points entrapping the nerve.5

  • If the trigger point is "active," it will refer pain or other sensations. If it is "latent," it may cause a decreased range-of-motion and weakness.8 Active trigger points often start with some impact to the muscle, such as an injury, poor posture or body mechanics, repetitive use, or a nerve root irritation. Any of the perpetuating factors can also indirectly activate trigger points and make you more prone to developing trigger points that are initiated by impacts to muscles. Active trigger points may at some point cease causing pain, and become latent.9 Latent trigger points can easily return to being active trigger points, often leading the patient to believe they are experiencing a new problem, when in fact it is an old problem being re-aggravated. Latent trigger points can be reactivated by overuse, over-stretching, chilling,10 or any other of the perpetuating factors. (The chapter on Perpetuating Factors can be found on the Pain Relief with Trigger Point Self-Help CD ROM)

  • In a study of thirteen healthy individuals with the same eight muscles being examined in each subject, two people had latent trigger points in seven of those muscles, two people had latent trigger points in six muscles, three had latent trigger points in five muscles, two had latent trigger points in three muscles, two had latent trigger points in two muscles, two had latent trigger points in one muscle, and only one person didn't have latent trigger points in any of the eight muscles! This means that most people have at least some latent trigger points, which could be easily converted to active trigger points. This also means that some people are more prone to develop problems with muscular pain than others.11

  • With pressure on the trigger point, you can often reproduce the symptoms, but being unable to reproduce the referred pain or other symptoms by applying pressure does not rule out specific trigger points. I still work on the trigger points that could be causing the problem, and if my patient improves, even temporarily, I assume that one of the trigger points I worked on is indeed the source of the problem. For this reason, I don't work on all the possible trigger points in one session, since I won't know which trigger point treated actually gave the patient relief.12

  • Trigger points can cause symptoms not normally associated with muscular symptoms, such as sweating, ringing in the ears, dizziness, urinary frequency, buckling knees, and tearing of the eyes.13

  • Trigger points may cause other muscles fibers to contract. They will also cause weakness and loss of coordination of the involved muscles and an inability of the muscles to tolerate use. Many people take this as a sign that they need to strengthen the weak muscles, but unless trigger points in the affected muscle are inactivated, strengthening (conditioning) exercises will likely encourage the substitution of other muscles, further weakening and de-conditioning the muscle with the trigger points.

  • Trigger points limit range-of-motion due to pain. Some muscles are more likely to have a larger degree of restriction than others. Once trigger points are relieved, range-of-motion is restored.14

  • Muscles containing trigger points are fatigued more easily, and don't return to a relaxed state as quickly when use of the muscle ceases.15

  • Patients are often surprised that the same area on the opposite side is also tender, since that side isn't causing them pain. Over half the time, the opposite side is actually more tender with pressure. Unless it is a recent injury, usually both sides eventually get involved (i.e., if the right mid-back is painful, there are also tender points on the left mid-back). For that reason I almost always work on both sides and tell patients to do the self-help on both sides.16 One possible explanation is that after the initial increase in sensitivity with trigger point activation, and the problem becomes chronic, the body releases pain-masking chemicals and numbs the side of the original pain out somewhat (hypoesthia), and that has not yet happened on the opposite side.17

  • Women are more likely than men to develop trigger points.18 I have noticed this is particularly true in menopausal women. Some teenagers (of both sexes) going through puberty also seem to have a tendency to develop trigger points, leading me to believe there is a connection between hormonal changes and one potential cause of trigger points.19

  • People who exercise regularly are less likely to develop trigger points than those who exercise occasionally and overdo it.20

  • Part of the current hypothesis about the mechanism responsible for the formation of trigger points is the "energy crisis component." The sarcoplasmic reticulum is a part of the cell responsible for storing and releasing ionized calcium. The type of nerve ending that causes the muscle fiber to contract is called a "motor endplate." This nerve ending releases acetylcholine, which tells the sarcoplasmic reticulum to release calcium, and then the muscle fiber contracts. If it is operating normally, when contraction of the muscle fiber is no longer needed, the nerve ending stops releasing acetylcholine and the "calcium pump" in the sarcoplasmic reticulum returns calcium into the sarcoplasmic reticulum. If a trauma occurs or there is a marked increase in the nerve endplate release of acetylcholine, an excessive amount of calcium can be released by the sarcoplasmic reticulum causing a maximal contracture of a segment of muscle, leading to maximal energy demand and impairment of local circulation. If the circulation is impeded, the calcium pump doesn't get the needed fuel and oxygen to pump calcium back into the sarcoplasmic reticulum, and the muscle fiber continues to contract. This vicious cycle continues until there is outside intervention that stretches the contracted portion of the muscle fiber.24 The areas at the ends of the muscle fibers (either at the bone or where the muscle attaches to a tendon) also become tender as its attachments are stressed by the contraction in the center of the fiber.25

  • For a list of things that cause and keep trigger points going, see the section on perpetuating factors. (The chapter on Perpetuating Factors can be found on the Pain Relief with Trigger Point Self-Help CD ROM)

A Word About Fibromyalgia

Allopathic (Western) medicine defines fibromyalgia as a chronic disorder associated with widespread muscle and soft-tissue pain, tenderness and fatigue. Diagnosis is made by pressing 18 areas to check for tenderness, and if at least 11 of the points are tender and the pain has been present for at least three months, you are diagnosed positive for fibromyalgia. Usually you will be prescribed some kind of pain medication and counseling for chronic pain management.27

Most fibromyalgia patients also have at least some trigger points, but there are also distinct differences. Trigger points restrict range-of-motion, while hyper-mobility is common with fibromyalgia. With trigger points, usually only the trigger point itself is tender, whereas with fibromyalgia patients pretty much everywhere is tender to some degree.28 Seventy-five percent of fibromyalgia patients also have fatigue, don't feel rested upon waking, and have morning stiffness.29

Recent Western research has leaned toward a body-wide metabolic and neurochemical cause, including deficiency of the neurotransmitter serotonin30, which causes increased pain sensitivity.31 Although allopathic medicine has not found a definitive cause for fibromyalgia, in terms of Chinese medical diagnosis, there is always a component of dampness, and the tissues will feel somewhat "spongy" to the touch. Dampness easily combines with heat or cold, and typically the condition will be aggravated by either hot or cold weather, or the application of heat or cold. A damp-producing diet (see the section on Diet in perpetuating factors on the CD ROM) will cause and keep fibromyalgia going, and needs to be changed. Living in a damp climate will aggravate fibromyalgia, and typically patients will feel better in a dryer climate. The digestive system is responsible for transforming fluids, and if it is not working well, you will tend to accumulate dampness in various body parts, and for some people that is in the surface layers of the body (see the section on Nutritional Problems in perpetuating factors on the CD ROM). Acupuncture and damp-draining herbs and foods are very successful with treating fibromyalgia, as long as the practitioner is careful not to overtreat the patient. Massage will help with the acute part of the pain, but will not treat the underlying conditions causing fibromyalgia.32

If you have fibromyalgia, Fibromyalgia & Chronic Myofascial Pain: A Survival Manual, by Devin Starlanyl and Mary Ellen Copeland, is an excellent resource and it gives an in-depth look at the physiology of the condition. This Western resource discusses the concept of "interstitial edema," which I believe confirms the Oriental concept of "Damp-heat or Damp-cold in the Muscles." Interstitial edema is where "interstitial fluid" is found in the "interstitial space," or "Third Space." It's neither inside the cells nor outside the cells, so the structure of the interstitial space is hard to visualize, but there is a transfer of informational and other substances between blood and lymph through the interstitial space. Lymph fluid is composed of interstitial fluid, and it brings to cells substances that they need, and carries away excess liquid and metabolic waste. If something interferes with the flow of lymph, such as lack of exercise, improper breathing, constipation, or muscle tightness and restricted range-of-motion, all the excess liquid and metabolic waste can become trapped in the sluggish lymph, leading to swelling of the tissues.33

Treatment of trigger points with professional help and the self-help techniques on this CD ROM will help manage the pain associated with fibromyalgia, but you will also need to address the underlying causes and perpetuating factors in some manner in order to obtain lasting relief.

Trigger Point Books


© Copyright Valerie DeLaune, LAc, 2004-2018

<-- Back to Introduction

Many of the Common Symptoms, Causes of Trigger Points, Helpful Hints, Stretches, and Exercises are drawn from Travell and Simons Myofascial Pain and Dysfunction: The Trigger Point Manual. Please assume that any text prior to a footnote is attributed to the source noted in the footnote. Janet G. Travell, M.D., David G. Simons, M.D., and Lois S. Simons, P.T., Myofascial Pain and Dysfunction: The Trigger Point Manual, , vol. I, Upper Half of Body, 2nd ed. (Baltimore: Williams & Wilkins, 1999), pg. 13
  1. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 57.
  2. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pp. 67-68.
  3. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 77.
  4. Janet G. Travell , M.D., and David G. Simons, M.D., Myofascial Pain and Dysfunction: The Trigger Point Manual, vol. I, The Upper Extremities, (Baltimore: Williams & Wilkins, 1983), pp. 12-14.
  5. Neuromuscular Therapy Training, Fall 1991, Jeanne Aland, instructor.
  6. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 574.
  7. Travell & Simons, M.D.s, Vol. I, pp. 12-14.
  8. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pp. 19-20.
  9. Travell & Simons, M.D.s, Vol. I, pg. 12-14.
  10.  (David G. Simons, M.D., speaker, STAR Symposium, Columbus, May 22, 2003)
  11. Author's experience or education
  12. Travell & Simons, M.D.s, Vol. I, pg. 28.
  13. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pp. 21-22.
  14. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 24.
  15. Author's experience or education
  16. Neuromuscular Therapy Training, Fall 1991, Jeanne Aland, instructor.
  17. Travell & Simons, M.D.s, Vol. I, pp. 12-14.
  18. Author's experience or education
  19. Travell & Simons, M.D.s, Vol. I, pp. 2-14.
  20. Travell & Simons, M.D.s, Vol. I, pg. 28.
  21. Author's experience or education
  22. Travell & Simons, M.D.s, Vol. I, pg. 32.
  23. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pp. 71-72.
  24. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 76.
  25. Travell & Simons, M.D.s, Vol. I, pp. 19-20.
  26. http:/, search on Fibromyalgia, 12/03/03.
  27. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pp. 39-40.
  28. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 38.
  29. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg. 38.
  30. Travell & Simons, M.D.s, Simons, P.T., Vol. I, 2nd ed., pg.17.
  31. Author's experience or education
  32. Devin Starlanyl and Mary Ellen Copeland, Fibromyalgia & Chronic Myofascial Pain: A Survival Manual, 2nd ed. (Oakland: New Harbinger Publications, Inc., 2001),
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Copyright © 2004-2018 Valerie DeLaune, LAc