The Complete Guide to Trigger Points & Myofascial Pain (2019)
.com
BUYPainScience
NOW
• Good advice for aches, pains & injuries
PAINS THERAPY THEORY NEW BOOKS CONTACT
Search this site
Google
Table of Contents
Trigger Points & Myofascial Pain Syndrome
FULL VERSION
registered to Mark Bacon privacy
Go to:
Your Account Page
Customer Introduction & Help
Book Introduction
BOOKMARK ?
Turn bookmark prompting
OFF
Turn bookmark
prompting
OFF
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
5995
$
USD
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Introduction for Customers
Thank you for your business. This section (blue border) is an introduction to this e-book just for customers.
The complete e-book begins below this section. If you have any problems, read on for some tips and help,
and please do not hesitate to contact me personally. ~ Paul Ingraham, Publisher
Some basics about your purchase and this e-book
This large web page is the complete tutorial/e-book. There is nothing else you have to download, and nothing
will be delivered by post. Please do not wait for the mailman!
Viewing this page on a tablet or laptop computer is the best way to read it for most people. You should save
this address in your web browsing program so that it is easy to get back to this page later (called
“bookmarks” in most web browsers, “favourites” in Windows Explorer). But I can always easily help you
get back here.
You have access to this page for life. The book will be updated over time; if you return in a year or three, it
will be a like a new edition. Updates are summarized in the updates section.
The tutorial has an automatic bookmarking feature: the book will remember where you stopped reading,
and offer to return you there when you return here later. more You can also bookmark sections “manually”
using ordinary browser bookmarks for specific sections: go to a section with the table of contents, and then
create a bookmark. more
Links to Books
Status
More information
Trigger Points
PURCHASED
order PS4582281 +
Sep 9, 18
Neck Pain
PURCHASED
order BONUS +
Sep 9, 18
Muscle Strain [sample]
BUY $1995
summary
IT Band Pain [sample]
BUY $1995
summary
Low Back Pain [sample]
BUY $1995
summary
Patellar Pain [sample]
BUY $1995
summary
Plantar Fasciitis [sample]
BUY $1995
summary
Shin Pain [sample]
BUY $1995
summary
CURRENCY ?
USD – US
USD
–Dollars
US D
Complete the set for $60
The eBoxed Set is a steeply discounted, optional bundle of all eight of my books. The set is
ideal for professionals, and some keen patients. ? Purchased individually, they would run
you about $160 USD , but the set is only $7950… minus the value of the one book you’ve
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
already paid for. So you can complete your set for just $5995. Read more about the set.
[new tab/window]
CURRENCY
?
USD – US–Dollars
USD
US D
Or just buy a total of 4 tutorials individually — once you’ve paid as much as the value of the set, you will
be automatically granted access to everything.
Q. I just don’t like reading on the computer. Can I print this? Or use my iPad, Kindle, etc? Or read offline?
A. Printing this page works fine for such a big document. The best way to read it without being tied to a
computer is on a tablet or smart phone, especially an iPad. Get an overview of your reading options,
including offline reading.
Q. What format is this e-book in? It’s not a PDF or regular e-book …
A. No, it’s not a “traditional” PDF or a regular e-book that you would read on, say, a Kindle or Nook. I call
the tutorial an “e-book” because it certainly is in spirit. Technologically, it’s just a huge webpage with a
special address. This has some great advantages and some downsides. If you want to know more about
why I use this format, see my rant about what’s wrong with the ebook industry, and how I’m making a
better product for my customers.
Q. Can I lend this tutorial to friends and family?
A. Yes! Just not with too many people at once, please — the suggested maximum is three. You can share
the address of this page (just make sure you include the customer ID code at the end of the address) with a
few people at a time. Over-lending will probably trigger a warning not to share quite so much. ��
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Trigger Points & Myofascial Pain Syndrome
A guide to the unfinished science of muscle pain, with reviews of every theory and selftreatment and therapy option
Paul Ingraham & Tim Taylor, MD, updated Jul 5, 2019
© 2001–2019 Paul Ingraham, Vancouver, Canada. Access to this document was purchased by Mark Bacon
(customer #3003958). privacy Private sharing on a small scale is just fine — you can lend it to up to 3 people
— but this ebook may not be shared widely by any means. Access may be revoked if this page is accessed
from too many locations, too quickly. If you find this document posted publicly, it has definitely been
pirated! If you did not borrow access personally from Mark Bacon, please purchase access for $19.95 from
the PainScience.com eBookstore. Thank you for supporting a small business and low-DRM
publishing. what’s that? ~ Paul Ingraham, Publisher
TABLE OF CONTENTS
• • • • • dots indicate updated sections
?
Navigation
Top of Page
Customer Introduction (Tips & Help)
Start of Book
Where you left off before purchase
BOOKMARK ?
Appendices (Notes, Further Reading, Updates, etc)
Bottom of Page
Introduction
1.1
Trigger point therapy is not a miracle cure for chronic pain — but it helps
1.2
What exactly are muscle knots?
1.3
Why muscle pain matters
1.4
The shabby state of trigger point science
1.5
Why are trigger points so neglected by medicine?
1.6
Does your trigger point therapist have the big red books?
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
1.7
A brief note about the relationship between fibromyalgia and myofascial pain syndrome
1.8
Trigger points may explain many severe and strange aches and pains
1.9
Two typical tales of trigger point treatment
1.10 The
myth of the trigger point whisperer
Diagnosis
How can you tell if trigger points are the cause of your problem?
2.1
• Trigger point diagnosis is not reliable … but it also may not matter that much
2.2
Where are the charts and diagrams of trigger point locations in this tutorial?
2.3
Quick checklist: classic trigger point symptoms
2.4
Slow checklist: a more detailed diagnostic checklist for myofascial pain syndrome
2.5
Negative checklist: signs/symptoms that are probably not caused by trigger points
2.6
• Identifying your trigger points by feel: tissue texture and other palpable signs
2.7
“Out of nowhere”: a signature symptom of trigger points
2.8
Chasing pain: hurting in all the wrong places (referred pain)
2.9
• Nerve pain is overdiagnosed
2.10 Case
study: a story about nerve pain that wasn’t really nerve pain
2.11 •
Morning symptoms: an uncomfortable daily mystery for many people
2.12 •
From the frying pan of injury pain to the fire of trigger point pain
2.13 •
Could it be ________? Regional pains that trigger points get confused with
2.14 •
Many other causes of chronic widespread pain that should not be ignored
2.15 •
Hypermobility and Ehlers-Danlos syndrome
2.16 •
Case study: “Bursitis” strikes again!
2.17 Predictably
2.18 •
unpredictable: trigger point symptoms are erratic by nature
All the noise! Trigger points and crepitus (joint popping and more)
2.19 What
are the worst-case scenarios for myofascial pain syndrome?
2.20 Worst
Case Scenario 1: Being triggery
2.21 Worst
Case Scenario 2: Rare but extremely severe cases of myofascial pain syndrome
2.22 Worst
Case Scenario 3: Quick-start trigger points
The science of trigger points
It’s a little half-baked, but at least it’s not boring
3.1
The dominant theory of trigger points spelled out in a little more technical detail
3.2
Micro muscles and the dance of the sarcomeres
3.3
One: The vicious cycle (why trigger points are stubborn)
3.4
Two: Good pain (why pressing on trigger points hurts like hell but feels like heaven)
3.5
Three: Tightness (why stretching is appealing but underwhelming)
3.6
Four: Weakness (why muscles with trigger points might be weak)
3.7
Everything we just discussed … in a few bullet points
3.8
Triggers for trigger points: what makes patches of sarcomeres go haywire?
3.9
The all-powerful acne analogy
3.10 The
evolution of muscle pain: does muscle “burn out”?
3.11 Referred
Pain Science (basic)
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
3.12 Referred
3.13 Other
3.14 •
pain science (advanced)
trigger point theories
Quintner: “It’s the nerves, stupid”
3.15 “The
bamboo cage” — lessons from immobilization torture
3.16 Case
study: an example of getting unstuck and feeling “giddy with joy”
3.17 Muscle
3.18 •
knots are not inflammatory: the myth of the inflamed myofascial trigger point
Adhesions and contracture: when trigger points freeze in place
3.19 The
scar tissue issue — are you scarred for life?
3.20 Trigger
points in animals
• Basic Trigger Point Therapy (Mostly Self-Massage)
What can you do about garden variety trigger points?
4.1
Basic self-massage instructions
4.2
How do you know it’s working? Getting a trigger point to “release”
4.3
Basic tips and tricks for better, longer-lasting trigger point release
4.4
Top 5 mistakes beginners make
4.5
What about massage tools?
4.6
• Can you damage your nerves when self-massaging?
4.7
Don’t hesitate to recruit amateur help
4.8
A little more perspective on amateur assistance
4.9
How to get adequate professional help
4.10 Common
medications that might make a difference (and might not)
Advanced Trigger Point Troubleshooting
What can you do about severe and persistent trigger points?
5.1
A brief detour: why not The Trigger Point Therapy Workbook?
5.2
• Some important things to keep in mind about placebos
5.3
Fundamental limitations of trigger point therapy, and how to take advantage of them
5.4
Several more treatment mistakes and problems (that you can fix)
5.5
More serious barriers to success
5.6
Massage efficacy according to science
5.7
Upgrade your self-massage technique
5.8
Don’t get hung up on anatomy, and be persistent
5.9
Focusing on one trouble spot versus “a little bit of everything” — which is the better strategy?
5.10 More
5.11 •
information about exactly how to rub (moving strokes)
Yet more information about exactly how to rub (pressing and holding)
5.12 Using
“press and hold” to identify a trigger point release in progress
5.13 Identifying
5.14 Referred
5.15 Don’t
your trigger points by feel
pain is not a diagnostic feature of trigger points!
be fooled by “reverse referral”
5.16 Beyond
the tennis ball: commercial massage tools
5.17 Thumping
trigger points with vibrating massage tools
5.18
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Commercial massage tools to avoid
5.19 Massage
tools: 7 free (or very cheap) and tools from objects not originally intended for massage
5.20 The
sock trick
5.21 The
bath trick
5.22 Introduction
5.23 Stretching
to non-massage self-treatments for trigger points
(executive summary)
5.24 Mobilizations:
5.25 Case
massaging with movement and the Goldilocks zone
study: mobilizations prove to be crucial factor in recovery from neck pain that started in the 1970s
5.26 Trying
to squirm your way out of trigger point pain? Don’t do it! Consider a little more method in your madness
5.27 Strengthening:
should you take your trigger points to the gym?
5.28 Thermotherapy
5.29 Breathing
5.30 Neutral
5.31 An
deeply is free, safe, and possibly good therapy for trigger points
positioning: find a comfortable muscle length and rest there
introduction to medicating muscle pain (hint: not a great option)
5.32 Anti-inflammatories
5.33 Voltaren®
and Tylenol
Gel, an intriguing new option
5.34 The
nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids
5.35 The
surprising futility of muscle relaxants such as Robax-whatever, Valium and other benzodiazepines
5.36 Lidocaine
patches
5.37 Combination
treatments: why and how to throw everything at it but the kitchen sink
5.38 Troubleshooting
5.39 Case
referred pain: the referred pain field guide
study: referred pain causes a “heart attack” and completely fools dozens of professionals
5.40 Troubleshooting
negative reactions to treatment
Perpetuating Factors
What makes trigger points stubborn?
6.1
Troubleshooting “stuck” trigger points — adhesions and contracture
6.2
Troubleshooting stress (without meditation or yoga, unless you like that sort of thing)
6.3
Troubleshooting posture, ergonomics, and muscle imbalance
6.4
Troubleshooting mysterious perpetuating factors
6.5
The relationship between trigger points and other physiological disorders and diseases, especially fibromyalgia
6.6
Way beyond stubborn: troubleshooting extreme cases
6.7
Reality checks: some self-treatments that don’t work at all (or not nearly as well as you would hope)
Medical Factors That Perpetuate Pain
The effect of statin drugs, nutritional and hormonal deficiencies, infections, and inflammatory diseases
7.1
Some usual, unusual, and unique medical disclaimers
7.2
Getting tested and treated: the hard way, the easy way, and the right way
7.3
Pain-causing drug side effects: statins (cholesterol-reducing drugs) and bisphosphonates (for osteoporosis)
7.4
Nutritional and hormone deficiencies
7.5
Vitamin D deficiency
7.6
Thyroid hormone deficiency
7.7
Iron deficiency (and excess)
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
7.8
Vitamin C deficiency
7.9
Vitamin B12 deficiency
7.10 Vitamin
B1, B2, folate, and magnesium deficiencies
7.11 Testosterone
7.12 Estrogen
deficiency
deficiency
7.13 Infections
7.14 Inflammation
7.15 Smoking
7.16 Overall
treatment strategy
Stretching
Stretching is generally over-rated … but it might be good for trigger points
8.1
The anecdotal evidence for stretching (is just huge)
8.2
Case study: A cautionary tale of stretching: that time I almost ripped my own head off
8.3
Winning a tug-of-war: how stretching might help trigger points in principle
8.4
The bad news about stretching for trigger points
8.5
Like a knot in a bungie cord
8.6
The spray-and-stretch method, if it works, implies that stretch alone may not work
8.7
Other practical limitations of stretching for trigger points
8.8
What about neurology? Stretch tolerance
8.9
What about stretching the antagonist muscle?
8.10 Stretching
“conclusions”
Getting Help
How do you find good therapy for your trigger points?
9.1
Types of therapists and doctors and their relationship to trigger point therapy
9.2
Massage quality control issues (“But I’ve already tried massage therapy … ”)
9.3
Two case studies: highly-trained therapists failing miserably
9.4
Worst practices in massage therapy
9.5
How to find good trigger point therapy
9.6
The Pressure Question: how much is too much?
9.7
• Pain in three flavours: the good, the bad, and the ugly
9.8
Training your therapist
9.9
Other kinds of therapies
9.10 How
about spray and stretch therapy?
9.11 How
about the Paul St. John Method of Neuromuscular Therapy?
9.12 How
about transcutaneous electrical nerve stimulation therapy? (TENS or ENS)
9.13 How
about ultrasound therapy? (ESWT and “Sonic Relief™”)
9.14 How
about chiropractic joint adjustment and popping?
9.15 How
about myofascial release and fascial stretching?
9.16 •
Maybe stabbing will help! Dry needling
9.17 •
How about trigger point injection therapy?
9.18 How
about Botox injection therapy?
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
9.19 How
about nerve blocks?
9.20 How
about acupuncture?
9.21 Acupressure:
9.22 How
what if we pressed those points instead of puncturing?
about Active Release Techniques® (ART)?
9.23 Measuring
progress in trigger point therapy
Final Thoughts
How is a lemon like a trigger point?
Appendices
11.1 Appendix
A: Trigger Point Reference Materials or: Diagrams, Diagrams, Diagrams!
11.2 Appendix
B: The Perfect Spots
Spot #1 for pain almost anywhere in the head, face and neck, but especially the side of the head, behind the ear,
the temples and forehead
Spot #2 for pain anywhere in the low back, tailbone, lower buttock, abdomen, groin, side of the hip
Spot #3 for pain in the shin, top of the foot, and the big toe
Spot #4 for pain in the upper back (especially inner edge of the shoulder blade), neck, side of the face, upper
chest, shoulder, arm, hand
Spot #5 for pain in the elbow, arm, wrist, and hand
Spot #6 for pain in the low back, hip, buttocks (especially immediately under the buttocks), side of the thigh,
hamstrings
Spot #7 for pain in the side of the face, jaw, teeth (rarely)
Spot #8 for pain in the lower half of the thigh, knee
Spot #9 for pain anywhere in the chest, upper arm
Spot #10 for pain in the bottom of the foot
Spot #11 for pain anywhere in the upper back, mainly between the shoulder blades
Spot #12 for pain in the lower back, buttocks, hip, hamstrings
Spot #13 for pain in the low back, buttocks, hamstrings
Spot #14 for pain any part of the shoulder, and upper arm
11.3 Appendix
11.4 Reader
C: Trigger Point Therapy Resources
feedback … good and bad
11.5 Acknowledgements
11.6 What’s
new in this tutorial?
11.7 Notes
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Trigger points or muscle “knots” are sensitive spots in soft tissue, and too many of them is
“myofascial pain syndrome.” They are usually described as micro-cramps, but the science is halfbaked and their nature is controversial. Regardless, these sore spots are as common as pimples,
often alarmingly fierce, and they seem to grow like weeds around injuries. They may be a major
factor in back and neck pain, as a cause, a complication, or a bit of both.
Trigger point therapy mostly consists of rubbing and pressing on trigger points — which can feel
like an amazing relief. Dry needling is a popular (and dubious) method of stabbing trigger points
into submission with acupuncture needles. Treatment is not rocket science 5 — it’s much too
experimental to be so exact! It’s a bit of a crapshoot, lots of trial and error, but anyone can learn
enough to relieve some minor pain problems cheaply and safely, and maybe some bigger ones, too.
Advanced therapy for people with many stubborn trigger points goes beyond fighting brush fires
and in search of medical factors.
There are many possible causes of unexplained aches and pains, but trigger points are an
interesting piece of the puzzle for many people, and offer some potential for relief.
Does your body feel like a toxic waste dump?
It may be more literally true than you
realized! Some evidence shows that a knot
may be a patch of polluted tissue: a nasty
little cesspool of waste metabolites. If so, it’s
no wonder they hurt & no wonder they cause
so many strange sensations: it’s more like
being poisoned than being injured. Back pain
is the best known symptom of the common
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
muscle knot, but they can cause an
astonishing array of other aches & pains.
Misdiagnosis is much more common than
diagnosis.
1.1
Trigger point therapy is not a miracle cure for chronic pain — but it helps
Trigger point therapy isn’t “too good to be true” — it’s just ordinary good. It’s definitely not
miraculous. 6 It’s experimental and it often fails. 7 Good therapy is hard to find (or even define),
because many practitioners are amateurish hacks and some treatment methods are way out in left
field and potentially harmful (to your wallet at least). They are often barking up the wrong tree,
treating so-called trigger points when there’s actually another problem.
And yet good trigger point therapy is under-rated. It can be a safe
self-treatment with the potential to help with many common
pain problems that don’t respond well — or at all — to anything
else. 10 Done wisely, it’s worth dabbling in (or even basing a
career on it).
For beginners with average muscle pain — a typical case of
nagging hip pain or low back pain or neck pain — the advice
PRO Attention physicians & therapists:
This massive tutorial is written for both
patients and professionals. It includes
analysis of recent research that you won’t
find in any text, crafted to suit any skill
level. 8 Footnotes add a optional layer of
advanced detail that you can take or leave.
given here may well seem almost miraculously useful. I get a lot
Trigger points are more clinically important
of email from readers thanking me for pointing out simple
than most health professionals realize, and
treatment options for such irritating problems. Some are
body pain seems to be a growing
gobsmacked by the discovery that their chronic pain could have
problem. 9 It’s a rewarding topic for
been treated easily all along.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
doctors and therapists, that makes clear
The Complete Guide to Trigger Points & Myofascial Pain (2019)
path to helping quite a few people you
For veterans who have already tried — and failed — to treat
severe trigger points, this document is especially made for you.
You should learn more before giving up. This will get you as
probably couldn’t help before. Even if you
already know about myofascial pain
syndrome, you will get new ideas here.
close to a cure as you can get; I can give you a fighting chance of
at least taking the edge off your pain. And maybe that is a bit of a miracle.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
About footnotes. There are 413 footnotes in this document. Click to make them pop up without losing your
place. There are two types: more interesting extra content, 1 and boring reference stuff. 2 Try one!
1.2
What exactly are muscle knots?
When you say that you have a “muscle knot,” you are talking
about a myofascial trigger point (TrP).[Wikipedia] A few trigger points
here and there is usually just an annoyance, but many bad ones
PRO Whatchacallit? Names matter. One
of the biggest challenges with getting the
is myofascial pain syndrome (MPS). [Mayo]
word out about trigger points is which
TrPs are to MPS as pimples are to acne.
many different labels over the decades. 11
There are no actual knots in there, of course — it just feels like it.
current, accepted terminology: it’s a
Although their true nature is uncertain, the usual explanation is
myofascial trigger point!
word exactly to get out — they have had
Can we all just stick with this one? Use the
that a trigger point is a small patch of tightly contracted muscle,
a micro-cramp afflicting just a tiny patch of muscle tissue (as opposed to a whole-muscle spasm
like a “charlie horse” 12 ). The story goes on: that small patch of muscle chokes off its own blood
supply, which irritates it even more, a vicious cycle dubbed a “metabolic crisis.” This swampy
metabolic situation is why I sometimes think of it as sick muscle syndrome.
TrPs can be vicious. They can cause far more discomfort than most people believe is possible. Its
bark is much louder than its bite, but the bark can be painfully loud. It can also be a weird bark —
trigger points can generate some odd sensations, and the source may not be obvious.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
1.3
Why muscle pain matters
During a minor cyst removal from my chest many years ago, a potent stab of hot pain made me
jump under the knife. “Very sorry,” the surgeon said. “I slipped and poked your pectoralis major
with my scalpel, and only the superficial tissue is anaesthetized. Don’t worry, it won’t happen
again.” And it didn’t. But I had learned a useful lesson: muscle tissue is sensitive stuff! 13
Muscle pain matters. Aches and pains are an
extremely common medical complaint, 14
and trigger points seem to be a factor in many
of them. 15 16 They are involved in
headaches (including migraines) 17 18 , neck
pain and low back pain, and (much) more.
What makes trigger points clinically important
— and fascinating — is their triple threat.
They can:
Trigger points show up like party crashers:
whatever’s wrong, you can count on them to
make it worse & in many cases they actually
begin to overshadow the original problem.
1. cause pain problems,
2. complicate pain problems, and
3. mimic other pain problems.
Muscle just hurts sometimes. Trigger points can cause pain directly. Trigger points are a “natural”
part of muscle tissue. 19 Just as almost everyone gets some pimples, sooner or later almost
everyone gets muscle knots — and you get pain with no other explanation or issue.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
It’s complicated. Trigger points complicate injuries and other painful problems. They show up like
party crashers: whatever’s wrong, you can count on them to make it worse, and in many cases they
actually begin to overshadow the original problem.
“It felt like a toothache.” Trigger points mimic other problems. Many trigger points feel like
something else. It is easy for an unsuspecting health professional to mistake trigger point pain for
practically anything but a trigger point. For instance, muscle pain is probably more common than
repetitive strain injuries (RSIs), because many so-called RSIs may actually be muscle pain. 20 A
perfect example: shin splints. 21
The daily clinical experience of thousands of massage therapists, physical therapists, and
physicians strongly indicates that most of our common aches and pains — and many
other puzzling physical complaints — are actually caused by trigger points, or small
contraction knots, in the muscles of the body.
~ The trigger point therapy workbook, by Clair Davies, p. 2
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
1.4
The shabby state of trigger point science
Trigger point science is a bit disappointing. 22 Trigger points are under-explained and overhyped. They aren’t a flaky diagnosis, 23 but they’re not exactly on a solid scientific foundation
either. Some critics have harshly criticized conventional wisdom about them. 24
None of that is a deal-breaker, though: muscle
pain is still an important topic, “trigger
points” is a useful work-in-progress label for
whatever is going on, and everyone agrees
that something painful is going on. So all the
The science of trigger points is a bit shabby.
They are under-explained.
more reason to have a rational tour guide to
take you through a murky subject. What’s
useful in the theory of trigger points? Who disagrees and why? What’s half-baked and obsolete?
What are the major pitfalls?
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Sometimes half-baked ideas turn out okay if you just keep them in the oven. Trigger point science
may be a bit of a hot mess, but it also isn’t over.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
1.5
Why are trigger points so neglected by medicine?
Family doctors aren’t really equipped for
troubleshooting chronic pain.
Cartoon by Loren Fishman, HumoresqueCartoons.com
Trigger points are medically neglected because medicine has always had many much bigger fish to
fry, and musculoskeletal medicine has only just recently started to get any real attention. 25
Chronic pain with no obvious cause is a relatively unstudied epidemic, and not many doctors
know what to do with it or even try.
If trigger points are a muscle tissue dysfunction or pathology — which is plausible but far from
proven — that’s another reason they have fallen through the medical cracks: “Muscle is an orphan
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
organ. No medical speciality claims it.” 26 Muscle tissue is the largest organ in the body, complex
and vulnerable to dysfunction, and the “primary target of the wear and tear of daily activities,”
nevertheless “it is the bones, joints, bursae and nerves on which physicians usually concentrate
their attention.” 27
Family doctors are particularly uninformed about the causes of musculoskeletal aches and
pains 28 — it simply isn’t on their radar. They are busy with a lot of other things, many of them
quite dire. And the topic is just trickier than it seems to be, so it’s not really surprising that doctors
aren’t exactly muscle pain treatment Jedi.
What about medical specialists? They may be the best option for serious cases. Doctors in pain
clinics often know about trigger points, but they usually limit their methods to injection therapies
— a bazooka to kill a mouse? — and anything less than a severe chronic pain problem won’t
qualify you for admittance to a pain clinic in the first place. This option is only available to patients
for whom trigger points are a truly horrid primary problem, or a major complication. Medical
specialists may know quite a bit about muscle pain, but still aren’t all helpful to the average patient
for practical reasons.
An appallingly high percentage of doctors and other practitioners
are still pretty much out of the loop regarding trigger points.
~ The trigger point therapy workbook, by Clair
Davies, p. 2
Physical therapists and chiropractors are often preoccupied to a fault with joint function,
biomechanics, 29 and exercise therapy. These approaches have their place, but they are often
emphasized at the expense of understanding muscle pain as a sensory disorder which can easily
afflict people with apparently perfect bodies, posture and fitness. A lot of patient time gets wasted
trying to “straighten” patients, when all along just a little pressure on a key muscle knot might
have provided relief.
Massage therapists have a lot of hands-on experience of muscle tissue, but know surprisingly little
about myofascial pain syndrome. Their training standards vary wildly. Even in my three years of
training as an RMT (the longest such program in the world 30 ), I learned only the basics — barely
more than this introduction! Like physical therapists and chiropractors, massage therapists are
often almost absurdly preoccupied with symmetry and structure. The right hands can give you a
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
lot of relief, but it’s hard to find — or be — the right hands.
No professionals of any kind are commonly skilled in the treatment of trigger points. Muscle tissue
simply has not gotten the clinical attention it deserves, and so misdiagnosis and wrong treatment is
like death and taxes — inevitable! And that is why this tutorial exists: to help you “save yourself,”
and to educate professionals.
Those clinicians who have become skilled at diagnosing and managing myofascial trigger
points frequently see patients who were referred to them by other practitioners as a last
resort. These patients commonly arrive with a long list of diagnostic procedures, none of
which satisfactorily explained the cause of, or relieved, the patient’s pain.
~ Myofascial Pain and Dysfunction, by Janet Travell, David Simons,
and Lois Simons, p. 36
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
1.6
Does your trigger point therapist have the big red books?
In addition to many scientific papers, this tutorial is based on medical
textbooks like the massive two-volume set, “the big red books” —
Myofascial Pain and Dysfunction 31 — and “the blue book,” Muscle
Pain 32 These are not easy reading! 33
The Big Red Books
Must-have text books for any
therapist treating trigger points.
They don’t contain all the answers — indeed, they contain some nonsense — but anyone who
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
claims to treat muscle pain should still have the big red books in their office. They are just too
historically important not to have. So, if you don’t see dog-eared copies, ask about them — it’s a
fair, effective, polite way to check a therapist’s competence. Muscle Pain (the blue one) is just as
important. I highly recommend it to any professional who works with muscle (or should). It’s more
recent, and it covers a much wider range of soft tissue pain issues, putting trigger points in context.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
1.7
A brief note about the relationship between fibromyalgia and myofascial pain syndrome
Fibromyalgia (FM) is an illness of “hurting all over” — widespread chronic pain and decreased
pain threshold. It is also associated with fatigue, sleep disturbance, and “fibro fog” (mental
confusion). It is defined by its unexplained symptoms, 34 so “no one has FM until it is
diagnosed.” 35 Here’s a good 1-minute primer on fibromyalgia from One-Minute Medical School:
Fibromyalgia Syndrome
1:00
MPS is actually one of many possible explanations for the pain of fibromyalgia, but they may also
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
be separate conditions. FM might be a more clearly neurological disease, while MPS may be more of
a problem with muscle tissue. It would be nice if such a clear distinction were established someday.
FM and MPS are both imperfect, imprecise
labels for closely related sets of unexplained
symptoms, which makes them harder to tell
apart than mischievous twins who
deliberately impersonate each other. They
may be two sides of the same painful coin, or
overlapping parts on a spectrum of sensory
Fibromyalgia & myofascial pain syndrome are
harder to tell apart than mischievous twins
who deliberately impersonate each other.
malfunction, or different stages of the same
process. Some cases are effectively impossible
to tell apart. There may be no real difference between FM and severe MPS.
Add to that the fact that both conditions are controversial to the point where some people deny
they even exist, and it’s understandable that they get confused.
Note that the “tender points” of fibromyalgia are not the same thing as trigger points. 36
Whatever the causes or labels, therapeutic approaches for MPS seems to be helpful for some FM
patients as well, 37 although pure FM cases seem to be mostly immune to massage. 38 But this
book is still useful for many FM patients, insofar as it overlaps with our main topic. Dr. Taylor’s
advice about medical causes of pain are especially helpful; his wife is also a doctor and has
fibromyalgia and has gotten considerable relief from the recommendations shared here. So this is
not a fibromyalgia book, per se … but I certainly hope it’s of interest to fibromyalgia patients.
Fibromyalgic Tender Points
The “tender points” of
fibromyalgia are not the same
idea as myofascial trigger
points.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
1.8
Trigger points may explain many severe and strange aches and pains
Got a bizarre pain that just flared up one day? Sure, it could be something scary or rare. But in
many cases it’s more likely to be a trigger point.
This is where trigger points really get interesting. In addition to minor aches and pains, muscle
pain often causes unusual symptoms in strange locations. For instance, many people diagnosed
with carpal tunnel syndrome are actually experiencing pain caused by a muscle in their armpit
(subscapularis). 39 Seriously. I’m not making that up!
This odd phenomenon of pain spreading from a trigger point to another location is called “referred
pain.” The neurology will be explained in detail below. Here are some other examples of
interesting referred pain leading to misdiagnosis: 40
Sciatica (shooting pain in the buttocks and legs) is often caused by pain in the piriformis or other
gluteal muscles, and not by irritation of the sciatic nerve. Many other trigger points are mistaken for
“some kind of nerve problem.” (And, to be fair, some kinds of nerve problems can be mistaken for
trigger points! More on this to come.)
Chronic jaw pain, toothaches, earaches, sinusitis, ringing in the ears (tinnitus), and dizziness
may be symptoms of trigger points in the muscles around the jaw, face, head and neck. 41 42
A sore throat or a lump in the throat is often caused or aggravated by trigger points anywhere
around the throat. 43
“Appendicitis pain” often turns out, sometimes after surgery, to be caused by a trigger point in the
abdominal muscles. Wow.
Severe MPS is often mistaken for fibromyalgia (and other causes of pain hypersensitivity).
Sometimes trigger points cause such severe symptoms that they are mistaken for medical
emergencies. I treated a man for chest and arm pain — he had been in the hospital for several
hours being checked out for signs of heart failure, but when he got to my office his symptoms were
relieved by a few minutes of rubbing a pectoralis major muscle trigger point. The same trigger
point sometimes raises fears of a tumor. Here’s a particularly excellent example sent to me by a
physician who had this experience:
I narrowly escaped a breast biopsy because of trigger points in the pectoralis major. I’d
had bad chest pain for a month. I was on the table, permit signed, draped. The doctor
wasn’t sure: she said she wanted another mammogram. I left confused, relieved … but
still hurting.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Then I lucked out: my regular internist was puzzled, but thought it might be “soft tissue.”
That made me go to a physical therapist. The physical therapist pulled out the big red
books on trigger points, and we read together. Treatment was a complete success. A
month-old severe pain that I had been treating with ice packs in my bra and pain-killers
— gone!
Janice Kregor, competitive swimmer, retired pediatrician and
medical school instructor
Another client once spent three days in hospital for severe abdominal pain that doctors couldn’t
diagnose — her pain was mostly and quickly relieved by massaging a trigger point in her psoas
major muscle. 44
I once suffered a dramatic case of a “toothache” that was completely relieved by a massage
therapist the day before an emergency appointment with the dentist: a particularly vivid
experience.
However, the vast majority of symptoms caused by myofascial pain syndrome are simply the
familiar aches and pains of humanity — millions of sore backs, shoulders and necks. Some of
which can become quite serious.
Is this like you?
Muscle knot pain can be savage. Over the
years I have met many people who were
in so much pain from muscle dysfunction
that they could hardly think straight. Is
muscle pain “trivial”? Not if you have it!
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
1.9
Two typical tales of trigger point treatment
The relationship between trigger points and mild-to-moderate pain is often so straightforward that
“therapy” is so easy it barely deserves to be called therapy. One of the nice things about working
with trigger points is that sometimes they do make me seem like a miracle worker, because they are
such a clinical “slam dunk” for garden variety persistent pain — pain undiagnosed and untreated
by a string of other health professionals.
For instance, Lois McConnell of Vancouver came to see me complaining that she’d had moderate,
chronic back pain for several years. She’d received some common misdiagnoses, particularly
sacroiliac joint dysfunction. 45 But she had a prominent gluteus maximus trigger point 46 that,
when stimulated, felt exactly like her symptoms — a deep ache in the region of the low back and
upper gluteals. In just three appointments, her pain was completely relieved. She was quite
pleased, I can tell you!
Just wanted to give you a quick update … my back has been absolutely fine.
Unbelievable … or perhaps not, considering what I’ve learned from you! A big
thank you for all your help.
~Lois McConnell, retired airline executive, suffered chronic low back
and hip pain for a few years
Or consider Jan Campbell. Jan developed a hip pain sometime in early 2004 during a period of
intense exercising. The pain quickly grew to the point of interfering with walking, and was
medically diagnosed as a bursitis, piriformis strain, or arthritis. I did not believe any of these were
likely (see below for more about the misdiagnosis of bursitis), and treated a trigger point in her
piriformis muscle once on June 12, 2004. Her symptom was 100% relieved for about eight months,
before it slowly began to reassert itself (as trigger points often do, despite our best efforts — more
about that to come).
One trigger point therapy treatment completely relieved a nasty stubborn hip
pain that I'd had for five months!
~Jan Campbell, retired French language teacher, Palm Springs,
recovered easily from several months of hip pain
Every good trigger point therapist has a bunch of treatment success stories like this. Although most
such cases involve relatively minor symptoms, this is not to say that they were minor problems. In
almost every such case, the pain was relatively mild but extremely frustrating and persistent for
many years, then relieved easily by a handful of treatments — an incredible thing, when you think
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
about it. So much unnecessary suffering!
But of course trigger points don't always yield so easily…
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
1.10
The myth of the trigger point whisperer
Can a good enough massage therapist remove all trigger points in a session? Is there such a thing
as a “trigger point whisperer”?
I got this question by email, and it shows a common theme: the optimistic/desperate quest for the
mystique of the magic super therapist who can fix anything in two or three sessions. Or even
less. 47 The idea is an annoyance to all honest, humble professionals who know better … and more
or less impossible to believe if you know the basics about pain and muscle knots. The skill of a
therapist is only one relatively minor factor among many that affect the success of massage therapy
for trigger points — or any therapy, for any pain problem.
Trigger points are not little switches that can
be flicked off (“released”) by anyone who has
sufficiently advanced technique — they are a
mysterious, cantankerous, complex
phenomenon. Even the best therapists can be
defeated by a no-win situation. 48 And nearly
any therapist can luck out and get great results
with the occasional patient when all the
planets are aligned: sometimes trigger points
respond well to virtually any intervention. It
Even the best therapists can be defeated by a
no-win situation & nearly any therapist can
luck out & get great results with the
occasional patient when all the planets are
aligned.
really depends.
For comparison, can a good enough dog
trainer train any dog in a hour? Even Cesar “Dog Whisperer” Millan says he can’t if the dog is
traumatized, sick, and/or injured, and requires hours of smart, gradual conditioning. It depends on
the situation.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
It depends, it depends, it depends. This is a major theme in this document, and it is why I am
dedicated to teaching concepts and principles, not treatment recipes and formulae — and that’s why it’s
an important thing to cover in the introduction.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
Part 2
DIAGNOSIS
How can you tell if trigger points are the cause of your problem?
Trigger points have many strange “features” and behaviours, and can easily be confused with
many other common undiagnosed causes of pain. 49 Because of their medical obscurity and the
half-baked science, they are often the last thing to be considered in spite of their clinical importance
and distinctive characteristics. There are several things you can look for that will help you to feel
more confident that, yes, muscle pain is the problem instead of something else. The next several
sections will discuss all of them in detail, comparing and contrasting with other conditions.
Whether you knew it or not, you were probably already familiar with trigger points even if you’d
never heard of them before starting this tutorial.
Almost everyone has a head start in self-diagnosing trigger points, because almost everyone
already more or less knows what it’s like to have a muscle knot. If you have ever had muscle
stiffness, wrenched your neck around trying to stretch and wiggle your way free of discomfort, or
gotten a friend or partner to dig into that nagging sore spot in your back, then you already have some
experience with this — you have trigger points. You have pain and stiffness that feels like it’s in your
muscles. You have sensitive patches of soft tissue, much more tender that the surrounding tissue,
in locations where there’s no obvious reason for it.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
This is where the free introduction to the tutorial ended.
But there may be many things you don’t yet know about how trigger points behave and feel:
Trigger point pain often comes “out of nowhere.” While straightforward injury pain tends to be
predictable, 50 trigger point pain often wanders, switches sides, comes and goes, and changes
quality.
Trigger points are probably much more common than “nerve pain.” 51
Trigger points are also probably much more common than several other common causes of chronic
widespread pain.
Trigger point pain tends to occur in response to a standard set of typical aggravating factors:
muscular fatigue, muscle stagnancy (being “stuck” in awkward positions, shortened or
lengthened), chills, sensory annoyances (like hats 52 ), proximity of other kinds of pain or trauma,
and lifestyle factors like sleep-deprivation, smoking, and anxiety. If you know what they are, and
correlate them with other typical signs, they can really help to clinch a general diagnosis.
There are many normal and abnormal lumps and bumps in people that are not trigger points, but
which constantly fool amateurs… and even plenty of professionals who should know better. This is
the top cause of wild goose chases in the trigger point therapy business. And the number two…
Like a mirage, trigger points are often not actually at the location of the discomfort. The
phenomenon of “referred pain” is a huge diagnostic curve ball, and misleads even experienced
therapists. It’s quite difficult to be sure of the location of a trigger point — see the next section.
2.1
Trigger point diagnosis is not reliable … but it also may not matter that much
2018 — Additions: Added an informative and entertaining example.
Finding trigger points is tricky work for professionals and even harder for beginners. Consider this
example from my inbox, from a husband trying to help his wife:
As I pushed down on the muscle knot, it literally moved from her lower to her upper
back, ending up in the trapezius area. It looked like it was like out of horror movie. I’ve
never seen anything like it: it was like the muscle picked itself up and rolled to another
area on her back. I felt like I was playing a cat and mouse game with a muscle knot: it
moved everytime I try to apply pressure! When I finally cornered the knot I was able to
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
successfully apply pressure, she stated when I did that she felt/heard a popping sound.
Did I burst the trigger point?
I don’t know what he was chasing, 53 but it wasn’t a muscle knot. They cannot be chased around
under the skin like “a cat and mouse game.” They do not move or pop any more than you a knot in
a 2×4. Chant it with me:
Not every lump under the skin is a trigger point!
Not every lump under the skin is a trigger point!
Not every lump under the skin is a trigger point!
Further along, I’ll explain exactly what trigger points are supposed to feel like, and what kinds of
things can be confused with them, but the rest of this chapter is just about the problem of diagnostic
reliability in principle.
It’s hard to treat what you cannot find
I go out of my way to warn chronic pain patients that trigger point therapy will probably not solve
all of your problems. On the one hand, trigger points are surprisingly clinically significant and
somewhat treatable, and thus they present a nice opportunity.
On the other hand, trying to find good trigger point therapy is like trying to find a good bagel west
of Montréal.
Perhaps the biggest problem of all is that it’s tough to treat what you cannot locate … and it’s hard
to find trigger points by feel, which is the only option most people have, most of the time. The
reliability of trigger point diagnosis is in considerable doubt. A 2017 review of a half dozens tests of
how well therapists agree on the locations of trigger points concluded that the “use of manual
palpation for identification of MTrPs is unreliable.” 54 Older reviews came to similar
conclusions. 55 56 Ruh roh.
So are a lot of common diagnostic challenges, so “unreliable”
isn’t actually as bad as it sounds — but it’s not easy, and
probably only better practitioners can do significantly better than
someone playing pin the tail on the donkey. With wellestablished official guidelines and proper training, diagnosis
might be much better. But there are no such guidelines, and many
professionals probably do not even know what the candidates
are.
What’s a reliability study? An experiment
designed to test the ability of health
professionals to agree on a diagnosis. If they
can all find the same problem on the same
patient, then it suggests that their methods
are reliable. Reliability studies are cool
because they are a good way of
understanding the value of an idea in
chronic pain management. Many classic
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
The review cited above, Rathbone et al , was forced to just
“estimate” trigger point detection reliability from six studies, all
barely adequate and too different from each other for pooling the
theories of pain causes cannot be reliably
diagnosed. For more information, see Is
Diagnosis for Pain Problems Reliable?
data for a more stastically powerful answer (meta-analysis). A
score of 0 is the same as random — diagnosis by coin flip — and a score of 1.0 is perfect. Trigger
points came in at 0.36 to 0.54, or even a bit higher at 0.68 (when just looking for localized
tenderness, the most reliable criteria they identified).
Those scores do technically mean “unreliable”! It’s far from perfect. And yet they are also not
actually all that bad for a difficult diagnostic challenge. They represent “fair” to “moderate”
reliability, even “substantial” for the best criterion.
The evidence strongly suggests that trigger point diagnosis is possible-but-difficult in principle and
downright sketchy in practice: lots of misses are inevitable, which jibes perfectly with my
observations in the wild. Despite the theoretical potential of trigger point therapy, few patients seem
to be able to find good help for their trigger points, and the failure often starts with clinicians who
don’t even know where to look for common trigger points, let alone a good understanding of best
diagnostic practices. I have repeatedly encountered cases where well-trained therapists appeared
to be oblivious to the most obvious of “perfect spots” for massage.
Clear proposals for diagnostic criteria exist and probably will, eventually, lead to better tests of
better clinicians. A 1996 paper describes an (infamously) failed initial attempt to confirm that the
diagnosis of trigger points is satisfactorily reliable, but reported greater success with practitioners
who were better trained and prepared. 57 Those authors also pointed that some diagnostic signs
are more difficult to reliably detect than others, and some trigger points are harder to diagnose in
some muscles than others. But, with training, therapists were able to achieve more reliable
diagnosis. So maybe the reliability problem will ease over time.
Probably it will take a couple generations, though. If it happens at all. There’s been no major
improvement in this department in the last 20 years.
Do we actually even need to locate trigger points
precisely?
You need to know where a button is to press
it. Some treatments for trigger points do
The best way to diagnose a trigger point is to
kill it!
depend on precision, dry needling especially
and also the most common form of massage
treatment, ischemic pressure (just pressing on the trigger point).
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
But there are other options, and just because it’s tough to confidently locate a specific trigger point
doesn’t make it impossible to work with them in general. A steam roller driver does not need to
know the exact location of every bump in his path flatten them. You don’t have to know exactly
where a trigger point is to treat it with massage. Heating pads, foam rollers, stretches, vibrations all
cast a wide net.
You actually don’t even have to be certain that it’s there. A strong clinical suspicion of a trigger
point can be enough reason to proceed with treatment. Indeed, as I’ve been telling patients and
professionals for years, the best way to diagnose a trigger point is simply to try to get rid of it: if
you treat a muscle as if there’s a trigger point in it, and the symptoms improve significantly, there’s
your diagnosis! “Presumptive treatment” is fair game.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
2.2
Where are the charts and diagrams of trigger point locations in this tutorial?
Seems like some diagrams would be a pretty useful tool for diagnosing trigger points, no?
Yes. And no.
If I had a buck for every patient who’s ever tried and failed to make sense of a trigger point chart …
! Trigger point reference materials can be useful, of course, but they also confuse patients as often
as they help, and maybe more often. You can get lost fast when trying to find something in your
anatomy based on a diagram and/or a description. Even the pros routinely get stumped by the
complexity of the anatomy. Even if everyone’s anatomy was exactly the same — it’s really not —
even the difference between hefty and skinny can throw you off. More about this below when we
get into the huge challenge of identifying trigger points by feel.
So this tutorial is not an encyclopedia of trigger points and that is deliberate. My goal is to teach
concepts and principles — the know-how, the skills, the tips and tricks that are flat out more useful
than muscle-by-muscle descriptions of trigger points. I could tell you where the trigger points are …
but I’d rather show you how to find them for yourself. It’s the ol’ teach-a-man-to-fish thing.
Precisely locating trigger points is somewhat over-rated anyway! 58
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
That said … who am I to argue with market forces? There’s certainly a strong demand for trigger
point reference material. Charts sell to therapists like hotcakes, and some of the most popular
content on PainScience.com has always been my Perfect Spots series of articles. See Appendix A for
overview of reference resources, and a quick reference guide to the Perfect Spots.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
2.3
Quick checklist: classic trigger point symptoms
For most people, most of the time, confirming a trigger point diagnosis is this simple. Check all that
apply — if you have more than half of these, and no other apparent explanation for your pain, you
probably have some trigger points.
You have sore spots in muscles.
Your pain usually occurs in specific areas of your body.
The problem feels more like muscles than joints.
Your pain is primarily dull, aching, and nagging.
You feel a lot of stiffness as well as pain.
Affected areas feel weak and heavy.
The checkboxes are for your visual
Stretching is appealing (but not very effective).
convenience only. There’s no form
Hot showers and baths are usually helpful.
here to “submit.”
Anti-inflammatory medications don’t really work.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
2.4
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Slow checklist: a more detailed diagnostic checklist for myofascial pain syndrome
We can’t ever truly confirm a diagnosis of myofascial pain syndrome, because the condition itself is
hypothetical. Any chronic pain that appears to be of muscular origin has other possible
explanations (and less hypothetical ones). However, if there are enough of the right clues, it’s
reasonable to suspect pain of muscular origin, and that suspicion can even be fairly strong in some
cases. But “fairly strong” is about as good as we can get for a hypothetical pathology that has huge
symptom overlap with other causes of chronic pain.
A “trigger point,” on the other hand, cannot be “diagnosed” (explained) at all: it can only be
described. It’s just a sore spot, and only you can say if you have a sore spot! It’s just a symptom, a
subjective experience. While it’s the most important symptom that suggests the diagnosis of
myofascial pain syndrome, it’s only one.
This checklist is designed to help you decide how likely an MPS diagnosis is. As with the short list,
check all that apply (but there’s no form to submit — the checkboxes are just a visual convenience).
This can only be a guideline: there is (literally) no way to actually confirm this diagnosis. However,
the more of these items sound like a good description of your experience, the more reasonable and
useful it may be to accept a muscle pain diagnosis as a working theory.
Sore spots. By definition, trigger points are sore spots. They are disproportionately sensitive to
pressure for no obvious reason: too much pain with too little pressure (compared to problem-free
areas of your body). Of course any tissue will hurt if you press on it hard enough, and some spots
are naturally sensitive. Trigger points are obviously and unusually sore. If you have chronic pain in
an area and you find unusually sensitive spots in soft tissue nearby, spots that shouldn’t be sore as
far as you know, that boosts the plausibility a diagnosis of myofascial pain syndrome more than
any other single factor.
No other obvious cause for pain! And by “obvious” I mostly mean “injury.” One of the simplest ways
to diagnose trigger points is just by elimination: if there is no obvious trauma, then trigger points
are more likely to be involved. Obviously there are other possibilities.
Feels like muscle! As opposed to bone, joints, and guts especially. Pain is a difficult sensation to
interpret, but trigger points do often feel like muscle pain. Many small and subtle clues can
contribute to this subjective impression: a sense of moderate depth (deeper than skin, shallower
than bone), for instance, or sensitivity to flexing and stretching. Muscle pain can be much sharper
than expected, but usually it’s dull. If your pain is mainly aching, and nagging, with a strong
“stiffness” component — and there are no obvious signs of other kinds of pain, like stabbing or
burning or electrical sensations — then trigger points may be the source of your troubles.
You had an injury, but it’s old. If an average injury happened more than twelve weeks ago, you have
probably more-or-less healed, and any continuing pain that you have is increasingly likely to be
caused by trigger points. (There are other reasons pain persists after healing, but trigger points are a
strong possibility.) This is the “out the frying pan, into the fire” phenomenon, discussed in another
section, and in a separate article, Muscle Pain as an Injury Complication: The story of how I finally
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
“miraculously” recovered from the pain of a serious shoulder injury, long after the injury itself had
healed.
You crave stretch. You crave it because trigger points, more than other sources of pain, make you feel
stiff and stuck. 59 With trigger points, stretching may feel difficult or even like you are “pulling on
the pain,” but it will probably also feel relieving at the same time, a “good pain,” like scratching an
itch. Similarly, muscle pain tends to make people generally squirmy: a craving not just for stretch,
but for movement in general.
Despite craving stretch, it usually fails. Although it seems like a fine idea, stretching trigger points
mostly doesn’t help, except for a little short term relief, like you might get from joint popping. In
some cases it may provide more relief, but most MPS sufferers will be underwhelmed by the
benefits of stretching. However, because it does often temporarily take the edge off, stretch remains
appealing.
Aching, not sharp. Your pain is primarily dull, aching, nagging pain, as opposed to sharp, stabbing,
burning, aching. Although nearly any quality of pain is possible, and flared up trigger points can
get more focal and intense and toothachy, trigger point pain is usually a dull ache. There aren’t a lot
of unclear causes of aching pain. For instance, arthritis usually has an aching quality, but it’s also
obviously joint pain.
Similar pain around the body. Tendinitis in your ankle and a nerve impingent in your wrist are
obviously different problems in different places; trigger points often feel like the same problem in
different places. For “triggery” people, trigger points cause pain of a similar quality in a patchwork
around the body, but especially in the meatier tissues of the trunk (neck, shoulders, upper back, low
back, and hips). Other problems do cause widespread pain, of course, but usually more uniformly,
like the diffuse all-over sensitivity of the flu, or muscle soreness after unfamiliar exertion.
Abnormal texture. You might be able to feel a lump in your muscle and a hard and ropy texture
around it, but probably not. This is an unreliable way to diagnose trigger points, especially for
beginners. There are some muscles where trigger points may stand out more clearly, 60 but there
are many normal anatomical structures that feel like bumps and ropy structures, as well as common
harmless abnormal structures, especially “back mice” (lipomas). 61
Anti-inflammatory medications don’t help much. Since there is probably little or no inflammation
involved in trigger points, anti-inflammatories like Aspirin or ibuprofen (Motrin, Advil, etc) don’t
do much. If they do help, that hints that the problem may involve damaged tissues (such a
wounded facet joint or a ruptured intervertebral disc). Anti-inflammatory drugs mostly only work
on acutely inflamed tissue, and fail with many other conditions, including trigger points, so their
lack of effect is only one small clue. (Note that the effects of other drugs, are not very
informative. 62 )
Wandering pain. One of the clearest signs of muscle-dominated pain is symptoms that change
location capriciously, either moving to another area of the body altogether, or erratically shifting
around and spreading out from a predictable epicentre. In addition to moving, trigger point pain
also often changes quality, and comes and goes without much rhyme or reason (the “outta
nowhere” phenomenon). Not all trigger point pain is so erratic — indeed sometimes it can be
maddeningly stubborn in one spot — but it often is. On the other hand, pain driven by other kinds
of tissue trouble tends to stay put.
Chronic or severe stress in your life. People who suffer from excessive muscle pain often have a
medical history littered with other conditions that are caused or particularly sensitive to stress (e.g.
63
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
ulcers,
panic attacks, insomnia, irritable bowel syndrome, etc).
Weak and “numb.” Trigger points cause weakness in the affected muscles, a “heavyness” that can be
mistaken for the effect of a nerve pinch, like sciatica. They do not cause the kind of true numbness
(often with tingling) that we mostly know from the dentist or limbs “falling asleep.” You can still
feel a light scratch. True numbness is neither a common nor rare complication of MPS, so its
presence or absence is not informative. The presence of that dead, heavy feeling, however, does
suggest trigger points.
Heat helps. Hot showers and baths and other forms of heating, even just warm weather, are almost
always at least transiently helpful. Many kinds of chronic pain are helped by heat, 64 but not all,
and fibromyalgia pain is the most interesting exception: it is usually worsened by hot weather, 65
while MPS patients almost always prefer to be warm. This is one of the only obvious differences
between these otherwise extremely similar conditions. If you like to be toasty, score a point for a
trigger point diagnosis.
The pain of stuckness. The discomfort of trigger points may be experienced as stiffness following
periods of immobilization (e.g. hours in an airplane seat, or even a movie). This is a weak signal
because there are several other possible causes of stiffness, particularly in older people (most
notably arthritis and the progression of many subtle sources of inflammation that accumulate over
the years, known as “inflammaging”). But relatively widespread stiffness in a younger person with
no other known health issues, trigger points are a more plausible suspect.
If you checked off a many of these, congratulations: you have a little more diagnostic clarity!
Myofascial pain syndrome is definitely maybe a possible explanation for your problem. And that’s
about as sure as we can ever be.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
2.5
Negative checklist: signs/symptoms that are probably not caused by trigger points
In the sections below I’ll discuss several explanations for pain that isn’t trigger point pain, but can
seem like it. To start, here’s another simple checklist of symptoms that should lead you away from a
trigger point diagnosis. The more these “sound like you,” the less likely it is that a diagnosis of
muscle pain is meaningful, and a few of these items are deal-breakers that can eliminate a muscle
pain diagnosis to a high degree of certainty.
Bruise-like sensitivity to pressure at any point in a muscle (as opposed to an actual bruise) usually
indicates delayed onset (post-exercise) muscle soreness, not trigger points. Trigger points are
pressure-sensitive points, not whole muscles.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Extreme sensitivity to light pressure — like you’d get with an open wound or an infected hangnail,
say — disqualifies trigger points. Even the worst trigger points easily tolerate more pressure than
acutely inflamed tissue.
Pain that occurs consistently and sharply with a specific movement, and which intensifies strongly if
you try to push through it, almost always indicates damaged tissue, not a trigger point.
Pain that steadily becomes worse and worse over a period of days and weeks typically indicates a
more serious disease process. Although trigger points can certainly get worse over time, it tends to
be erratic, not relentless and steady. If you have this kind of pain, particularly in the absence of
other trigger point symptoms, please see your doctor.
Obvious muscle wasting is not a symptom of myofascial pain syndrome, not even a rare one. 66
Trigger points cannot directly cause any noticeable loss of muscle mass; at most, they could co-exist
with a condition that does. If you have an obvious loss of muscle mass with no obvious explanation, please
consult a physician.
Pain that comes on instantly — what we call an “oh, shit” moment — is not trigger point pain. Trigger
points can flare up rapidly, and they do routinely form in the aftermath of an injury (see the section
about trigger points and injury)… but usually not instantaneously. Even “several minutes” would be
fast for trigger points. A matter of seconds is probably possible in rare cases.
Pain that feels “electrical” or is associated with tingling (classic symptoms of neuropathy) is probably
not caused by a trigger point, or at least not directly. This is a hard one, because some people will
describe trigger point pain as electrical — but if they could compare it directly to typical nerve pain,
most would agree that nerve pain is much more “electrical” in quality. A good basis for comparison
is a funny bone hit: that’s what I mean by a good nervy “electrical” zap, hot and shooting and jolty.
Most people have hit their funny bone. The more your pain feels like that, the less likely it is to be
caused by muscle.
Non-pain irritation, like itching, actually could be caused by a trigger point … but it usually isn’t.
Mostly, trigger points just cause pain and stiffness. However, occasionally the disturbance of the
trigger point seems to be interpreted as another kind of sensation. The brain is basically saying, “Is
that a pain? Or an itch? I’m not sure.” 67 A real itch can confuse things even more. For instance, it’s
difficult for us to precisely locate sensations in the back, so if there was an actual itch close to the
pain, it’s entirely possible that we would interpret that as an “itchy pain” — or even just as an itch.
A “mobile” bump under the skin. This is probably the most common diagnostic error made by feel.
For instance, a reader sent this in, trying to describe his alleged trigger point, “I don't think it's air
but I didn't know a muscle knot could be mobile.” Well, they can’t — that is something else. There
is no model of trigger point physiology (not even a hypothetical/controversial one) that involves a
palpable bump that moves independently of the tissue it’s embedded in. A trigger point will not
feel like it can be pushed around between the skin and the muscle. A “cyst” is the most likely
explanation for a mobile-ish bump. Please check with a doc about bumps like that.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
2.6
Identifying your trigger points by feel: tissue texture and other palpable signs
March — Edited: Thoroughly edited for clarity. Stronger focus on the many ways palpation can go wrong.
It’s important to understand that you may or may not be able to feel a trigger point with your
fingers, and it’s dazzlingly easy for beginners to get this wrong. Hell, it’s easy for professionals to get
it wrong, as discussed above in the diagnostic reliability section. The only defense against this
uncertainty is a lot of humility, and the best possible understanding of what you are looking
(feeling) for as well as possible, which is what this chapter is about. Two key points:
1. If you can’t feel a trigger point, it doesn’t mean it isn’t there.
2. If you think you can feel one, it doesn’t necessarily mean that it is there. It may be normal anatomy.
Or abnormal anatomy but not a trigger point. Or your imagination!
Bear in mind, as always, that we’re dealing with a hypothetical critter here, the sasquatch of
pathology. It may literally not exist as a palpable lump. Maybe not in everyone, or maybe not in
anyone. We’re groping for the unknown here. But we’ll assume for the sake of practicality that there
is, in fact, something there to find.
In any case, it’s important to try to link what can be felt with your fingers with symptoms and
other subjective signs. A trigger point cannot be diagnosed by touch alone, but this section is mostly
about “touch alone.”
Will muscles with trigger points feel tight?
You expect cacti and scorpions to be found in an arid environment. Similarly, tightness is the
presumed natural habitat of the trigger point. Like most assumptions about the body, it’s not a safe
one. The texture of muscle is not a great indicator of anything at all, trigger points or otherwise.
That sounds like heresy to most massage therapists, who are fond of telling patients that they are
“really tight,” and the goal of all massage therapy seems to be to “soften” muscles, treating a firm
muscle texture as the enemy. Early in my career I got interested in whether or not this made any
sense, and, after a decade of experience and waffling, I decided that it did not. I’m not saying that
muscle texture isn’t an indicator of anything ever — such absolutes rarely work out — but I don’t
think is a good or reliable one, and in particular it isn’t a reliable indicator that “here be trigger
points.”
In a simple 2010 experiment, the hardness of the trapezius muscle (top of shoulder) was tested and
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
compared with sensitive points, and before and after intense exercise. 68 In a dozen healthy
patients, sensitive spots were not just softer but the softest spots in the muscle — the opposite of the
correlation that most people expect. In general, “a heterogeneous distribution of pressure pain
sensitivity and muscle hardness was found.” So much for tightness or hardness mattering. Clearly
muscle can be sensitive without it being obviously rigid. The conventional wisdom that “tight”
muscles are a problem is probably a misleading oversimplification.
Different body types naturally have different textures that seem
to be independent of myofascial pain syndrome or any other
pain problems. I do have a Vague Professional Impression™ that
lean and skinny folk are somewhat likely to suffer from aches
and pains than people with fatter and/or more muscular bodies,
but it is vague indeed. Maybe it’s just easier to find trigger points
in lean people, not that they are any more likely to have them.
A prominent trigger point can exist in a muscle that doesn’t feel
the slightest bit “tight.” The trigger point itself may feel more
like a denser patch of muscle than a hard nodule — a subtle
difference! The tightened muscle fibers containing it — the
“strap” — may not be an obvious “strap” or “cord” of muscle at
Sometimes muscle can feel as hard as bone.
Here’s an old therapy joke about tight
muscles …
Therapist: Can you feel this bone here?
Patient: Yeah.
Therapist: That’s not a bone. That’s a
muscle.
Patient: No way!
Therapist: Way!
all, but just an indistinct thickening. And that “signal” can easily
be lost in the “noise” of the natural variability of muscle tone and texture.
For what it’s worth, I’ve also never observed any significant, lasting change in a patient’s tissue
texture. People who show up for a massage with rigid cables of muscles often still have them as
they walk out — even if they are delighted by a change in pain and sensitivity.
More detail about what trigger points might feel like
If it can be felt, it will probably feel like a lump of harder or denser tissue somewhere along the
length of a tight “strap” or “cord” of muscle fibres, about the size of a lentil. The cord may twitch
when the trigger point is stimulated. Subjectively, those signs will usually be associated with
intense, distinctive, and familiar sensitivity… and relief after rubbing, ideally!
All of these details are variable, but the size is particularly unclear and unpredictable. The average
trigger point seems to be about the size of a lentil, but every now and then you’ll get one that’s as
big as an almond, and in rare cases in large muscles a trigger point may be walnut-sized. (Why
such huge variation? Some ideas can be found below in the science sections.) However, in principle
many trigger points may be just too small to feel — the size of a grain of sand, or even literally
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
microscopic! Good luck finding one of those.
Trigger points can vary
widely in size!
Some may be hidden in thick tissues, or under thick fat, of course. And others are surrounded by
other bumpy anatomical structures that will throw you off. This may be an extremely common
problem. When I massaged for a living, it was routine for people to ask me “What’s this? Is this a
trigger point?” while pointing to a bone or some other completely normal anatomical structure.
The normal structure could even be normally sensitive — or abnormally, for some other reason,
confusing things further. A particularly common example are benign cysts, which often feel like
they move a little between the skin and the muscle — definitely not a trigger point (see the negative
checklist).
Some trigger points may be tiny, deep, and surrounded by larger, normal bumps! This makes them
effectively impossible to identify clearly with your fingertips.
Not a mobile bump! One more time, because it’s important, a trigger point will feel embedded in muscle, and not
sliding between skin and muscle. See the negative checklist; and I described an example of this misconception in the
diagnostic reliability section.
The key objective and subjective symptoms of a trigger point
Putting it together, here are the official key features, both objective and subjective:
The tight band. Trigger points usually live in a strap of muscle that may be distinct from the
surrounding muscle — basically some of the muscle fibres are tighter than the others. It could also
be absent, or obscured by any number of factors (especially the presence of lots of other trigger
points) — but if you can find it, it is one diagnostic sign, 69 reported by many clinicians over the
decades.
Twitchy. If the muscle twitches slightly as you hit the sensitive spot, it’s called a “local twitch
response,” and that also tends to indicate the presence of a trigger point. It often isn’t easy for
beginners to detect, and it’s all too easy to confuse with ordinary flinching in response to painful
pressure. But, if you notice a distinct and isolated muscular twitch, it’s a good sign that you are
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
pressing a trigger point.
Intense and distinctive sensitivity. A trigger point will usually be the most sensitive spot in an
area. 70 Although a wide variety of types of pain is possible, it’s most likely to be a dull and
sickening pain, combined with a paradoxical feeling of relief. The combination is often described as
“good pain.” This contrasts rather sharply with pain from stressing injured or naturally vulnerable
tissue, which definitely will not feel good.
Familiar sensitivity. The sensitivity a trigger point will often feel “like” a problem that has been
bothering you, or has bothered you in the past. It will feel accurate (located in what seems like the
right spot to you), relevant to the problem (related or connected to it in some way that may or may
not be obvious), or simply similar to a symptom you’ve been having. This “recognition” factor can
increase your diagnostic confidence a fair bit. 71
Those are the four main things that can help to confirm a trigger point diagnosis: two symptoms
that only a trigger point’s owner can confirm, and two signs that might be felt by whoever’s hands
are on the job, yours or your therapist’s. I can’t emphasize strongly enough that these are
guidelines, not firm rules, and none of them are diagnostic on its own.
That paradoxical “good pain” concept is particularly important. It’s not a euphemism or a joke.
Trigger point pressure often really is both unpleasant and desirable at the same time: the “Ow!
Don’t stop!” effect. Because of it, people often really crave pressure on trigger points — often much
more than is wise, in fact. With sustained but moderate pressure or kneading, the tenderness
usually gradually fades and the knot seems to melt or unravel. For better or worse, that imperfect
and imprecise word “release” is usually used to describe this, and it is the goal of trigger point
therapy. There will be much more about how to get so-called “releases” later. For now, there is
more to learn about how to identify trigger points.
That’s no trigger point, that’s a ________
Thanks to reader SKY (her actual initials) for sharing this cringe-inducing tale of low palpatory
intelligence, which demonstrates that even some professional massage therapists really have no
idea what a trigger point actually feels like, and may fixate on any odd lump just like an amateur:
A massage therapist was giving a massage to a middle-aged man, and started working
deeply on his upper ribs below his clavicle. She couldn’t get the knot relaxed at all, and
kept working harder …
… until he told her she had found his pacemaker.
Oops. Many therapists wouldn’t have made that mistake, but unfortunately the story doesn’t
surprise me much. For all the talk of “magic hands” and the much-touted palpatory prowess of
massage therapists, this is hardly the only counter-example I’ve witnessed and heard of — it’s just
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
one of the worst.
One more (really cool) example of a misleading bump: abnormal bone
There all kinds of things that can and do fool experienced therapists, because anatomy is simply
chock-a-block with abnormalities. In fact, abnormalities are so common they probably shouldn’t
even be considered abnormal. Specific anatomical variations are exceptions, but almost everyone
has them: variation is the rule. 72
For example: ossification, or the formation of bone in where it doesn’t belong. (Technically an
ossification a genuinely abnormal pathology, a kind of benign tumour, and not an “anatomical
variation,” but whatever — it’s just weird anatomy for our purposes.) In the CT scan image below,
a portion of the patient’s quadratus lumborum muscle has been converted to bone. 73 And not just
any bone, but a substantial bone, about the size of a radius or ulna! It has grown between the pelvis
and the spine, echoing the fibre direction of part of the quadratus lumborum muscle.
Holy unwanted bone,
Batman!
Heterotopic ossification of
the quadratus lumborum
muscle. It’s surprising how
often this kind of jiggerypokery goes on in bodies.
This is an incredible image, and a dramatic reminder that not everything you feel in your body, or
anyone else’s, is necessarily supposed to be there. And not every hard lump in muscle is
necessarily a trigger point! This particular ossification was probably quite obvious to palpation, but I
think you’d be surprised: what we think we feel is very strongly shaped by our expectations. It
would not shock me if you gave such a patient to ten professionals to feel and an alarming
percentage of them miss it entirely or misinterpret it: “Wow, you’re really tight in your right low
back! Your quadratus lumborum is hard as bone!”
Yeah, literally!
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
2.7
“Out of nowhere”: a signature symptom of trigger points
Some chronic pain has an obvious cause and is relatively consistent: you know what’s wrong, and
as long as it stays wrong, it hurts. Frozen shoulder, for example. Although we don’t know why
shoulders “freeze,” the problem is definite, a diagnosable pathology. There are no “good days”
when a shoulder is freezing: it hurts all the time, every time it moves in certain ways. It doesn’t
come and go.
If it did, you’ve have to doubt the diagnosis.
Even when there is no known cause for chronic pain — which is typical with back pain, for
instance — the pain is either constant, or predictable (hassling you predictably with certain
activities).
Chronic but erratic pain is a major subcategory, and perhaps the hardest of all to understand. Why
would pain come and go without rhyme or reason? Is there something wrong or ain't there? Some
pathologies do act like that, and there several reasons why pain might be erratic.
But in the absence of other obvious causes, trigger points might be the culprit. We have to beware
of blaming any weird pain we can’t understand on trigger points, but sore spots that flare up
unpredictably are a real phenomenon.
Trigger points have many intriguing clinical features, but the “out of nowhere” thing might be the
most interesting of all: the tendency of muscle pain to both come and go without much rhyme or
reason. Pain the surges without any obvious mechanism of injury. Pain you wake up with —
common with neck cricks and back pain, and discussed more below. Pain that disappears for three
days when, as far as you know, you didn’t do anything to help it disappear. And then it comes
back, without doing anything to help it re-appear, as far as you know.
Trigger points lead to a lot of second guessing about what you could possibly have done to cause
such a pain. Both patients and professionals often thrash around looking for “the” aggravating
factor that supposedly explains flare-ups, whether they understand trigger points or not. For lack
of a better explanation they often fixate on something relatively trivial that doesn’t really have
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
much explanatory power. Whatever it is — stress, your golf swing, the phase of the moon — it
usually can’t possibly explain all your bad days of pain. Instead it will “sort of” explain “some”
incidents, but the bottom line is that you’re just not sure.
If you find yourself engaging in this kind of puzzled reaching for an explanation … you may have
trigger points.
Erratic pain — the phenomenon
First let’s look at this only in terms of the clinical phenomenon: a description, not an explanation.
Many people have the sensitive spots in muscle that we call “trigger points,” whatever is actually
going on.
Those sore spots are often at or near sites of unpredictable flare-ups of pain with no obvious cause.
While there may be an obvious provocation like exercise, it’s not consistent.
Relief is nearly as unpredictable. The pain might last an hour, a day, a week, a month, and it’s
usually unclear why it finally eases.
But there is a little more predictability: relief does often seem to follow “instinctive” self-treatments
like rubbing, warmth, and rest.
But then it will surge back again “out of nowhere.”
Whatever the cause, this is an extremely common experience, a pattern of symptoms that occurs
much more frequently than diagnosis with any other recognized type of injury or pathology. If it’s
explained by trigger points even some of the time, it’s important. So now let’s frame it in terms of
our best understanding of what trigger points actually are: a micro cramp.
If trigger points cause pain like this, there are probably two main reasons why. First, they are
probably irritated by many and/or unknown and largely uncontrollable factors — really just too
many for mere mortals to sort out. (Which is hardly unusual in biology: we rarely have any idea
what triggers an eyelid twitch, an outbreak of hemorrhoids, or ten thousand other problems large
and small.)
Second, they are probably “sneaky” by nature, developing for quite a while before becoming
symptomatic.
Sneaky trigger points: “latent” versus “active”
Trigger points can become quite clinically significant (sensitive only to pressure) before they start
just hurting (painful without apparent provocation). When they are relatively young and minor,
they are simply beneath our notice, a little sore to the touch, but otherwise painless. This
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
phenomenon really helps to explain a lot of trigger point situations.
We distinguish between two kinds of trigger points, on either side of the threshold where they are
impossible to ignore: “latent” when they only hurt when poked or otherwise provoked, “active”
when they hurt without any obvious provocation.
Comparison of Latent and Active Trigger Points
Latent
stiffness, tightness
hurts only if poked
sneaky, stealth mode
Active
stiffness, tightness
hurts, period
“loud” and impossible to ignore, like your brother-inlaw
Based on how common active trigger points are, it’s a good bet that latent trigger points are
probably quite common. We grow them like little alien babies in our tissues. 74 Most of them stay
that way, causing only minor stiffness, and maybe not even that. Our population of latent TrPs is
probably a factor in the creakiness we all feel as we age, even if we never get an active trigger
point. But some of them … drum roll … in most people, sooner or later, some of them will become
active. And when they do, it will usually happen quickly and with relatively little provocation.
It is when trigger points burst into activity that we have an episode of pain that seems to come “out
of nowhere.” The thing is, it didn’t actually come out of nowhere: the trigger point was well
developed already. It just woke up. It got pushed over a threshold.
The speed and ferocity with which trigger
points “activate” is not always the same.
Sometimes they become symptomatic slowly
and erratically, minor at first, then worse and
worse over time. At other times trigger points
activate so fast that it is almost like an injury,
and you could swear that you actually tore a
Practically everyone has latent trigger points
& lots of ‘em. We grow them like little alien
babies in our tissues.
muscle rather than just waking up a trigger
point. In fact, both patients and professionals
routinely mistake an activated trigger point for a torn muscle, but it’s usually clear that the onset of
pain wasn’t nearly as sudden and severe as a true muscle tear. (More about telling the difference
later.)
But most trigger points, most of the time, are in the baffling middle zone: they activate at moderate
speed in response to unclear/moderate stresses, giving the appearance of an unreasonable amount of
pain with no obvious cause.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Trigger points are irritated by too many factors to track
The other major reason that trigger point pain comes “out of nowhere” is that trigger points seem
to respond to an incredible array of physical and mental stresses — so many that there is no way to
know, on any given day, whether they will all add up to a problem. We don’t know what bothers
trigger points any more than we know why sometimes muscles twitch or cramp at night (both
fasciculations and night cramps are ubiquitous unexplained muscle behaviours).
A “rogue wave” is a rare type of large ocean wave that occurs when just exactly the right
combination of other waves comes together to make a really big wave. (Satellite studies in recent
years have proven that they occur regularly — and can be seen from space, yikes! Scary and neat.)
Well, a bad flare-up of trigger point pain is sort of like a rogue wave: a bunch of aggravating
factors coming together to make a really bad day for you.
There is no way to predict rogue waves … or trigger point flare-ups.
Silly analogy?
All good analogies are a bit silly. In this picture, a rogue wave
capsizes a Coast Guard ship in California, December 29,
2007. Believe it or not, serious flare-ups of trigger points are
a lot like rogue waves — the result of interactions between
many complex variables.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
2.8
Chasing pain: hurting in all the wrong places (referred pain)
I first heard the phrase “chasing pain” from Doug
Fairweather, RMT, the owner and director of the school
where I studied in Canada’s Okanagan Valley. Doug is tall
and thin and speaks as precisely as an engineer but always
gently, softly, and slowly.
“Chasing pain,” he explained to me, “is when you treat
only the tissues where the pain is, and you forget to look
for the source of pain in other places.”
It was an idea that I would return to many times over the
years. The key to the surprising clinical importance of muscle
pain is the somewhat spooky way it can cause symptoms
somewhere else — a bit of neurological strangeness called
“referred pain.” Referred pain makes trigger point therapy
interesting and much more difficult.
Referred pain is felt some distance away from its cause,
which can be any source of pain, like a trigger point. Or a
heart attack! When heart attacks cause pain in the left arm, that’s the best-known example of this
phenomenon: pain referral from the heart muscle to the arm. The problem is in the heart, and yet
the pain is strongly felt in the arm. Interestingly, a trigger point in the chest musculature can cause
the same referred pain, imitating a heart attack! I tell a story about a case like this below.
Referred trigger point pain usually feels like a wave of sensation spreading out from the trigger
point, sometimes leading to an area where the discomfort is felt more intensely: the trigger point
and a hot spot of referral, connected by a “bridge” of more diffuse pain. In some cases, there is no
bridge at all, just the soreness of the trigger point and the aching in the referral zone, with no
sensory connection between them — except that you feel the referred pain more vividly every time
you press on the trigger point.
For instance, you might have a trigger point in the muscles of the forearm, near the elbow — but
when you press on it, you feel pain in your hand and fingers! Like magic. Seriously: when you
press on the trigger points near the elbow, pain spreads like a stain down the forearm and right
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
into your hand … possibly feeling very much like annoyingly familiar symptoms in your wrist and
hand. This is probably a common cause of a lot of so-called carpal tunnel syndrome. 75 The
symptoms are in the wrist, but their cause is in the forearm muscles (not the capral tunnel).
Or, for instance, if I pressed on a trigger point in your neck muscles, you might feel pain behind your
eye — a pain just like the headaches you get once every week or so. Trigger points are one likely
cause of “cervicogenic headache” — headaches that are coming from the neck — which is on of the
best common examples of referred pain. You might feel surprised or even alarmed by such a
strange sensory connection, but it’s normal and common. Eye pain caused by pressing on neck
muscles doesn’t mean there’s anything wrong with your eye.
Why does pain refer?
Although referred pain is odd, it’s quite easy to explain the basics of the phenomenon: the body is
simply not wired for precisely locating internal irritation and injury. We literally just have a hard
time figuring out where pain is coming from when it’s deeper than skin. The brain gets kind of
confused, and interprets the pain as coming from a broad area of tissues. The science of it will be
discussed in more detail later on.
Simple referred pain patterns. Most referred pain patterns are not all that interesting: usually the
pain just spreads out around the trigger point, like egg white around a yolk. It’s often a bit
asymmetric, spreading down and out to the sides (laterally and distally). I consider it simple as
long as the referral zone is clearly “connected” and relativey close to the trigger point.
Consistent patterns. Referred pain patterns are surprisingly consistent from one person to the next.
When people tell me that they get their headaches “behind the eyes,” I can show them a chart of
the referred pain pattern that causes them so much misery. When I press on a common trigger
point in the back of the shoulder and casually mention that it may cause pain in their elbow, clients
are impressed.
“How did you know that?” they usually ask.
“Ancient Caucasian secret,” I tell them. “I looked it up in a textbook!”
Common referred pain patterns from trigger points were first published in 1953, and later in more
detail. Exactly how this was determined will be revealed in the referred pain science section.
Bizarre patterns. Referred pain patterns can be quite bizarre. I have seen scores of peculiar cases.
One women felt pain in her knee when pressing on her heel. Another had a hand that ached when I
pressed on a trigger point in his shoulder. Time after time, pain in one part of the body turns out to
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
be caused by a trigger point in another.
Chasing pain and misdiagnosis
Obviously referred pain can lead to misdiagnosis. Unfamiliar with referred pain patterns, all kinds
of health professionals mistakenly assume that the problem is where the pain is. They “chase pain.”
Either they don’t know about referred pain, or they underestimate it. One of most dramatic cases of
pain chasing I’ve ever seen was a massage therapist working on a severe anterior shoulder pain, for
several weeks, touching only the front of the shoulder. The problem turned out to be entirely in the
back of the shoulder, in a muscle called infraspinatus, which commonly causes anterior shoulder
pain. (This case is described in detail below.)
Patients “chase pain” as well, picking at the site of pain like a scab, oblivious to the possibility that
the problem might actually be coming from somewhere else. In the negative checklist section, I
mentioned that an itch usually isn’t caused by a trigger point — but it can be. I know of a patient
who suffered an itch between his shoulder blades so severe that he actually scratched an open sore
on his back. After months of torture, it was finally completely relieved by massaging what
appeared to be a trigger point just a few centimetres higher on his back than the itch. Talk about
“scratching an itch!”
Trigger point pain routinely does not originate from where you feel it, and presents one of the
greatest challenges for therapy. And so, referred pain will be explored in much more detail in both
the science sections and treatment sections.
Referred pain from trigger points particularly leads to the most common of all trigger point
misdiagnoses: mistaking trigger points for nerve pain …
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
2.9
Nerve pain is overdiagnosed
February — Editing: This chapter now plays nicer with related sub-topics, and I’ve emphasized the differential diagnosis context a little
more.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
How can you tell the difference between trigger points and nerve pain? Fortunately, it’s usually
easy, because nerve pain is distinctive. Nerve pain is neuropathic pain, the symptoms that arise from
damage to the nervous system itself, central or peripheral, either from disease, injury, or pinching.
It usually causes more “electrical” sensations, much more tingling and numbness, and in much
more specific locations than trigger points. This section ends with a reference chart comparing
trigger point and nerve pain.
Usually. Not always.
In spite of these common differences, the number one general category of misdiagnosis for trigger
points is probably nerve pain. Patients particularly, and poorly-trained massage therapists, are
unaware that nerve pain is so distinctive and tend to assume that any strange, spreading pain is
“some kind of nerve injury.” That assumption will often lead people to describe their pain with
“nervy” language, which boosts the odds that health professionals will also be bamboozled by the
difference. It all results in a great deal of barking up the wrong trees.
It’s certainly possible for trigger point like symptoms to resemble neuropathy and vice versa. I will
discuss both. The next section is case study of a woman with very “nervy” hip pain that responded
brilliant to trigger point therapy. And one expert suspects that trigger points may actually be nerve
pain — that crank nerves are the cause of myofascial pain syndrome — and I’ll discuss that much
further along in “Quintner: ‘It’s the nerves, stupid’.”
But those are details. Our culture paranoia about neuropathy is the bigger story, and that’s what
this chapter is about.
The fear of nerves (is stoked by pharmaceutical advertising)
I recently came across this full-page advertisement in National Geographic magazine:
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
“Do you feel burning pain in your feet?” the ad asks. “Or uncomfortable tingling, numbness,
stabbing, or shooting sensations? If so, you may have nerve pain.”
Yes, you might. But this kind of symptom is less common than patients and most doctors believe.
Plenty of so-called neuropathy is probably caused by myofascial pain syndrome.
Yet nerves have a mystique. They make people nervous, so to speak. The whole idea of nerves gets
people anxious. Could it be a nerve? people ask. Is this a nerve problem? What if it’s a nerve? Is
something pinching my nerve? Something must be pinching a nerve.
I once had a nice older Italian client who
would ask me, over and over again, in a thick,
sing-songy Italian accent, “So, it’s-a nerve,
eh?” No, I would say, it’s just a muscle knot,
not a nerve. And then — as if we’d never
Nerve pain is a lot less common than
patients & doctors believe.
discussed it — five minutes later he would ask
again, “So, that’s-a nerve, eh?” He was
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
obsessed with nerves!
Like everyone else is. Sometimes it seems to me as if modern civilization is still getting used to the
whole idea of nerves. When people talk about their nerves, it’s like they’re talking about something
just revealed by science early last year. They speak with some awe about something barely
understood … and feared. Nerves! It could be my nerves!
Schematic of nerve root wiggle room
On the left are the approximate proportions of
a healthy nerve root & the hole it passes
through (intervertebral foramen). When the
spine is pulled or compressed, the holes get a
little larger or smaller, as shown on the right …
but there’s still lots of nerve root room.
In general, nerves have extremely generous “wiggle room.” For instance, in the lumbar spine, the
holes between the vertebrae that the nerve roots pass through can be more than a couple
centimetres at their widest, while the nerve roots themselves are only about 3-4mm thick. 76 If you
stretch or compress the spine, the holes do change size a little — as much as 70–130% in the looser
neck joints, 77 a little less in the low back. 78 But even at their smallest, there’s still plenty of room.
Although nerve root impingement certainly does occur, you can see that it’s not going to happen
all that easily even where it’s most likely.
And here’s a neat thing: even if you do have nerve pain, treating trigger points may be a good way
of helping it. 79 This may occur because irritated nerves appreciate the improvement (stimulation)
of tissue health in the vicinity.
The case study in the extra section (next) nicely illustrates just how much trigger points can seem
like nerve pain.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Comparison of Nerve Pain and Trigger Point Pain
Nerve Pain
often causes tingling and pins and needles
electrical, zappy, hot, burning
often causes true numbness
Trigger Point Pain
almost never causes pins and needles
deep, aching, stabbing
may cause a “dead” or “heavy” feeling, but you
will still be able to feel light touch on the skin
very specific pattern/locations
sometimes quite variable
injured nerves tend to produce continuous symptoms, or trigger point pain, while it certainly can respond
symptoms that occur predictably in response to a certain to position and movement, is usually more
movement or position
variable and unpredictable
only a few nerves in the body are commonly hurt
although more common in certain areas, trigger
point pain also routinely occurs everywhere else
For a couple practical examples, see “Quintner: ‘It’s the nerves, stupid’”: I explore cluneal nerve
entrapment and meralgia parasthetica, both of which may be a little more likely to masquerade as
trigger points than other neuropathies, but both of which also still often have clear symptoms of
nerve botheration. And in the next section, an example of the reverse: pain that seemed a lot like
neuropathy but probably was not.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
2.10
Case study: a story about nerve pain that wasn’t really nerve pain
I once helped with a young woman who had “sciatica” — the mother of all nerve pinches. The
sciatic nerve is biggest single peripheral nerve in the human body. Allegedly, either her sciatic
nerve, or one of the lumbar nerve roots it emerges from, was being pinched and sending hot zaps
of pain down her leg. She came to me with this diagnosis already in place. She also had some
tingling in her feet (much like in the magazine advertisement). The description of her symptoms
did, indeed, sound a lot like nerve distress. On the face of it, it did seem likely that something was
being pinched. Although nerve pain isn’t nearly as common as trigger point pain, it certainly can
happen.
But a couple things didn’t seem to fit the story. For instance, she had no numbness at all — no dead
patches of skin, which are strongly characteristic of true nerve impingement. Instead, she had a lot
of “dead heaviness” in the leg, a different kind of numb feeling, much more closely associated with
trigger points than with nerve pinches.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
I quizzed her carefully about the quality of her
pain. She assured me it was “zappy” and
“electrical,” definitely “sharp” … just as you
would expect of nerve pain. But there was
something about her hesitation as she made
On the face of it, it did seem likely that her
sciatic nerve was being pinched.
these statements that gave me the impression
that she was interpreting an intense nonneurological pain as a “zappy” pain simply due to her strong belief that she had a nerve problem.
When you think a pain is nervy, you’re much more likely to interpret, feel, and then describe it in
nervy terms.
So I did some experimenting.
This young woman’s “nerve” pain could be vividly reproduced by pressing on muscle knots that
were nowhere close to any nerve tissue. Pressing on the side of her hip, on a gluteus medius trigger
point several centimetres away from the sciatic nerve, she reported the same “electrical” pain
flowing down her leg, even producing the weird, tingling sensations in her foot. This mostly
eliminated a diagnosis of sciatic nerve impingement. 80
I was actually surprised. The symptoms really did seem awfully neurological to me at first. But the
evidence was hard to argue with, and — in retrospect — I realized that I had been sucked in by
“nerve anxiety” myself. In fact, her symptoms were strongly consistent with a diagnosis of
myofascial pain syndrome (muscle knots). The only thing about her case the least bit unusual is
that her muscle knots produced referred pain more similar to nerve pain than usual, and even that
may have been a by-product of my earlier leading questions. That is, I may have accidentally
encouraged the use of terms like “electrical” by basically suggesting them to her: “Is it an
‘electrical’ sensation?” If allowed to describe her pain in her own words, she might have done so in
a less “nervy” way.
Muscle knots are always doing this: fooling patients and professionals alike. Likely more common
than nerve problems, and often more painful, muscle knots nevertheless get upstaged and
misdiagnosed. Do you feel burning pain in your feet? Or uncomfortable tingling, numbness,
stabbing, or shooting sensations? If so, you may have muscle knots!
The take-home message of this section: do not underestimate the power of trigger points to cause pain
that seems like a nerve pinch.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
2.11
Morning symptoms: an uncomfortable daily mystery for many people
May — Rewritten: Heavily revised to basically be an abdridged version of the article Morning Back Pain, focusing on trigger points. This
section had been aging poorly, full of unsubstantiated speculation and dubious premises. It’s on much firmer footing now.
Lita Scruton of Ontario asked me for an explanation of her morning back
pain:
Every morning I awaken stiff and have to get out of bed. No sleeping
past 7am for me, ever! I can’t take the discomfort. So why during the
day I can do anything, even exercise, and have no discomfort? Why
do my muscles get so painful while I am suppose to be relaxed and
resting? If I awaken during the night to use the bathroom they feel
great, but any time after 6am, it is a whole different story. Can you
help me solve this mystery?
You’re not alone, Lita! Countless people who are more or less pain-free
during the day nevertheless experience significant pain and stiffness first
thing in the morning, especially in the back.
Is pain & stiffness your
alarm clock?
Do you bail out of bed early
every morning with low back
pain, neck pain & more?
People wake up with pain so much that it seems like sleep is almost
dangerous. One of the top mechanisms of “injury” in my massage therapy
practice over the years was, apparently, sleep! It is absolutely amazing how many patients came to
me with a new pain and told me “it was just there one morning” or “I woke up with it.” Indeed, in
many cases they are woken by the problem. I still hear this kind of story constantly from readers
and friends. I’ve also experienced it myself many times.
There are four main ideas about what causes morning back pain, including trigger points and
myofascial pain syndrome. (Of course! Why else would I be bringing it up here?) The other three
are:
inflammatory back pain (pathological inflammation from autoimmune disease)
inflammaging (the slow but steady increase in chronic mild inflammation as we age)
awkward sleeping postures
There’s also a lot of overlap with fibromyalgia in this sub-topic. Both known for their morning
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
hijinks. 81
Trigger points in the morning
Trigger points may be associated with morning pain in general, and back pain especially, because:
The paraspinal muscles seem to be particularly vulnerable to trigger points, for reasons no one
understands. Just the way it seems to be.
And tissue stagnancy and postural stress seem to be a major cause of flare ups of trigger point pain,
and both are an issue at night. We are often pretzeled into awkward positions in our sleep for long
periods, 82
Awkward positions (postural stress) can be quite painful, even injurious. Sleeping often involves
slightly awkward positions held for periods long enough to cause sustained compression,
pinching, and oxygen starvation of tissues (which may or may not have already been vulnerable or
irritated). The dose makes the poison: it doesn’t have to be an obviously bad posture to cause
trouble. Just a little awkwardness will do the job if you’re stuck that way for long enough.
Although people can also carelessly tolerate postural stresses while wide awake, it’s more of a risk
at night.
And awkward position or not, just being still is always inherently uncomfortable. We like to move,
and sitting or lying down always gets unpleasant eventually. Forced immobilization is a potent
torture method (as discussed in the chapter about the “bamboo cage”). Trigger points in particular
may be aggravated by stillness. 83 Morning pain could be a wake-up call (ha ha), letting you know
that you have a bumper crop of mostly asymptomatic (“latent”) trigger points that flare up
overnight. In Lita’s case, trigger points could account for the consistency of her symptom timing,
and for the peculiar way in which she is fine at 6am, yet can’t stay in bed past 7am, but then is fine
again by 8am as she gets moving and her trigger points calm down.
That’s the highlights of the role of trigger points in morning pain. I discuss all of these topics in
detail in a dedicated article: Morning Back Pain.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
2.12
From the frying pan of injury pain to the fire of trigger point pain
May — Revised: Significantly expanded and modernized (for the first time since it was originally written, I think).
If injury is the frying pan, trigger points are the fire. This section of the tutorial is important if
you’ve been injured — or, in rare cases, if you’ve been injured and the only symptom of it is the
trigger point pain in the region!
Trigger points seem to be a routine complication of most injuries. In the aftermath of an injury,
pain and stiffness in the area often increase significantly. At first, this isn’t surprising: inflammation
and sensitization are normal features of wound healing. Spasm and fatigue of muscles around the
injury may also play a role, but already we’re venturing out on a scientific limb here (more on this
below).
As time goes on, this halo of symptoms can get surprisingly persistent, severe, and sprawling. It
gets harder to explain in terms of normal post-injury sensitization. It starts to resemble the
phenomenon of TrPs: focal soft tissue soreness associated with aching and stiffness. And
sometimes those symptoms can become so severe that the original injury becomes the least of your
worries. In fact, trigger points can be such a serious complication of injury that they can
overshadow it even in the early stages, obscuring the fact of an underlying injury and making it
appear as though a patient has mysterious musculoskeletal pain.
This graph shows how trigger point pain increases & then dominates, even
as injury pain is fading away.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Case study: a dislocated pelvis
I worked for a long time with a woman with a substantial pubic diastasis, or dislocation of the
pubic bones: a serious injury that neither or us knew she had. All we know was that she had an
extraordinary amount focal sensitivity in many muscles around the pelvis, with severe aching and
stiffness. Her diastasis had never healed and was an ongoing source of pain, and yet she had no
awareness of a primary problem at that location, which was just one of many sore spots, and not
the worst one. Her widespread pelvic pain completely overshadowed the injury itself. I had been
treating a complication, giving her temporary relief from the consequences of an injury — a game of
therapeutic Whac-A-Mole, treating trigger points that were doomed to be re-excerbated by the
unhealed injury.
Despite significant experience with severe trigger point
complications, even personal experience, I never even considered
the possibility of a serious physical trauma in the region as the
ultimate source of her pain. I had underestimated the potency of
trigger points as a complication of an underlying injury.
Basically, her pelvic pain was so bad that I never dreamed that it
had a single specific root. I feel bad about that oversight to this
day.
What kinds of injuries can be complicated
by trigger points? Probably almost
anything: sprains, strains (muscle tears),
fractures, overuse injuries and tendinitis,
lesions and lacerations. Anything painful,
anything that forces you to awkwardly
work around an injury in order to get things
done.
I’m hardly alone in having made that mistake: patients and pros
often don’t suspect that trigger points are a significant injury complication because they don’t think
that trigger points (if they know about them at all) can possibly causes as much discomfort as the
pain of an injury. But I have now come to the point where I believe that you should simply never
underestimate the potential ferocity of a trigger point. This power that trigger points have to
complicate and overshadow injuries is one of the most important things to understand about them.
When she finally got her diagnosis — with the help of a more experienced clinician than I was, plus
some imaging — she was able to minimize irritation of the injury, finally giving it a chance to heal
over the next 2-3 months. As it healed, it became possible to actually resolve the widespread
muscle pain in her pelvis: every massage brought greater and more lasting relief, until finally one
day she came in and said, “I don’t think we need to work on that anymore!”
How does injury trigger trigger points?
It’s an article of faith among trigger point therapists and experts that injury can “activate” trigger
points — a trigger point trigger — along with almost any other source of stress:
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Tigger points are activated directly by acute overload, overwork fatigue, radiculopathy,
and gross trauma. Trigger points are activated indirectly by other trigger points, visceral
disease, arthritic joints, joint dysfunctions, and emotional distress.
~ Siegfried Mense, David G Simons, and IJ Russell, Muscle pain:
understanding its nature, diagnosis and treatment, 2000 p. 213
Like the Dude said: “Yeah, well, that's just, like, your opinion, man.” Unfortunately, it’s never clear
what statements like that are actually based on. Probably because they aren’t based on much of
anything.
There is not much direct evidence that trigger points are a complication of injury, let alone that
they can be worse than the injury itself, as I have claimed. There is some weak/indirect
evidence, 84 85 but mostly I’m willing to endorse the dogma based on my own clinical
observation and personal experience. It may be largely unsupported dogma, but it’s unsupported
dogma that fits nicely with my own experience with this subject.
Here are a few possible explanations for why TrPs crop up around a healing injury and constitute a
significant complication:
Muscular reaction to the injury may be exhausting and stressful, making muscles more vulnerable
to TrP formation. But note that the idea of “protective spasm” (aka “muscle splinting”) is a bit
simplistic and probably only one facet of very complex muscular response to trauma. 86
Inflammation in the region might contribute directly to TrP formation. Although trigger points
don’t seem to be especially inflamed, per se, that doesn’t mean inflammation can’t be a trigger.
When tissue is injured, we immediately develop protective sensitivity that powerfully discourages
us from disturbing injured tissue. This sensitization is obvious in the short term with simple
injuries, but it definitely has slower and subtler effects. Our pain threshold may be somewhat lower
and funky for a long time after an injury, and that could simply lower the threshold at which
trigger points cause discomfort, without actually changing how they work, like rocks exposed by an
unusually low tide: they were always there, they just weren’t obvious before.
Whatever causes trigger points to form around injuries, we tend to underestimate their severity
and their longevity. Never underestimate a trigger point! They can produce worse pain than most
healing injuries, and for much longer. While some trigger points resolve spontaneously, or
relatively easily with some treatment, they tend to last and last, especially around injuries —
perhaps because even minor ongoing provocation from the original injury constantly “recharges”
them. While most injury slowly but surely heals, trigger point pain often overstays its welcome.
How can you tell if the pain of trigger points has actually replaced your injury pain?
You should be suspicious when an injury doesn’t seem to be healing, with no other obvious
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
complications, and the main persistent symptom is just simple pain, either the same or actually
worse than the original.
Obviously there should be some obvious sore spots too, around and near the injury site (as
opposed to the injury site itself 87 )
Most injuries improve steadily, even slow-healing sprains. In fact, healing usually accelerates: the
better you get, the faster you get better. You should be able to detect that improvement from day to
day with most injuries, and week-to-week at the worst. If you can’t, or if you are feeling even
worse than before, then there’s a strong possibility that trigger points have formed and are now
dominating the situation.
But there are exceptions, of course, other reasons why an injury is slow to recover:
The affected tissue may be naturally slow to heal, as in the case of damaged cartilage, ligament, or
tendon. Some cases are particularly slow.
Mysterious failure of healing is a rare but well-known phenomenon. Sometimes tissue just won’t
heal, and we don’t know why. These are often dramatic medical crises, like fracture non-union, but
I have long suspected that there are more ordinary possibilities.
You might not actually be aware of the injury or its extent, and you’re constantly re-injuring or
irritating it, preventing complete healing. This was exactly what was going in my case study above:
the patient who didn’t even know that she had dislocated a joint.
Or there could be a low-grade infection. A classic example of that is frozen shoulder, some cases of
which may actually be caused by an infection of the joint after surgery or injection: 88 it could
appear to be caused by stubborn trigger points when it’s actually an infection.
But most of the time, an injury that seems to be hurting too much, months after it should have
calmed down, has probably been overtaken by trigger points.
My own “into the fire” story (and a good example of the worst case scenario)
The worst outcome is that trigger points completely “replace” the injury, fooling everyone into
thinking that the injury has not healed. And I have experienced this, unfortunately.
In addition to seeing countless cases like this as a hands-on professional, I also have lived it. In the
summer of 2008, I seriously injured my shoulder. I tried to stop someone else from catching a
Frisbee, which went badly. I was playing goaltimate (a variation of the intense Frisbee sport,
ultimate, a sport that has wounded me many times). I leapt high in the air, tumbled clear over the
other player who was catching the disc, and fell a couple of feet onto the tip of my shoulder …
tearing my ligaments (an acromioclavicular joint sprain). It was a nasty injury. Unfortunately,
months later, I was in more pain than ever.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
And I was fooled by the persistence of pain. I thought the injury wasn’t healing. Ironically, after
years of teaching this principle to my own patients, I failed to recognize that I had jumped out of
the frying pan of injury and into the fire of trigger points. When I realized that was probably what
was going on and I started presumptive treatment, the results were quick, dramatic, and lasting.
Correlation is not causation, “but it sure is a hint.” 89
The story of my recovery illustrates this fascinating principle of injury healing. For readers who are
injured, please read about it — I can’t think of a better way for you to discover how this works. I
tell the whole story in, Muscle Pain as an Injury Complication: The story of how I finally
“miraculously” recovered from the pain of a serious shoulder injury, long after the injury itself had
healed.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
2.13
Could it be ________? Regional pains that trigger points get confused with
March — Edited: A thorough editing, especially to the information about frozen shoulder, part of an ongoing effort to upgrade differential
diagnosis information in the book.
As mentioned repeatedly so far, trigger points are often mistaken for other problems. A toothache
is probably usually caused by a cavity or some other genuine dental problem, but sometimes it is
caused by trigger points in the muscles of the jaw (I saw a clear case shortly before writing this,
which is probably why I thought to use it as an example just now, and I’ve experienced that
particular phenomenon myself). Many aches and pains are probably sometimes are caused by
trigger points instead of a more common and better-known problem.
But what about pain that is routinely blamed
on the wrong thing, when the real explanation
is probably a trigger point? Could your pain
be caused by bursitis? A sciatic nerve pinch? A
herniated disk? A little bit of time spent
discussing these may help you clinch a trigger
point diagnosis.
There are literally dozens, if not hundreds, of
pains which sometimes are caused by trigger
points.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Here are some of the things trigger points are
often and easily mistaken for. 90
Could it be a muscle strain? Yes … but probably not, and it’s easy to tell the difference, which
makes it all the more exasperating that this is such a common misdiagnosis. It is probably the most
common of all trigger point misdiagnoses, and perhaps even the most common misdiagnosis in
medicine. So sad!
Here’s a checklist of the signs and symptoms of a true muscle strain. If you can say, “Yeah, that’s
me,” to all of these, then congratulations: you almost certainly have a real muscle strain, and you
should probably stop reading this tutorial and go look at Save Yourself from Muscle Strain!
However, many people who are diagnosed with muscle strain actually have trigger points.
Did it hit you suddenly during strong stretching or in a moment of athletic intensity? In other words,
did you have an “oh, shit” moment?
Is the injury fairly recent? A few weeks old at the most?
Do you have just one muscle (or muscle group) that’s both weak and painful to use?
Is there a spot in the muscle that’s especially sensitive? (It may even be little bit deformed — is there a
bump or a depression?)
But if you “woke up with it,” or the pain came on slowly over several days, or if it’s six months old,
or if the pain isn’t consistently in one particular place … then we’ll be talking about other
possibilities.
Could it be bursitis? Probably not. If your doctor has told you that you have bursitis, I can
practically guarantee that you don’t have bursitis. If it weren’t so disturbing, it would be amusing
how often doctors diagnose any specific body pain they don’t understand as “bursitis.” But bursitis
is quite a distinctive condition — it causes severe sensitivity to very light touch, and often redness
and/or swelling as well, and only in quite specific anatomical locations (where bursae live). A nice
little case study of bursitis misdiagnosis follows this section.
Could it be a herniated disk? Probably not.
This is the mother of all common
misdiagnoses that scare people unnecessarily.
Disc herniations are feared out of all
proportion to their actual frequency or
severity. The scientific evidence is strong that
herniated disks are often asymptomatic, 91
It’s a bit of an in-joke in my profession that
doctors diagnose any pain they don’t
understand as “bursitis”!
often absent in many people who do have
pain, 92 93 94 and recover spontaneously far
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
better than people realize. They are clearly only one surprisingly minor factor in chronic low back
pain. And yet doctors still overuse MRI to overdiagnose and overemphasize the power of
herniations, despite an avalanche of official medical guidelines recommending against it. 95
Medical care for the Jetsons?
For many years now, MRI scans
have been the ultimate in
futuristic medicine. But while
these machines are miraculous in
some ways, they can be worse
than useless for diagnosing low
back pain.
Most back pain should not be attributed to disk herniations. In many cases, trigger points in cranky
lumbar paraspinal muscles are probably a more important factor and a more treatable one. They
might be the entire problem, or they might just complicate an otherwise trivial herniated disk (or
other relatively minor tissue issue). And treating them seems to be an effective way of indirectly
helping other problems in the low back. Why? Perhaps, for instance, because healthy nerves in
healthy tissues do not hurt. 96 Relieving trigger points may be a way of improving tissue health to
the point where nerves are no longer sensitive to minor stresses.
If you have low back pain, please read Save Yourself from Low Back Pain!
Could it be a pinched sciatic nerve? Or any other nerve? Usually not. Peripheral neuropathy can
certainly happen, but it’s rarely easily mistaken for trigger points, and will mostly have distinctive
symptoms like sharper and shooting pain, tingling, numbness and weakness. As discussed in
detail above, nerve pain is overdiagnosed in general — but in the back, buttocks, and legs, because
the sciatic nerve is an extremely popular scapegoat. While it is possible for it to get painfully
pinched by the piriformis muscle, there are three important considerations: (1) the piriformis
muscle may stop pinching the sciatic nerve if its trigger points are relieved, (2) the sciatic nerve
may be less sensitive to pinching if its muscular environment is healthier, and (3) piriformis trigger
points themselves routinely cause pain to shoot down the back of the leg, a more diffuse pain than
sciatica, more of an ache and a “dead, heavy” feeling instead of true numbness. But even if you’ve
got zappy, nerve-pinched feelings, remember: relieving trigger points may still the best way to
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
cope with it.
Could it be frozen shoulder? Maybe, but trigger points are definitely possible. Frozen shoulder is
not just “shoulder pain” — which involves pathological seizing up of the joint — but a lot of
shoulder pain gets misdiagnosed as frozen shoulder. Even when shoulder pain does match the
classic symptoms of frozen shoulder, it’s not necessarily a true frozen shoulder (that is, adhered or
contractured). A significant percentage of cases seem to be caused by muscle dysfunction, which
we know because it disappears under anaesthesia (which is fascinating). 97 And trigger points are
probably a major factor in many of those cases. I could probably run out onto the street and find
someone with this kind of pain before getting to the nearest intersection.
Frozen shoulder is most common among middle-aged women, and the biggest differences from
trigger point pain are: a painful “freezing” stage during which pain gets inexorably worse over
months, often with night pain, and then yielding to a relatively painless restriction of motion,
especially reaching up and behind the back.
Could it be tennis elbow (tendinitis)? There are cases of true tendinitis in the elbow, caused by
overuse of the wrist and finger extensors, but there are also cases of unexplained elbow pain, many
of which are probably just caused by fatigued and irritated muscles, which will usually means
there’s some trigger points there generating most of the pain. Also, tendinitis and trigger points
probably routinely co-exist. Things are complicated further by an especially distinctive, non-rare
referred pain pattern from the anterior scalene muscle in the neck to the forearm, which can
explain part or all of so-called tennis elbow. 98 See Massage Therapy for Neck Pain, Chest Pain,
Arm Pain, and Upper Back Pain and/or Save Yourself from Tennis Elbow! for more information.
Could it be carpal tunnel syndrome? Another difficult maybe. There is considerable potential for
trigger points to lead to misdiagnosis of carpal tunnel syndrome. Yet again, trigger points causing
CTS-ish symptoms are probably quite a bit more common than the genuine condition that they are
imitating. And, as with the previous two items, trigger points are such a common complication of
true carpal tunnel syndrome that it can be difficult to separate the two problems. “True” carpal
tunnel syndrome involves impingement of the median nerve in the wrist with clear weakness in
the hand, numbness and tingling in the thumb side of the hand, and nasty pain (especially at
night). Yet many cases that actually have those symptoms nevertheless seem to respond fairly well
to massage for trigger points in the forearms that refer pain to the wrist and hand, which raises the
question, “Was it really carpal tunnel syndrome? Or was it CTS that was so aggravated by trigger
points that treating them effectively solved the problem?” And then there’s the truly incredible
number of cases of frank misdiagnosis, where the classic signs and symptoms of carpal tunnel
syndrome are missing or barely there, but the patient gets diagnosed with it anyway. (And selfmisdiagnosis is extremely common too. 99 ) Such patients often obviously have strong referred pain,
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
and a bit of forearm massage routinely solves the “carpal tunnel syndrome.”
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
2.14
Many other causes of chronic widespread pain that should not be ignored
April — Rewritten: Totally revised and tripled in length, this chapter is “like new.” I also moved it to the diagnosis section of the book to
give it greater importance.
In the last section, we looked several ways that people can hurt or be injured in specific areas that are
sometimes hard to tell apart from trigger point pain. In this section, I’ll review other causes of
widespread chronic pain. 100 As with any of the more localized pains, these can also be complicated
by trigger points, or just co-exist with them, of course.
Trigger points often have something to do with unexplained chronic pain, but definitely not always.
Sometimes trigger points are only a small part of a much more complicated picture, and sometimes
they have absolutely nothing to do with it. The major premise of this book is that they are a likely
explanation for a lot of cases of chronic widespread pain, and that treatment is cheap and safe
enough that it’s worth trying before worrying about other possible causes.
But you shouldn’t ignore the other possible causes!
I am always delighted when people discover trigger points as a possible cause of their pain,
because it gives them a legitimate reason for hope. But fairly often I am also alarmed to see people
go shoot past “hope” and into excited overconfidence. While Trigger points can cause chronic pain,
but there are quite a few other possibilities! It’s very important to bear that in mind as you
troubleshoot a tough case.
What’s covered here?
I will review several possible culprits briefly, the ones that are the most likely to be confused with
myofascial pain syndrome. For a more thorough and general review of causes of chronic pain, see
30 Surprising Causes of Pain: Trying to understand pain when there is no obvious explanation.
Topics covered in this chapter:
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Pathological sensitization
Pain with literally no specific cause
Chronic low-grade inflammation and “inflammaging”
Myelopathy and dysautonomia
Referred pain
Syphilis
Facioscapulohumeral Muscular Dystrophy (FSHD)
Autoimmune diseases
Lymphoma
Topics covered elsewhere in the book:
Fibromyalgia
Hypermobility spectrum disorders and Ehlers–Danlos syndrome (next chapter)
Vitamin D and magnesium deficiencies
Drug side effects
And a few others that deserve at least a mention, but if I get into any more detail you will get
bored, and no one wants that:
benzo withdrawal (I suspect it’s a fairly common and unsuspected problem, and it's certainly one I
have a lot of tragic personal experience with)
painful anatomical oddities like os trignum syndrome (and there are quite a few of these actually)
Whipple’s disease can cause a bunch of joint pain (interesting but super rare)
the acne drug Isotretinoin (Accutane) may cause joint pain and, in rare cases, symptoms that mimic
rheumatoid arthritis and axial spondyloarthritis
chronic low-grade infections, maybe a bigger deal than we realize (and also overlaps with some
crankery)
Pathological sensitization
Pain itself often modifies the way the nervous system processes pain, so that a patient actually
becomes more sensitive and gets more pain with less provocation. It is basically a disease of hurting
too easily, a basic cause of pain that can itself have a bunch of other causes and complications,
including practically anything else discussed in this chapter.
Trigger points could actually a symptom of sensitization. (This idea is quite closely related to
Quintner’s hypothesis that trigger points are peripheral neuropathies: see “It’s the nerves, stupid.”)
The only thing we know about them for sure is that they are sensitive spots. So how can you tell if
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
tissue is “sensitized” but not triggery? There’s no way to know for sure, but the consistent absence
of a taut band of muscle tissue would be one major clue. Another clue would be a lot of sore spots
that don’t seem to have anything to do with muscle.
See Sensitization in Chronic Pain: Pain itself can change how pain works, resulting in more pain
with less provocation.
Pain with literally no specific cause
Some chronic pain is probably an emergent property of a big mess of synergistic stresses, with
literally no one specific cause. The problem is having too many other problems! This is a good news
scenario in the sense that it might be treated by relieving enough of the contributing factors … but
bad news in the sense that it may be like fighting a hydra. Trigger points may just be one head of
the hydra.
“Spasms”: cramps, dystonia, spasticity, etc
Trigger points are just one hypothetical muscle malfunction. There are others that aren’t so
hypothetical (although they do remain surprisingly underestimated and underdiagnosed, as with
trigger points). No one has any doubt about the cause of pain when they get a massive calf or foot
cramp, but not all cramps are so obvious, and there are other types of insidious and uncomfortable
muscle contractions. See Cramps, Spasms, Tremors & Twitches: The biology and treatment of
unwanted muscle contractions.
Chronic low-grade inflammation and “inflammaging”
Chronic, subtle, systemic inflammation is a possible factor in stubborn musculoskeletal pain. It can
have many underlying causes, from bad genes to mild autoimmune disease (including allergies),
smoking or other severe biological stresses, chronic infections, and even just getting old (known as
“inflammaging”). The greatest culprit is metabolic syndrome: a set of biological dysfunctions
strongly linked to poor fitness, obesity, aging, and likely emotional stress and sleep disturbance as
well. Along with sensitization, this is one of the major mechanisms by which other problems cause
pain. See Chronic, Subtle, Systemic Inflammation: One possible sneaky cause of puzzling chronic
pain.
Myelopathy and dysautonomia
An irritated spinal cord — usually irritated by being slightly pinched by a narrow spinal canal —
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
can cause an astonishing variety of problems, including widespread pain, without ever clearly
giving itself away. Symptoms can be in virtually any location in the body, if the location of the
trouble is high in the spine. This can go on for years, bad enough to cause pain but never bad
enough to be easily diagnosable.
Worse and weirder, intermittent irritation of the spinal cord may have some very weird side
effects, “dysautonomia” — excessive sympathetic arousal, causing you to react as if stressed. 101
Subtle dysautonomia from chronic mechanical irritation of the spinal cord is definitely a plausible,
sinister, and thoroughly obscure explanation for some chronic pain and anxiety.
Referred pain
This tutorial has already discussed referred pain from trigger points in detail, but remember that
referred pain doesn’t just come from trigger points! Anything that hurts inside the body — any tissue
deeper than the skin — is difficult for the body to locate. Chronic, undiagnosed pain often involves
referred pain from somewhere other than the location of the symptoms, and can have any kind of
cause. Referred pain results in an amazing amount of barking up the wrong tree; this confusion
will dominate your story regardless of whether trigger points or something else entirely is causing
the referral.
Syphilis
Believe it or not, syphilis can be fly under the diagnostic radar for ages, eventually manifesting
primarily as chronic aches and pains may develop. There’s often other symptoms too, but not
always. It’s a rare cause of chronic pain, but it should be noted: some patients with unexplained
chronic widespread pain probably have syphilis.
Facioscapulohumeral Muscular Dystrophy [early stages]
This is a fairly common and usually mild form of muscular dystrophy that often goes undiagnosed
for decades, before it eventually causes enough weakness and atrophy in the shoulders and face to
be identified. Until then, guess what it does? Makes your muscles sore! All of them! It specifically
causes excessive delayed-onset muscle soreness. Biology is destiny, and this condition is a really
good example of it. How many people out there are in that multi-decade period of wondering why
they get so sore so easily, before finally being diagnosed with FSHD?
Autoimmune diseases [early stages]
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
The autoimmune diseases are a huge class of pathologies that can cause essentially any nonspecific symptoms for a long time before diagnosis. It can take literally years for the situation to
clarify. These are conditions like lupus, rheumatoid arthritis, celiac disease, inflammatory back pain
(spondyloarthritis, a common cause of the phenomenon of morning back pain), and — the big one
— multiple sclerosis.
The spasticity of early MS is particularly likely to get mixed up with a diagnosis of myofascial pain
syndrome. One particularly good and sinister example of an MS symptom that can seem like a
trigger point problem: the “MS hug,” which feels like a painfully tight band around the chest.
Although the feeling of constriction is the classic symptom, many patients also just experience
widespread and erratic pain in the chest wall, probably from erratic, isolated painful contractions.
Cancer, especially lymphoma (cancer of the lymphatic system, lymph nodes)
Any cancer can manifest as a chronic pain problem, depending on the details of the disease
(remember, cancer is a disease with many, many forms). But lymphoma is the most notorious
generating extremely unpredictable symptoms for long period before diagnosis. It will usually also
cause other symptoms, like serious malaise and fatigue, but not always.
Fake diseases
Let’s wrap up with the silly stuff. There are literally dozens of bogus diseases that have basically
been invented by cranks and quacks and the desperate-but-näive to explain chronic pain.
Whole books can and have been written about this, but here are a few highlights relevant here,
conditions that I consider to be unequivocal nonsense that are often invoked to explain
fibromyalgia and/or myofascial pain syndrome. In a couple cases there might be a grain of truth
somewhere under all the fertilizer, but too little to worry about here. Most of these are discussed in
my fibromyalgia guide, unless otherwise linked.
electromagnetic sensitivity
repressed emotion
energy disturbance
adrenal fatigue
defective metabolism
vaccination injury
leaky gut syndrome
spinal subluxation
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
2.15
Hypermobility and Ehlers-Danlos syndrome
January — Addition: Added excerpt from a comedic and interesting article about a patient with Ehlers–Danlos syndrome who’s shoulder
was dislocated by a massage.
2018 — Editing: Some minor clarifications and additions.
Some people are much more flexible than average — pathologically flexible. Hypermobile patients
get hurt easily — especially repetitive strain injuries — and have a lot of chronic body body
pain. 102 Hypermobility seems be linked to all the bafflingly stubborn, strange medically
unexplained problems: fibromyalgia, chronic fatigue syndrome, temporomandibular joint
syndrome, and inflammatory bowel disease!
Obviously, there’s a lot of overlap with myofascial pain syndrome here too. Hypermobility may be
one of the things that drives the formation of trigger points — perhaps a consequence of the
constant striving to stabilize joints, or just a neurological response to pain arising from other
sources. We can only speculate: this has never been studied. All my comments on the relationship
between hypermobility and trigger points are just educated guesses.
Let’s get a little more specific than “hypermobility.” There are many types of hypermobility, with a
wide range of severity, from trivial “party trick” flexibility (“double-jointed”) with no apparent
consequences — especially early in life — all the way to full-blown genetic disorders of the
connective tissue with many serious medical consequences. There’s a huge gray zone in the middle
of under-diagnosed and under-treated people, who are definitely having problems but may never
figure out why or what to do about it.
Hypermobility spectrum disorders (HSD) are a group of conditions defined by joint
hypermobility — unexplained joint looseness. HSD is a bucket diagnosis for people with
symptomatic hypermobility, but without a connective tissue disorder that explains it, like Ehlers–
Danlos syndrome or Marfan syndrome. Most connective tissue disorders are relatively obvious,
but EDS can easily evade diagnosis, making it a prime suspect in many cases of chronic pain…
Ehlers–Danlos syndrome (EDS) is a closely related group of conditions with known genetic causes
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
that includes hypermobility along with lax and fragile tissues that injure easily and heal poorly
(especially skin), with many consequences. The most common form of EDS is hypermobile
EDS(hEDS), and it is the only form of EDS without a known genetic cause. It’s tricky to distinguish
hEDS from HSD. 103 However, hEDS is probably associated with serious rheumatic diseases (i.e.
psoriasis, ankylosing spondylitis, rheumatoid arthritis)… and this is fresh science and likely to be
missed, “perhaps due to a lack of gravitas surrounding the hEDS diagnosis.” 104
Given the musculoskeletal troubles that we know hEDS can cause, it is reasonable to guess that less
severe hypermobility (HSD) may also be both clinically important and yet even less obvious.
So, hEDS/HSD is serious … but it’s not taken seriously. Even
doctors who know about hEDS/HSD usually assume that it’s
mostly a minor condition, and would definitely not refer patients
on to a rheumatologist. And even if they did, many
rheumatologists probably wouldn’t take it seriously either! They
tend to be preoccupied with more obvious and dire cases.
To sum up, hyperbmobile-type Ehlers–Danlos syndrome (hEDS)
is the most common major sub-type of EDS, a connective tissue
disease without a genetic marker, which probably causes a lot of
body pain but isn't well understood and is rarely diagnosed.
And if you have joint looseness that cannot be explained by
Exactly the wrong therapy If chronic body
pain is caused by a subtle disease that make
connective tissue fragile, how tragically
misguided it would be to try to help by
stretching those connective tissues! And yet
that’s exactly the point of “fascial release,”
an extremely popular form of massage
therapy, which overlaps with trigger point
therapy to some degree (there’s a chapter
about it later on). Later in this section, I
share a story of massage injuring an EDS
patient.
hEDS or any another connective tissue disease, that might be
hypermobility spectrum disorders (HSD), which is probably almost as clinically important as hEDS
but even less well understood and even harder to diagnose.
Taking hypermobility seriously
Collectively, HSD/hEDS are probably quite common. If you suspect that hypermobility could be at
the root of your troubles, I strongly recommend that you do some more reading and pursue a
diagnosis as best you can. Hypermobility is probably one of the major possible causes of extremely
stubborn myofascial pain syndrome.
Or, much worse, the idea of trigger points could be completely unrelated, a red herring. I see a lot
of people get very excited about the idea/hope that trigger points explain their pain, and might be
treatable. In many cases that excitement is justifiable, and relatively harmless even if it’s wrong. But
it could also send someone on a long-term detour from a correct diagnosis that they really need!
Trigger points are probably a commmon complication of hypermobility, and so learning to treat
them probably isn’t going to be a total waste of time … but for some hypermobile patients, chasing
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
trigger points could be a pointless, harmful distraction.
Here’s a short checklist of reasons for clinical suspicion of HDS/EDS. This is not a comprehensive
diagnostic checklist … just enough to give you a sense of whether you should be looking into this
more deeply, and asking your doctor to take it seriously with you:
too many sprains, strains, and RSIs
too many dislocations of joints (joints "pop out")
poor balance and/or co-ordination
thin, stretchy skin that is easily cut and torn
digestive problems like diarrhoea or constipation
you’ve wondered and worried about diagnoses like fibromyalgia
too many aches and pains for your age … and probably too many damn trigger points!
Obviously many people without hypermobility could check of at least a couple items on that list,
and virtually every patient reading this book will at least claim the last one! But if you check off
more than a couple, it’s probably time to learn more about hypermobility.
Manipulating hypermobile people is risky!
Massage for people with hypermobility has the potential to do real harm. While it’s possible that
cautious trigger point therapy (de-emphasizing tissue stretch) could be safe and helpful, there’s
still a hazard: joints may be too unstable to manipulate. Here’s an excerpt from a funny, poignant
tale of a patient with Ehlers–Danlos syndrome who was injured by a massage therapist. 105 (Great
illustrations, too!) Here’s an excerpt about her medical history:
So there I am, blissed out on the massage table. Zinfandel Blush has marinated me like a
chicken breast. The whales are climaxing in the background, and I'm drifting off to sleep.
She runs her oil-covered hands down my arm and gives it a gentle tug to stretch out my
stiff shoulder, but it just keeps coming, until pop! It comes clean out of the socket.
Dislocated.
Now I am very much awake. Zinfandel Blush is screaming. She has literally just pulled a
client apart with her bare hands.
The door is flung open and the manager comes running in.
The therapist's face is covered in tear-streaked mascara and her blonde top-knot is flailing
around like my dislocated arm. The manager slams on the lights, hits the fire alarm and
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
yells about an ambulance.
I am too preoccupied to explain that I dislocate frequently. That my jaw fell out in Costa
just the other day. And that this, whilst being painful and understandably alarming to
innocent bystanders, is a regular occurrence.
Obviously this patient was aware of the risk, and probably failed to warn her therapist just how
vulnerable she was. (No massage therapist would ever incautiously manipulate a patient with
EDS… right?!) But bear in mind that plenty of patients aren’t aware of their own condition, and
halfway to an accidental dislocation is still a problem — certainly not therapeutic!
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
2.16
Case study: “Bursitis” strikes again!
June — Upgraded: Added more detail about greater trochanteric pain syndrome, making the section a little more useful to many readers.
Here’s an interesting anecdote from a patient misdiagnosed with bursitis:
I’ve had hip pain for three years, strong enough to keep me from sleeping at times.
Usually it’s on the side of the hip, but now it’s gravitated to the front of the hip, the top of
the leg, and to the tail bone area. The diagnosis has always been “bursitis,” but I’ve
started to wonder about that, especially now that it’s spreading — bursitis doesn’t spread,
I don’t think! I’ve had steroid injections, extensive massage and chiropractic therapy,
sessions with a movement educator, even intramuscular stimulation therapy, and nothing
seems to work, and no one has ever challenged the diagnosis. It was when the doctor told
me to set up an appointment with his receptionist to “rip out the bursa” that I knew it
was time to seriously look for another explanation.
~ Melinda Alltree, Vancouver
Bursitis misdiagnosis is particularly common in the location Melinda describes: right on the bony
bump on the side of your hip. The bump is the greater trochanter of your femur, a tremendously
sturdy piece of bone that all the hip muscles attach to and pull on. There is indeed a bursa between
the greater trochanter and skin, and it does indeed sometimes get inflamed.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
However, actual bursitis as the primary problem is fairly rare, and when it does occur it tends to
have the focal sensitivity of an infected hangnail. It is extremely sensitive. People with this kind of
bursitis often have a hard time even wearing pants.
Pain in this area is area is usually more aching and diffuse, with no single clear cause, and we call
this syndrome “greater trochanteric pain syndrome.” It is probably usually caused by a
combination of several things that overlap: maybe a little bursitis, but more likely gluteal tendinitis,
referral from deeper structures, minor peripheral neuropathies, and/or (my contribution)… trigger
points. It routinely co-exists with back pain, and so it likely shares some roots of back pain (like
TrPs).
In my clinical experience, almost everyone with trochanteric pain has extensive sensitivity in their
low back and gluteal musculature, in addition to soreness of the trochanter itself. Referral to the
lateral hip is common in this population of TrPs. I speculate that the trochanter is an intersection of
multiple referred pain patterns from several common trigger points, which goes a long way to
explain the way the trochanter is always the epicentre but never the only thing that hurts in the area:
it is always surrounded by a halo of more diffuse pain.
I’m pleased to report that Melinda sent me a happy update, letting me know that after seeking
trigger point therapy, she enjoyed substantial, lasting improvement in her pain:
As for my trigger points, we worked for an hour on perfect spot no. 12 and perfect spot
no. 6! It gave me great relief around the tailbone within two days. The pain is not totally
gone, but almost. I still have the pain in the ‘bursitis’ area but have been able to lay on my
right side every day now.
Remember, that’s after three years of hip pain! Just another trigger point therapy success story.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
2.17
Predictably unpredictable: trigger point symptoms are erratic by nature
Another “predictable” feature of trigger points is their un-predictability. They are predictably
unpredictable, consistently inconsistent, and even inconsistently inconsistent. Trigger point pain
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
may remain “stable” for two days, two weeks, two years … or forever.
The uncertainty is baked right in. Myofascial pain syndrome is a syndrome — a collection of related
symptoms. A trigger point is the theoretical cause of most MPS symptoms most of the time, and
trigger points themselves behave strangely according to rules and properties no one fully
understands. But there are also other common causes of pain that come and go and make MPS
appear to be even more varied and colourful.
By contrast, injuries and most other common musculoskeletal conditions like tendinitis tend to be
much more predictable: they more or less hurt in the same place, in the same way, in response to
the same stresses. I am often able to offer patients a tentative diagnosis of myofascial pain
syndrome on this basis alone: the symptoms are not enough like any other common problem. 106
Making things even harder: the phenomenon
of trigger point pain can also be consistent. In
fact, stubborn persistence is also a cardinal
feature of trigger points. Once activated,
trigger points are quite capable of lasting
literally for the rest of your life. Trigger points
can be forever, in some rotten cases. Pain that
Trigger points are predictably unpredictable,
consistently inconsistent, or even inconsistently
inconsistent!
lasts far longer than the healing time of any
ordinary injury is one of the main things that
should make you suspect a trigger point, because injuries heal and trigger points routinely don’t.
They are one of the major things that makes chronic pain so chronic.
But trigger points are equally capable of resolving at the same pace as a tissue trauma … or
disappearing hours after appearing … or remaining exactly the same for seven weeks and then
switching to the other side of your body … or driving you nuts for three years and then
“suddenly” yielding to (a) therapy or (b) who knows?
Getting the idea here? Myofascial pain syndrome could be called “uncertainty syndrome,” and
trigger points can be quite “flamboyant.” For instance, they can also cause strange sensations. You
can mostly thank your brain for this: it struggles to interpret internal pain without an obvious
cause, and literally makes stuff up, colouring the discomfort with our anxiety, confusion, and even
creativity. No one gets poetic about the weirdness of a toe stub — the nature and location of the
pain is straightforward — but they certainly do when trying to describe muscle pain. 107 But with
muscle pain, we don’t know what’s going on, and in many cases we literally can’t figure out where
it’s coming from. Consequently, they can be felt almost everywhere, or even in patterns that shift
from moment to moment or day to day. And it doesn’t help that they also come and go without
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
apparent rhyme or reason.
Patients with myofascial pain syndrome often crave the “solid ground” of a concrete injury
diagnosis, and who can blame them? The strangeness of trigger point symptoms can cause a lot of
consternation and wild speculation. While doctors misdiagnose, patients worry. It is not
uncommon for people to ask me if I think there’s any possibility that their trigger point could
actually be a tumor or some other ominous condition. In their minds, only something very serious
could cause such strange and strong sensations.
Fortunately, it’s usually straightforward to eliminate the scary and dire possibilities — none
behave very much like trigger points. 108 Serious medical problems can cause and aggravate
trigger points, of course, but they also tend to cause other, nastier symptoms that give them away.
If your main problem is muscle pain, chances are good that there is nothing medically serious going
on.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
Message from the Management …
Enjoying the tutorial so far? I hope so. Here are some tips and reminders about your tutorial:
You have access to this document online forever. Until the end of the internet. No matter how much is
upgraded or added. Bookmark this page, and/or save the address somewhere (or just ask me, if you ever
need to).
Get more for less. Can I upsell you? �� You can save 50% per tutorial by buying a bundle, an
“eBoxed Set.” DETAILS The cost of any previously purchased tutorials is subtracted. For details
and your set-completion price, see the Introduction for Customers at the very top of the page.
It’s nice to share. You’re welcome to share the tutorial by sending someone the address to the
document — too many requests from too many locations will result in a polite warning not to share quite so
much, but up to 3 other people can access it no problem. And, of course, I’d be delighted if you want to
recommend the tutorial for purchase. To do that, send someone this simple link:
https://www.PainScience.com/trigger-points
Observe and report! Spot a typo? Some broken formatting? Don’t be shy — do let me know. If you can find
10 errors for me, I’ll happily supply you with a free additional tutorial, and a gold star. Yes, this offer is for
“reel.” I’ve given out many free books for this over the years.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
2.18
All the noise! Trigger points and crepitus (joint popping and more)
2018 — Editing: A light re-write, de-emphasizing the dubious link to trigger points.
Active trigger points are associated with “crepitus” — a fun word,
which means “tissue noise.” Crepitus can refer to any crunching,
crackling, popping, snapping or grinding noise or sensation in the
human body. There are three common types of crepitus (at least):
1. “Rechargeable” joint popping, as in classic knuckle cracking. Joints
seem to pop more loudly, and more often, in painful and injured areas.
This is by far the most common and obvious of the three types. Note that no one really knows,
despite some commonly floated theories, what the $!#@&! joint popping actually is. It is fairly well
established that it’s harmless, fortunately. In 1998, Dr. Donald Unger won an “Ig Nobel Prize” for
diligently cracking the knuckles of his left hand only — never his right — every day for more than
sixty (60) years. What did he find? “There was no arthritis in either hand, and no apparent
differences between the two hands.… there is no apparent relationship between knuckle cracking
and the subsequent development of arthritis of the fingers.” 109
2. Tendon snap — tendons may cause a snapping noise as they move over projections of bone or other
bumpy anatomy. Common places for tendon snap are the shoulder and the hip. It’s possible that
tendons snap more if the muscles attached the tendons have abnormally high tone, and muscles in
the state may also be more likely to harbour trigger points.
3. Harmless breaking of adhesions between layers of connective tissue. Nothing important is actually
breaking, but it can sound and feel strange, kind of like pulling up carpet. See the adhesions section
for more information.
The increase in joint popping in troubled areas is fascinating, and I have an extraordinary example
of it. In February 2010, my wife was in a terrible car accident — while travelling alone in Asia no
less — and she had a great deal of healing to do. One of the most obvious effects of the accident has
been a spectacular increase in joint popping, particularly in her spine, near the vertebra she
fractured. It’s impressive! And it has lasted for many years so far since.
She had never really popped her spine before the accident.
I also have personal experience with this. Not only am I a “triggery” person, but my joints are
extremely noisy as well. Virtually every joint in my body pops regularly and spontaneously, some
of them very spectacularly.
And many patients and readers have reported this phenomenon to me over the years. But I have
yet to see anything in a medical journal and text about it; there is no scientific evidence about this,
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
and not even really any theories. My own guess — and it truly is just a guess — is that the popping
is linked to inflammation.
Don’t be alarmed by it, it’s the least of your worries — simply consider it an interesting partial
diagnostic sign of trigger points, something that crops up in the same conditions, perhaps for the
same reasons. Wherever you have pain, you are likely to have both extra trigger points and extra
crepitus.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
2.19
What are the worst-case scenarios for myofascial pain syndrome?
Sometimes people have a hard time believing that their pain could be caused by trigger points
because it’s just so bad. How could it be caused by “just” muscle? It’s important to understand that
nearly any amount of pain and misery is possible with trigger points, and with the human nervous
system in general. There are three noteworthy kinds of worst case scenarios that I will cover in the
next three sections:
1. unusually numerous and/or severe trigger points (being a “triggery” person)
2. rare but extreme cases where trigger points seem to “take over” and the diagnosis of myofascial
pain syndrome no longer seems adequate
3. isolated but fast and savage trigger point activation
Given the global reach of this tutorial and the ease of digital communications, I have had the
opportunity to talk to people suffering from more horrible trigger point problems than I would
ever have guessed existed. Working in relative isolation here in Vancouver in private practice, I
might well have never come across such cases, even after decades of clinical work. But, thanks to
this website, I have heard tales of the worst of the worst. And the extremes are surprising …
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
2.20
Worst Case Scenario 1: Being triggery
I recall a reader from one of Canada’s eastern Maritime Provinces who, after giving birth,
developed an alarming collection of hard nodules in her abdominal musculature which seemed to
have most of the typical diagnostic signs and symptoms of trigger points. And yet there was
nothing typical about their severity: they caused intense and constant pain, shortening her muscles
so much that she could barely stand up straight, as though her body was doing a permanent sit-up.
These trigger points didn’t go away in response to any therapy she tried, and she had certainly
tried a lot of therapies before she spoke to me. She had been in pain like that for more than three
years when I spoke to her.
As severe as it was, though, the severity was really the only unusual thing about it — in all other
respects it seemed like a typical case of trigger point pain. For instance, the problem remained
“regional” (it hadn’t spread throughout her body) and her trigger points acted like trigger points
— just really horrible ones.
She was a classic case of a “triggery” patient: someone whose muscles were extremely prone to
extreme trigger-point formation for unknown reasons. There was probably some X factor in her
case, something about her that predisposed her muscles to this fate. But her doctors had certainly
cleared her of any obvious diseases, and having X factors that complicate myofascial pain
syndrome is the norm. Almost every case of myofascial pain syndrome is aggravated and
sustained by poorly-defined X factors. The problem is that, in her case, she had some crazy “perfect
storm” that resulted in one of the worst cases I’ve ever heard of — one of the worst that was still
clearly myofascial pain syndrome, anyway.
There’s another way to be “triggery”: instead of being bizarrely intense, trigger points can also be
bewilderingly numerous — an endless plague of more or less average trigger points. This is
particularly striking in the young, who seem prematurely aged by the profusion of pain and
stiffness. I have seen many minor examples of this in my own massage practice, and heard about
more dramatic cases from readers around the world. They are characterized by common symptom
themes — for instance, an area like the low back, or the right side of the body, may consistently be
the most troubled — but also by a steady supply of unpleasant surprises in other areas of the body,
and constantly shifting cravings for pressure in different locations.
Such patients often present a great clinical challenge for a massage therapist, in that they seem to
want to be massaged everywhere at once, and no sooner do you arrive in one area than they
declare that the target has moved. In many cases, I suspect it’s not that therapist and patient are
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
struggling to “find the right spot,” because there is no one “right” spot. Instead, the patient’s
priorities and cravings are shifting rapidly: as helping hands “take the edge off” one spot, the
patient’s nervous system decisively announces the next-most-desperate area requiring attention. A
perfect analogy is the way that a back scratch can seem just perfect one moment, but then the next
moment there’s a great urgency for the scratch to be “just a little lower.” I think the same thing
happens in triggery patients, but the pain gives it a disturbing urgency. If you consider how strong
the “just a little lower” feeling can be, how strong must it be in someone experiencing serious pain?
No wonder it sometimes seems as though such a patient can’t be satisfied!
As bad as this scenario can be, I’ve heard of even worse. Unfortunately, although it’s rare, there
seem to be some people whose experience of myofascial pain is defined by trigger points that are
both extremely numerous and intense. Push far enough along the spectrum of badness in that
direction, and the diagnosis of myofascial pain syndrome ceases to be meaningful.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
2.21
Worst Case Scenario 2: Rare but extremely severe cases of myofascial pain syndrome
Turn the volume up loud enough on an average sound system, and the music stops being music.
That seems to happen to a few unlucky people who start out being merely “triggery” — a bad
enough situation to begin with. The pain signals become so loud and overwhelming that they lose
their meaning, and the patient is crippled by vicious and widespread chronic pain, just as severe as
painful diseases like rheumatoid arthritis or complex regional pain syndrome. In these patients,
trigger points (muscle knots) seem to have taken over the whole body, the problem changed into
something altogether different in the process — a whole that is greater and nastier than the sum of
its parts.
In July 2009 in Las Vegas I encountered an interesting analogy to this puzzle at the Science-Based
Medicine Conference. Mark Crislip, MD, an infectious-disease specialist from Portland (and host of
the popular podcast Quackcast), gave a superb presentation about the hypothesis of “chronic Lyme
disease.” He made a strong case that it is a misnomer, a meaningless diagnosis, an overconfident
attempt to define a problem that cannot actually be defined.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Some patients do seem to have some kind of post-infection meltdown. They don’t still
have an infection any more in any sense that we understand infection. But someone is
going to have to explain these patients to me someday.
And that is precisely how I feel about patients with unusually severe chronic trigger point pain: I
don’t think that they have myofascial pain syndrome in the same sense that we understand normal
muscle pain — clearly their cases have gone beyond that, but just as clearly they have had “some
kind of meltdown,” and “someone is going to have to explain” them to me someday. Although
these cases seem to have their origins in the same kind of myofascial trigger points that Travell and
Simons described so thoroughly, it is equally clear that this can lead to a new kind of predicament
in the body, one that is more scientifically puzzling than muscle pain (as if we needed any
additional mystery here).
All painful conditions share some characteristics, regardless of the source of the pain. As with any
chronically painful condition, the pain of trigger points probably becomes difficult to distinguish
from wholesale malfunction of the “pain system” — the sum total of all the neurology and
psychology that controls pain perception. Speaking generally, then, what is strange and extreme
and difficult about these patients may “simply” be the nature of pain system dysfunction. It isn’t so
much that they have severe trigger points (though they probably do), but that their pain systems
have been “fried” by the experience.
Pain is informative — or rather, it should be informative. It is supposed to tell us about problems
and threats, teach us what to avoid, tell us when to lie still. Pain system dysfunction begins
wherever pain starts to lose meaning, and that can begin quite early in any painful problem.
Anyone who’s had a headache for a few hours will be happy to tell you that they’re not learning
anything useful from the pain!
Pain system dysfunction is peaking whenever pain perception becomes seriously mismatched to
reality: when non-painful stimuli become painful, when “everything” starts to hurt regardless of
whether there is anything wrong or not, when the volume of pain is out of proportion to the
severity of anything actually happening in the tissues. In such situations, it is no longer your
“tissues” that are hurting, but the nervous system itself. The pain has become autonomous.
And yet there could well still be something wrong in the tissue as well — which tends to ensure the
persistence of the meltdown. Imagine waving a magic wand over such a patient and instantly
restoring normal pain perception: what would the patient perceive? Perfectly healthy, painless
tissues? Not likely! Probably pain would improve significantly, but the restored nervous system
would still be obliged to report a number of problems: either the original tissue pain, and/or new
tissue distress that arose from the terribly dysfunctional situation. Having scrambled pain
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
perception is probably hazardous in itself.
This is only an introduction to the subject of extreme myofascial pain syndrome. In general, the
whole tutorial frequently addresses the issue of myofascial pain that is more stubborn and severe
than average. There are also some sections later that offer some ideas about management of
particularly extreme cases — what on Earth do you do if you suspect that your “pain system” has
been “fried”? — and about people for whom trigger points seem to be a biological destiny, an
inevitable consequence of some other factor, unknown or known.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
2.22
Worst Case Scenario 3: Quick-start trigger points
This section describes a different kind of worst case scenario in trigger point pain. Worst case
scenarios are not solely concerned with widespread, disease-like infestations of inexplicably severe
trigger points. As already discussed above in the context of the “out of nowhere” phenomenon,
trigger points can also “activate” quite quickly and viciously.
Although most such quick-start trigger points are not especially severe, occasionally — even in an
otherwise healthy person, mostly free of trigger point pain — the onset can be both fast and severe.
Onset can be so fast and the pain so intense that misdiagnosis is all but inevitable, especially if the
pain is occurring in a vulnerable or “frightening” location. 110 In my experience, the very fastest
of these activations are effectively instantaneous, and the greatest intensities are enough to disable
the region and cause more or less total mental distraction — enough pain to stop the show.
Of course, these fast-activators don’t conveniently strike when you’re actually on a massage table!
And so I have had almost no opportunity to observe the onset phenomenon in patients. I have only
seen the aftermath hundreds of times. After an initially savage peak of pain, most such trigger
points fade down to being merely extremely uncomfortable, and are still throbbing away 2–5 days
later when the patient finally gets to me. Back in the days when I was advertising my hands-on
services, I would estimate that approximately “a lot” of calls from new clients were people in this
predicament: recent, sudden activation of a nasty trigger point.
As always, my own “triggery” body gives me some good source material for understanding what
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
life can be like for patients. To date, I have had two of my own quick-start trigger points severe
enough to qualify as examples of “worst case scenarios,” so I know what they feel like. 111 112
Based on these two personal experiences — and on a handful of experiences with clients who
experienced moderately fast/severe trigger point activations right on my table — I believe that it’s
likely that fast-activating trigger points can also be fast-de-activating if treated immediately. The
speed of relief may even be proportionate to how quickly you get to work on them. There is no
evidence about this, of course, and probably never can be: such an ephemeral phenomenon would
be effectively impossible to study.
Probably quick-start trigger points are most “dangerous” to the uninformed, who don’t recognize
them for what they are, because of the fear they cause. Undoubtedly, the true worst case scenario is
to not understand what’s happening, to panic, and to end up in the hospital sweating in agony and
caught up in a diagnostic wild goose chase. I’m confident this does happen.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
Part 3
THE SCIENCE OF TRIGGER POINTS
It’s a little half-baked, but at least it’s not boring
What’s in a knot? Here’s the oversimplified conventional wisdom since about the late 90s: a trigger
point is an unholy clump of contracted sarcomeres living in a nasty swamp of their own metabolic
waste products. (Sarcomeres are the very cool molecular machines that make muscles contract.) I’ll
summarize with key references first, and then spell out what this is based on more formally in the
next section, and then get into all kinds of interesting details.
Unfortunately, the conventional wisdom is just an imperfect theory. Even healthy muscle
physiology is still full of mysteries. For many years, this tutorial had an introductory section
confidently titled “Triggers points are good, hard science.” Unfortunately, I don’t really buy that
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
any more — the more you learn, the less you know. Trigger point science is still weaker and more
controversial than the average trigger therapist realizes, or is likely to admit.
Here are some of the pillars of trigger point science. They are not as sturdy as they could be, but
they are also far from useless. (The footnotes here are particularly rich and creamy: carefully
written summaries of the most important evidence about the nature and existence of trigger points,
fully up-to-date as of early 2016. Quite a bit more detail on each key scientific paper is available if
you explore the links.) This is the evidence we have so far that trigger points are a lesion in muscle
tissue, and that the “contraction knot” idea is roughly correct:
biopsies and “photos” of trigger points 114
scans of trigger points using new imaging
technologies 115 116
Unfortunately, no, none of these
measurements of their electrical activity 117
procedures are available as diagnostic
samples of their acidic, “toxic” tissue chemistry 118
tests for patients. 113
That all sounds pretty good. Surely things like pictures
and scans are great evidence? Smoking gun evidence,
even? No, not quite as good as that, unfortunately: hightech methods of imaging can be misleading. 119 Like seeing Jesus in a piece of toast, even
scientists striving to be objective still tend to see what they want to see, and find what they are
looking for … so it’s all debatable. And it is being debated.
The pioneers of trigger point research still are and always have been medical specialists and
scientists like Janet Travell, 120 David Simons, and Siegfried Mense. Their famous texts were
responsible for the first surge in awareness of trigger points in the 1980s. 121 Trigger point therapy
has respectable roots, especially as compared to many branded therapies and classic snake oils. It
began as a medical idea, not a product, 122
and many doctors specializing in chronic pain
care are well aware of that — such as Dr. Tim
Taylor, co-author of this book, who wrote and
maintains the section about medical factors in
Trigger point therapy has respectable roots,
especially compared to most trademarked,
body pain.
branded therapies. It began as a medical idea
Everyone agrees that something painful is
… not a product.
going on, however. The science and nature of
trigger points is interesting and sometimes
controversial, but the existence and medical
importance of a painful problem is not. Even the harshest critics of trigger points — and I know
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
some of them quite well, and I respect them — are not denying that people feel like they have pain
in their muscles, that there are sensitive spots. Muscles can certainly hurt. (That may seem like an
odd thing to have to say, but “what actually hurts” is an important part of the
controversy. 123 124 )
Also, the reality of the bizarro phenomenon of referred pain is unquestioned: press here, but feel it
there, sometimes rather dramatically. Detailed charts and databases of these patterns are widely
available. 125 The best online example is not very good, but here it is, for whatever it’s worth: The
Trigger Point Symptom Checker.
But there are some extremely different interpretations of why people have these symptoms, and the
main trigger point theory is much maligned by some truly smart critics. I have seperately
published a freely accessible article about these concerns and controversies. Its purpose is to take
criticisms of the conventional wisdom about trigger points seriously — a respectful, thorough, and
scholarly response. I am critically analyzing the “bath” to see how much and what kind of “baby”
is really in there … but I am certainly not chucking the whole thing. All that’s really at stake here is
an etiologic model (how trigger points work) for a very real and unpleasant experience. My muscles
hurt. My patient’s muscles hurt. There’s a world full of people with hurtin’ muscles! But there may
also be some grave problems with how we explain and treat that phenomenon. If there are, I will
report on them honestly — even if it undermines the living that I make from selling this book!
Despite the doubts, for now the science sections below are going to stay mostly as they are: an
exploration of the rather weird science of sarcomeres and trigger points as we have mostly known
it over the last 25 years, the conventional wisdom. And that’s fine, as long as you know that it’s not
holy writ, that “trigger points” are only an idea, and how they work is still ultimately a mystery.
Almost no matter where the march of scientific progress takes us, it will be worth understanding
trigger points in this way for many years to come (for the historical context if nothing else). And it
will always be worth understanding sarcomeres themselves, because they’re just neat.
3.1
The dominant theory of trigger points spelled out in a little more technical detail
You could skip this section and it probably wouldn’t make any difference in your life. But it needs
to be here.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Until further notice, the most popular provisional explanation for the trigger point phenomenon is
the “expanded integrated hypothesis.” It was presented in a 2004 paper by Drs. Robert Gerwin, Jan
Dommerholt, and Jay Shaw. 126 It is harrowingly detailed and technical. (Read the full jargon
version just below, if you dare!)
When abridged and oversimplified, the “expanded” part disappears — it was mostly just filling in
some details missing from the original integrated hypothesis (“a possible explanation”), which was
put forward by Travell and Simons in the second edition of the Big Red Books in 1999, which was
in turn an elaboration on the energy crisis hypothesis that debuted in the first edition in 1981. This
has been a work-in-progress for quite a while.
Here’s a careful translation of the expanded integrated hypothesis:
Under some circumstances, muscular stresses can cause patches of poor circulation,
which results in the pooling of noxious metabolic wastes and high acidity in small areas
of the muscle. This is both directly uncomfortable, but also causes a section of the muscle
to tighten up and power a vicious cycle. This predicament is often called an “energy
crisis.” It is a subtle lesion in the muscle. Research has largely been concerned with
looking for evidence of a lesion like this.
And here’s the full-jargon version, quoted directly from Gerwin, Dommerholt, and Shaw. Brace
yourself!
It can be hypothesized that the activating event in the development of the TrP is the
performance of unaccustomed eccentric exercise, eccentric exercise in unconditioned
muscle, or maximal or submaximal concentric exercise that leads to muscle fiber damage
and to segmental hypercontraction within the muscle fiber. Adding to the physical stress
of such exercise is hypoperfusion of the muscle caused by capillary constriction, which
results from muscle contraction. Capillary constriction is increased by sympathetic
nervous system adrenergic activity. The resultant ischemia and hypoxia adds to the
development of tissue injury and produces a local acidic pH with an excess of protons.
Acidic pH results in inhibition of acetylcholinesterase activity, increased release of CGRP,
and activation of ASIC on muscle nociceptors. Acidic pH alone (in the absence of muscle
damage) is sufficient to cause widespread changes in the pain matrix. However, the
breakdown of muscle fibers results in the release of several proinflammatory mediators
such as SP, CGRP, K+, 5-HT, cytokines, and BK that profoundly alter the activity of the
motor endplate and activity/sensitivity of muscle nociceptors and wide dynamic-range
neurons. Motor endplate activity is increased because of an apparent increase in the
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
activity of ACh. This apparent increase in effectiveness is caused by several factors that
include an increase in the release of ACh that is mediated by CGRP, presynaptic motor
terminal adrenergic receptor activity, and by AChE inhibition caused by CGRPand acidic
pH. AChRs are up-regulated through the action of CGRP, creating more docking sites for
ACh, thereby increasing the efficiency of binding to the receptor. The taut band results
from the increase in ACh activity. Miniature endplate potential frequency is increased as
a result of greater ACh effect. Release of BK, K+, H+, and cytokines from injured muscle
activates the muscle nociceptor receptors, thereby causing tenderness and pain. The
presence of CGRP drives the system to become chronic, potentiating the motor endplate
response and potentiating, with SP, activation of muscle nociceptors. The combination of
acidic pH and proinflammatory mediators at the active TrP contributes to segmental
spread of nociceptive input into the dorsal horn of the spinal cord and leads to the
activation of multiple receptive fields. Neuroplastic changes in dorsal horn neurons occur
in response to continuous nociceptive barrage, causing further activation of neighboring
and regional dorsal horn neurons that now have lower thresholds. This results in the
observed phenomena of hypersensitivity, allodynia, and referred pain that is
characteristic of the active myofascial TrP.
So that’s the messy guts of the “working theory” that the next several sections are based on.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
3.2
Micro muscles and the dance of the sarcomeres
A muscle is made of microscopic contractile units arranged in series and
bundles: the sarcomeres, tiny packages of proteins (especially myosin II, a
famous molecule). Muscles contract because sarcomeres contract.
Sarcomeres are little microscopic muscles-within-muscles. Micro muscles.
These molecular machines are the best example of how life is chemistry.
Although proteins have many impressive properties and do many
dazzling things, none is more defining of living things than this ability to
generate movement.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Most molecular biology is amazing if you can understand it, but hard to
connect to anything as familiar as wiggling your toes. Sarcomeres are an
unusual explanatory bridge between weird science and ordinary
experiences because they actually resemble the muscles they power.
Muscle cells & the
sarcomeres inside them, the
potent little bundles of
protein that power muscle
tissue. Unknown artist.
There’s something simple and beautiful about how they are so much like
miniature versions of the muscles they power.
You know how kids are so good at asking a chain of “why” and “how” questions? Sarcomeres are
the deepest possible answer to the chain of kid-questions that starts with, “How do we move?”
(Well, almost the deepest answer. 127 )
Sarcomeres are how chemistry lifts barbells.
Without sarcomeres, your heart could not
beat, your guts could not digest, your jaw
could not flap. You would never blink,
breathe, or burp. Sarcomeres are the ultimate
source of all movement, and they are powered
by the weird properties of mind-bogglingly
complicated molecules.
Without sarcomeres, your heart could not
beat, your guts could not digest, your jaw
could not flap. You would never blink,
breathe, or burp.
And sarcomeres can probably screw up.
The clinical relevance of sarcomere mistakes
Understand sarcomeres and their failure, and you might be able to make sense of muscle knots.
Specifically, troubled sarcomeres could explain four distinctive clinical characteristics of trigger
points:
1. why trigger points can be so stubborn
2. why applying pressure often helps
3. why stretching feels good (but also does not work any miracles)
4. why they make your muscles weak and heavy
This sarcomere science here is a just a primer for beginners and a refresher course for professionals.
I do want you to appreciate just how weird and wonderful sarcomeres are, but what we’re really
interested in is how sarcomeres have a starring role in your muscle knots.
The size of sarcomeres
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Cells are mind-bogglingly small compared to your hand, sarcomeres are mind-boggling small
compared to your cells, and atoms and ions are mind-boggling small compared to your
sarcomeres.
So sarcomeres are somewhere in the middle of the sizes of things.
They are long and thin. Wrap a few hundred of them together like a bundle of firewood, and then
line that bundle up end-to-end with a few thousand other sarcomere bundles, and you’ve got
yourself a single muscle cell or fibre. Even small muscles consist of millions of muscle fibres, and
therefore millions of millions of sarcomeres.
Sarcomeres are much too small for
microscopes. They are closer to the size of
molecules than cells. Compared to a muscle
cell, which is already crazy small — about 50
micrometres in diameter, so about 10,000 of
them could fit in the width of a fingernail — a
single sarcomere is like a grain of wheat in a
If you were the size of a water molecule, you
could wander around inside a sarcomere like
a mouse in Grand Central Station
silo. 128
As small as sarcomeres are, they are actually quite large as molecular-scale structures go. Every
sarcomere is a tidy little package of well-organized proteins, and proteins are massive for
molecules, and sarcomere proteins are big even for proteins. And so: if you were the size of a water
molecule, about a tenth of a nanometre, you could wander around inside a sarcomere like a mouse
in Grand Central Station. 129
How sarcomeres work
You wouldn’t think that a package of proteins, not even big proteins, could be all that clever, but
never underestimate organic molecules: they have a way of being even more freakishly amazing
than suspected by the last generation of molecular biologists — who were already pretty impressed
— and sarcomeres in particular can make hardened researchers cry. People who study these things
face the possibility of never really understanding their subject, of never even seeing a live specimen
doing its thing — live sarcomeres cannot be directly observed.
As of 2016, a new “muscle microscope” invented by Stanford researchers can “visualize and measure the force-generating
contractions of … individual motor units. This action has been studied for nearly 100 years, but this is the first time it has
ever been observed in the muscles of a living human.” Good job, Stanford! It’s a major leap forward, but it still falls well short
of direct observation of the internal mechanics of sarcomeres: it’s “just” observation of the gross structure of large bundles of
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
them.
Despite the limitations of observation, the internal structure of a sarcomere is reasonably well
understood from decades of elaborate inference and increasingly sophisticated imaging, even at the
nanoscale. We know they look kind of like forks:
A (ridiculously) simplified model of a sarcomere.
Imagine overlapping chains of proteins, like the tines of two forks meshed together. To contract the
sarcomere, the proteins grab onto each other and pull, increasing the overlap of the tines. To relax,
the proteins “just” let go. 130
That’s the structure. What about the function? We do not fully understand how sarcomeres do what
they do — we just know what they do in principle. The details of myosin activity happen at the
atomic scale and at extreme speeds. It’s like trying to watch a fast-forwarded football game from
orbit with a pair of binoculars. And so “the process by which myosin II generates motion is still not
completely understood,” Hoffman explains in Life’s Ratchet, “but substantial progress has been
made by structural (X-ray, electron microscopy), biochemical, flourescence, and laser tweezer
studies.” 131 It was the first molecular motor discovered, but “it remains [in 2012] one of the most
enigmatic.” Many details of how the stuff works remain surprisingly controversial. And that’s all
about pure myosin, a standalone molecular machine in a “test tube,” rather than the intense
metabolic environment of living muscle.
Normally, sarcomeres throughout the muscle contract with
amazing coordination, and they even sync up with the
contraction of sarcomeres in other muscles — precise
choreography of action spanning from the nanometre scale to the
metre scale! That is, things that are happening at the molecular
scale in your shoulder can be synchronized with sarcomere
activity in your lower legs. 132
Perhaps unsurprisingly, this system isn’t perfect. Sometimes,
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
Why are some trigger points so much
bigger than others? Earlier I mentioned
that trigger points can be microscopically
small, or as large as a walnut, or any size
between those extremes. Sarcomeres
explain this: a trigger point does not
increase in size due to the accumulation of
waste products or swelling as you might
expect, but because the number of involved
The Complete Guide to Trigger Points & Myofascial Pain (2019)
isolated patches of sarcomeres seem to contract independently of
sarcomeres increases. Swelling is minimal
the rest of the muscle. They probably do so briefly all the time,
and highly localized (microscopically
the microscopic version of an eyelid twitch or a shiver. Or they
localized).
may get “stuck” like that: a trigger point, a sustained,
Why do some trigger points affect more
inappropriate contraction, a microscopic version of a long-lasting
sarcomeres? No one really knows. Do
cramp or the spasticity seen in some diseases.
affected sarcomeres drag neighbouring
sarcomeres into the problem? Probably, but
We don’t know any of this for sure, but it’s all plausible: almost
no one really knows. If they do, what limits
anything that happens as a matter of course in biology can
the size of the trigger point? Why doesn’t it
happen too much, too little, or at the wrong time. And we do
just take over the whole muscle? Again …
have some evidence that patches of sarcomeres do indeed
no one really knows.
malfunction like this. Sometimes the proteins appear to grab
onto each other, pull hard, and hang on — the tines of the fork jammed tightly together.
Many experts have speculated about the kinds of stresses that provoke such malfunctions — cold,
overstretch, anxiety, trauma, pain, fatigue — but no one really knows.
The next four sections will explore the four ways that the conventional science of sarcomeres and
contraction knots might explain the clinical features of trigger points.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
3.3
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
One: The vicious cycle (why trigger points are stubborn)
I once bit the inside of my cheek seriously while vigorously chewing a steak. I swore, rolled my
eyes at myself, and carried on chewing … on the other side, carefully avoiding my bitten cheek,
which was already swelling. It’s hard to avoid biting a swollen cheek, though. I hit it a couple more
times that evening, and then — what really got me — a hard bite around 4am. I woke up with the
inside of my cheek blaring pain at me. A flashlight showed a fat white bulge deep in my mouth,
back where the big molars are close together even with your mouth wide open: the hardest spot to
avoid biting. And the more I bit it, the more swollen it got, and the harder it was to avoid biting
again.
It took five days to break the cycle. I chewed on dozens of ice cubes. I applied crushed up ibuprofen
pills. I cut little pieces of plastic to wedge between the wound and my molars. I had a dozen
infuriating setbacks where I bit myself again just as I thought it might finally be calming down. I
finally won the battle of the cheek by upping the bite-avoidance ante so far that I basically stopped
using my mouth for anything for several hours — I just did everything slack-jawed until the
nightmare was over.
There’s a reason they are called “vicious” cyles. Positive feedback is a bitch.
Trigger points are probably not only a vicious cycle, but one that is hard to interrupt. Tightly
contracted patches of sarcomeres generate a lot of tissue fluid pollution, waste products of
sarcomeres that are metabolically “revving” … and those “exhaust” molecules are then
accumulating, causing pain and other symptoms, and irritating the trigger point even more. This is
called a metabolic energy crisis, and it’s why I often informally refer to trigger points as sick muscle
syndrome.
Of course, “the feedback loop suggested in this hypothesis has a
few weak links,” wrote David Simons. Indeed, it does. He was
well aware that several links in the chain of causation were
PRO Some fascinating extra-curricular
reading for professionals Professionals are
simply guesses.
strongly encouraged to read David Simons’
Nevertheless, some recent research has helped the theory. 133
chemistry of energy crisis in trigger points,
Starting with a simpler study in 2005, and then a more thorough
one in 2008, a group of scientists using “an unprecedented, most
ingenious, and technically demanding technique” have
confirmed that there really are irritating metabolic wastes
floating in the tissue fluids of trigger points: “ … not just 1
noxious stimulant but 11 of them,” Simons explains. “Instead of
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
analysis of both the new evidence about the
as well as another new scientific article on
the use of magnetic resonance elastography
(MRE) imaging — a very promising new
way of taking pictures of muscle knots!
Simons writes that this technology “may
open a whole new chapter in the centuriesold search for a convincing demonstration
The Complete Guide to Trigger Points & Myofascial Pain (2019)
just a few noxious chemicals that stimulate nociceptors [danger-
of the cause of MTP symptoms.” Most
sensing nerve endings], nearly everything that has that effect
patients will be stumped by Simons’ thick
was present in abundance.”
scientific jargon, unfortunately.
Basically, the researchers analyzed tissue samples from in and around trigger points and compared
them with healthy muscle tissue. The differences were significant. The tissue of myofascial trigger
points is rotten with irritating molecules associated with inflammation, with pain, and with
immune function.
The vicious cycle basically explains why trigger points have the potential to last and last. Many
times I have worked with people who have had trigger points in the same location for decades. My
own trigger points are impressively long-lived: I’ve had a barely controllable patch of them in my
right hip for a decade now.
Positive feedback also helps to explain why trigger points, even when they do go away, strongly
tend to come back. Any well-established trigger point probably has some reason to be there in the
first place: it is a predictable response to some chronic stress or vulnerability. Even if it could be
completely eliminated on Monday — the
sarcomeres’ proteins restored to a healthy
degree of separation, every trace of metabolic
waste flushed away — there’s a good chance
that the conditions that led to it in the first
place will restore it by Friday.
Even if a trigger point could be eliminated on
Monday, there’s a good chance that it will be
back by Friday.
But more importantly: it’s unlikely that the
swamp physiology of the trigger point can be
completely eliminated in the first place. No matter what we do to it, there will always be some
excessive contraction left, the circulation at least a little restricted, and some junk molecules still
floating around in that spot — good conditions for the trigger point to flare right back up again.
This squares well with the clinical experience of every patient and professional trying to help: it
seems to be easy enough to make trigger points a little better, but incredibly difficult to make them
go away completely. Trigger point stubbornness explained. Just like cheek bites.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
3.4
Two: Good pain (why pressing on trigger points hurts like hell but feels like heaven)
Pressure on trigger points causes both good and bad sensations simultaneously because the trigger
point is sensitive, but the pressure is (hopefully) helping it at the same time. It’s a weird mix. Good
pain is an interesting subject because it’s a contradiction that somehow manages to make perfect
sense when you experience it.
And it comes from inside of people. Therapists have not imposed the idea of good pain on patients
the way that they have imposed many other common therapy ideas. Even massage newbies
recognize the sensory paradox clearly. It’s always fun and interesting to listen to an inexperienced
patient discovering good pain …
Oooh, wow … oh, that’s sensitive … but it’s good … but it’s definitely pain … but it’s
definitely good …
typical patient discovering “good pain”
The contradiction between the good and bad parts of pain can be strong. Good pain may involve
an undeniably nasty or gross or sickening component, a truly unpleasant quality, and yet still be
accompanied by a distinct sense of relief, like an itch being scratched.
No one knows how a painful massage can also feel so good at the same time. This is a sensory
phenomenon well beyond the reach of science: all we can do is speculate.
Taken at face value, the paradoxical sensation obviously implies that something good is going on
despite the discomfort, and that we can feel the benefit. There are lots of painful-but-relieving
analogies in medicine and biology. 134 That’s certainly what good pain in massage feels like, but
we can’t necessarily take that sensation at face value.
A satisfying sensation doesn’t necessarily imply successful treatment, unfortunately. Scratching
mosquito bites feels great… but it’s not helping them! Trigger points may be like mosquito bites: it
may feel terrific to massage those mysterious sensitive spots in soft tissue, but it may not be doing
much to actually “release” or resolve them. It may be a purely sensory experience, the satisfaction
of dealing with an “itch” that we cannot easily reach on our own.
Or, massage may actually improve tissue, directly changing trigger points, releasing and resolving
them. There are many possible and plausible mechanisms for it, and some of them obviously could
hurt and feel good at the same time. For instance, if the sarcomeres’ protein chains really need to be
pulled apart, like children fighting on a playground, and focused pressure can do it, I can easily
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
imagine how that would be painful-but-good, just like a stretch. Underneath thumbs and
fingertips, trigger points spread like bread dough — a straightforward “mechanical” cure for
trigger points, forcing sarcomeres to lengthen with overwhelming force, intense but helpful. “All
right, proteins, break it up, break it up!”
Or it could be a mixture of changing the
sensation and the state of the tissue. Changing
sensation could feed back into tissue state.
Trigger points feel like stuckness, but it isn’t
obvious how to get unstuck. Deforming the
Underneath thumbs & fingertips, trigger
points spread like bread dough
tissue with focused pressure feels like a relief
simply because it’s a change, like getting up to
stretch after hours in an airplane seat. Anything that changes it — even painful pressure — is such
a strong sensory relief that the trigger point becomes less irritated, which may be another vicious
cycle buster. I think of this as “freshening” the trigger point — treating it with novel sensory input,
basically. The trigger point changes because of the blast of fresh sensation, not because of any
direct biological effect of the pressure.
Whatever’s going on, the intensity of the relief tends to generate some amusing comments. When
you find a perfect spot in someone’s muscles and scratch it, people generally say things like:
Unh!
Ohhhhh …
Arrnnnghnnnnnaaaaaahhhh …
Yeah, that’s the spot, right there, right there, yeah, no, yeah, yeah slightly higher, ooh, perfect, yeah
yeah yeah …
Ah, you’ve got a live one there! (You’ve got to say this one in a rich Irish accent … )
Ooochiewawa!
Hel-lo!
Ew, gross! 135
Oh my God, oh my God …
What is that?
Holy #@*&!!! What the @#%!% is that?
Ah, the sounds of sarcomere separation! Clearly, trigger point squishing feels important. 136
There’s one more likely mechanism of good pain …
Referred pain spreads the goodness: it basically just makes trigger point stimulation feel bigger,
more important. Press on a small spot … feel it down your entire arm. Wow! Impressive! Even though
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
it’s just a thumb on a trigger point, it feels as though that “itch” is being scratched throughout an
entire region. Referred pain amplifies the good pain effect — or the bad pain effect, if the pressure is
too intense!
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
3.5
Three: Tightness (why stretching is appealing but underwhelming)
This section summarizes a important basic concept about trigger points and stretching. There is much, much more
information about trigger points stretching later on in the tutorial in the main stretching sections, including a more
detailed version of this section. “Tightness” was already discussed in more detail above: If you have trigger points, will
your muscles be “tight”?
Terms like “tight” and “stiff” are imprecise and do not clearly describe anything other than a
sensation. 137 But people with trigger points sure do feel tight and stiff and are forever trying to
stretch it out. Patches of contracted sarcomeres seem to be an obvious and quite literal cause for
that sensation. If we run with the mini-cramp theory, it has an obvious implication: a trigger point
must actually reduce the elasticity of a muscle, like a knot in a bungie cord.
Killer analogy, right? If I stopped there, it seems like quite a compelling image that artfully
connects the dominant idea of how trigger points work with an incredibly familiar human
symptom. It “explains” how trigger points restrict range of motion … which in turn strongly
implies the need to stretch them out. Such stories are the bread and butter of many professionals
who want to put a little science sauce on their work. But if it sounds too good to be true, it probably
is.
A knotted bungie cord actually still works well. Only a small segment of the cord is affected. Only
at the extremes of stretch are you going to see any difference in the maximum length, and that
much is probably true of knots in both muscles and bungie cords.
And good luck stretching the knot itself! The stretchiest parts yield, not the knot. Again, this is also
probably true of muscle.
Indeed, the flexibility of muscles does not in fact seem to be much affected by trigger points,
despite all the symptoms of stiffness and tightness, and it turns out that stretching is — although
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
super popular — actually a surprisingly lame method of treatment that seems to have almost no
consistent or lasting effect on trigger points. Probably because stretch probably can’t fix contraction
knots. If indeed that’s even what a trigger point is!
Nevertheless, it’s still possible that more and worse trigger points in certain types of muscles could
restrict range of motion, and stretching might help, especially if augmented in certain ways. Maybe.
I’ll return to this bungie-cord analogy in more detail later, along with much else about stretching.
Meanwhile, there’s one more clinical feature to try to explain with sarcomeres …
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
3.6
Four: Weakness (why muscles with trigger points might be weak)
People with trigger points don’t just report feeling stiff and tight, they
also report feeling weak. Their muscles feel “dead” or “heavy.” Just as
with stiffness and tightness, it’s not clear whether this symptom is just a
sensation, or if it represents measurably reduced contraction power. It could
also be a co-morbid symptom: it’s possible that something that causes
actual weakness/heaviness is also causing trigger points. 138
Trigger points might cause muscle weakness. We have almost no hard
data on the topic. A 2011 study did identify weakness in people with
trigger points compared to people without … but the side of their
“Weak as a kitten”? This
shameless use of cuteness
highlights a common symptom
of trigger points.
bodies with trigger points was no weaker than their other side. 139
That’s hard to interpret, and the study had flaws, chiefly that they only looked at people with latent
trigger points (sensitive, but not actively painful). And that’s literally the only study on the topic I
have found. So it’s basically still a scientific question mark with the usual “more study needed”
disclaimer.
But it does suggest that weakness could be a non-specific effect, a suppresion of vigour throughout
a region rather than reduced power only in affected muscles.
Speculating then, there are two clear reasons why a contraction knot might weaken a muscle:
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
1. Sarcomeres in the trigger point are already fully contracted, so they cannot contract more, so that’s at
least one part of the muscle knocked out of service.
1. Sarcomeres on either side are a little more
stretched out, and elongated sarcomeres have
a harder time initiating contraction.
Contracting over-stretched sarcomeres is like
Contracting over-stretched sarcomeres is
like trying to pull away from an intersection
trying to pull away from an intersection in
in fourth gear. This is an easy phenomenon
to demonstrate, and it’s well known to
fourth gear.
anyone who has spent any time in a gym:
muscles are much less powerful when
stretched out. For instance, a barbell that
you can’t budge when your arm is straight
may be relatively easy to lift if you pick it up with your elbow already bent. That’s sarcomere
overlap working for you! 140
These ideas seem tidy, and for many years in this book I presented them as fact rather than
speculation. Eventually I noticed that I was assuming that a contraction knot can make a significant
difference in muscle function … after arguing exactly the opposite with the knot-in-a-bungie-cord
analogy just above.
A few small patches of contracted sarcomeres may have a negligible impact on the overall
flexibility or power of a muscle. It could cause the feeling of a bit of weakness without having much
practical importance: a 1% loss of strength perhaps, barely measurable. Any loss of less than 5%
would be hard to confirm.
And it’s also possible — but pure speculation — that weakness does occur more profoundly when
more and worse trigger points occur in shorter muscles, where their effect is less “diluted,” where
the contraction knot constitutes a larger percentage of the mass of the muscle. Strength losses could
conceivably be quite dramatic and easy to measure, if only someone did. This phenomenon could
be going on every day for millions of people around the world... and we could go another twenty
years without any researchers actually studying the right patients in the right way to confirm it.
Or maybe having gross, sensitive spots in your muscles just makes them feel weak, without actually
being weak.
If trigger points cause muscle weakness (the feeling or the fact), should you try to strengthen your
muscles? This question will be addressed much later in the tutorial, in the treatment sections:
Strengthening: should you take your trigger points to the gym?
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
3.7
Everything we just discussed … in a few bullet points
Muscles contract because sarcomeres contract. Sarcomeres are like microscopic muscles.
A sarcomere is made of threads of protein that overlap like the tines of a fork, grab onto each other
like Velcro, and pull towards each other.
In a trigger point, theoretically, a patch of sarcomeres contracts excessively — a micro-cramp.
If correct, this model has some implications that start to make sense of the clinical phenomenon:
1. Trigger points are kept alive by a vicious cycle of super-contracted
sarcomeres producing lots of waste molecules.
2. Massage may help to relieve them by mechanically “squishing” the
condensed sarcomeres apart, and/or by relieving the sense of “stuckness,”
and probably other factors.
3. The contracted sarcomeres are like “a knot in a bungie cord,” which makes
them seem like something you should stretch out—but it doesn’t really
work out that way.
4. Overextended sarcomeres might make muscles weak and unresponsive to
stronger resistance training.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
3.8
Triggers for trigger points: what makes patches of sarcomeres go haywire?
Why would sarcomeres get into trouble in the first place? What exactly is their “damage”? What’s
wrong with the system?
The exact mechanism by which the tissue becomes dysfunctional is simply unknown, and it may
be a long time yet before we do understand it. However, there are many factors that may “trigger”
your trigger points — forces and factors and physiological circumstances that seem to be associated
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
with trigger point formation and aggravation …
Pain from any other cause, and other chronic health problems. Anything that stresses the system
seems to increase trigger point pain, but there are conditions that seem to more directly aggravate
trigger points. A classic example is fibromyalgia, which is usually complicated by many severe and
stubborn trigger points.
Injuries in particular cause disturbance of muscle and joint function to limit movement (although
probably not by causing “protective spasm,” as is often said 141 ) Muscles in the region develop
trigger points in response to the generally abnormal and dysfunctional situation, 142 and probably
also as a direct response to injury pain.
Sustained elongation or shortening, as routinely occurs in awkward working postures (poor
workstation ergonomics, etc). The further and longer a muscle strays from its most neutral length
— neither stretched nor contracted — the more likely it is to form trigger points. This explains
many common trigger point scenarios, because it particularly occurs with working postures,
especially blatantly awkward ones, and it also happens by accident in sleep (we wake up with new
trigger point pain because we slept in a weird position, with a muscle significantly stretched or
shortened for hours). Comedian Steven Wright: “‘Did you sleep well last night?’ ‘No, I made a few
mistakes.’”
Overexertion, either from strong contraction and/or general fatigue.
Stagnation and lack of stimulation of muscle tissue also seems to be a major risk factor.
Chills often lead to the formation of trigger points. The body reflexively increases muscle tone
(tension) when the overlying skin is chilled, or when the body is struggling to maintain body
temperature.
Psychological stress, especially anxiety about pain itself, has numerous consequences that lead in
complex ways to trigger point aggravation. The most obvious is probably that activation of the
sympathetic nervous system (“fight-or-flight” neurology) is known to activate trigger points.
Nutritional insufficiencies — slightly inadequate levels of nutrients — are given great importance
by Travell and Simons.
Smoking adversely affects essentially every system in the human body, including the muscular
system. People who smoke are known to suffer more from chronic pain.
Excessive caffeine consumption may cause muscle pain, although this is speculative. 143
This section is admittedly a bit redundant. I’ve already mentioned many of these in the context of
diagnosis, and I will discuss them again in the context of treatment — because eliminating these
factors may help. I will discuss them again below in the context of perpetuating factors — “factors
that make trigger points stubborn” — and Dr. Tim Taylor will have much more to say about the
medical ones.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
3.9
The all-powerful acne analogy
Trigger points are a lot like pimples. If you have skin, you’re going to get pimples. Some people
will get more and worse pimples than other people. And if you have muscle, you’re going to get
trigger points … maybe more and worse than other people.
I spoke to a reader on the phone about her severe myofascial pain syndrome. It quickly became
clear that she was fond of speaking about everything in the strongest possible terms — a drama
queen.
“I have five hundred injuries,” she said, for the third time in as many minutes.
“What do you mean by ‘injuries’?” I asked. “You keep saying that, and I’m not sure what you
mean.”
“I have five hundred trigger points,” she said. Ah. She was defining a trigger point as an injury —
what an interesting self-perception! But a trigger point is no more an “injury” than a pimple is an
injury. Oddly enough, however, pimples and trigger points are surprisingly similar:
Both are common. Practically everyone has a few pimples, and a few trigger points. A few lucky
people have very few of either. And a few unlucky people have a lot.
Both are dysfunctions. Just like pimples, trigger points are small dysfunctional (sick) patches of
tissue. A pimple is a tiny infection, which is certainly quite different than a trigger point. But the
infection occurs due to subtle dysfunction of the organ (skin is often considered an organ in
physiology). Skin is mostly quite good at preventing pimples, but sometimes it fails. Pimples occur
here and there when something goes a little bit wrong. If it starts to happen a lot, something has
gone wrong: the skin isn’t working quite right, and bacteria take advantage of the situation.
Similarly, muscle tissue is mostly good at not getting trigger points. But trigger points occur when
something goes a little bit wrong …
Both come and go without much rhyme or reason. Some risk factors for both problems are known:
muscle fatigue will provoke trigger point formation, excessive chocolate consumption may give
you a pimple bloom. This book offers quite a lot of detail about why trigger points may occur.
However, in both cases, no one really knows why some people get so many, and others get hardly
any at all.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
The take-home lesson is that trigger points are a more or less inevitable by-product of having
muscle. In the broadest possible terms, I believe that trigger points, like pimples, are a natural
consequence of the physiological trade-offs involved in having high-functioning tissue that can’t
possibly work perfectly all the time, under all conditions.
Both muscle and skin are much more volatile and biologically intricate tissues than most people
suspect. They are “busy.” They do a ridiculous amount of work, just like the more obviously
complex tissues. Nothing in the body is really inert or boring — and muscle and skin are much
more complex than most people suspect, and muscle is a particularly extreme performer. 144 Even
physiologists are more or less constantly amazed by their complexity, even after a lifetime of study,
even after the last century of surprises. Like computers, muscles work miracles … but they also
have bugs.
The only way to completely eliminate acne
from the human experience would be to
ratchet down a bunch of other vital, delicately
balanced skin functions — a cure worse than
the disease. On the other hand, if you tried to
Trigger points are more or less inevitable byproduct of having muscle.
make skin work any better than it already
does, you might well end up with ten times as
many pimples, and your purpose would be defeated! Evolution and biology are full of capricious
compromises like this — if the system goes too far this-a-way or that-a-way, it fails. 145
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
3.10
The evolution of muscle pain: does muscle “burn out”?
Muscle tissue is probably full of evolutionary compromises, just like the rest of biology. It has
probably gotten about as impressive as evolution can make it — and at the expense of longevity.
Performance with a price. This could generally be why muscle pain becomes so common as we age.
In short, we burn out.
All high-functioning systems — both evolved and engineered — usually walk a fine line between
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
performance and blowing up, and typically fail with age. For instance, all flying machines tend to
require intensive maintenance and are more or less constantly falling apart and being put back
together. The SR-71 Blackbird, the world’s fastest jet throughout its career, tolerated such extremes
of heat at full speed that its parts needed room to expand, and so they were engineered to be loosefitting on the ground, resulting in all kinds of challenges and risks, such as leaking expensive and
explosive jet fuel like a sieve — by design! 146 Fortunately, most of us never have to try to fly that
thing. But we all have to use our muscles. And muscle is probably just as volatile — performing on
a razor’s edge between performance and vulnerability, and with potentially significant
consequences even to relatively minor deviations from operational norms.
As a simplistic example, with a strong shot of adrenalin, you can get super-strength out of muscles
simply by recruiting every muscle fibre to contract simultaneously, instead of only a few at a time
as with the relay system we normally use. 147 Such great strength is possible only by paying a
price of rapid muscular fatigue. Natural selection picked the balance point: if we were any stronger
in general (via this mechanism), we’d get tired too fast and be food for big cats and such; any less
strong, and we’d be so weak that we couldn’t run fast in the first place.
Never mind athletics or combat! Every day, your muscles have got to pull off miracles of fast,
responsive, intense function in the course of performing quite ordinary actions. That function
almost certainly comes with biochemical price tags. In a general way, this is probably why we get
trigger points — they are glitches in an impressive but imperfect system, nonlethal and
uncomfortable trade-offs for having muscle that is rather amazing in terms of performance. If I’m
right, we should expect to see trigger points crop up (activate) at their operational extremes — and
indeed we do. They tend to form in response to things like over-exertion, cold, injury, as well as
anything that challenges the system as a whole like stress, sleep deprivation, and smoking. Systems
fail and misbehave when challenged.
This evolutionary theory of trigger point formation is also somewhat consistent with the age of
victims: children don’t suffer from trigger points anywhere near as much as adults. Myofascial
pain syndrome seems to get rolling in the 20s, peaks in the 30s and 40s, and then levels off, not
getting much worse in subsequent decades of life. Why don’t the young‘ns get trigger points?
Evolutionarily speaking, it would be a really bad idea if your muscles failed by your 20th birthday
simply because of their own high-functioning! Not a good system! Nature would be hard on
people born with that system, with the usual effect: more getting eaten, less breeding.
But past the age of 20? In the barbaric mists of history, your ability to survive into a third decade
was largely a moot point, evolutionarily speaking: most everyone passed on their genes by that
point (probably a few times), and you were worm food by 30. Evolution didn’t “see a need” for
muscles that could perform miracles with no consequences for three decades. So we didn’t get
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
them. And we never will. Broadly speaking, this is why aging sucks: once you are past breeding
age, you are in biological territory that evolution can’t touch. 148
It’s amazing how much mileage I can get out of the acne analogy. ��
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
3.11
Referred Pain Science (basic)
Referred pain is not just a muscle pain phenomenon. It occurs in many contexts in biology, and it’s
a great example of how trigger points are not a quack diagnosis. The fact that trigger points “send
pain” to remote locations sounds all spooky and weird, but is completely consistent with wellknown referred pain phenomena that occur in other medical situations. For instance …
Heart attacks cause the best known example of referred pain — the spreading of heart attack pain
through upper chest and in the left shoulder, arm or even hand.
“Ice cream headache” or “brain freeze” is also a kind of referred pain. It occurs when you cool the
vagus nerve inside the throat. Rather than your vagus nerve itself hurting, or even any tissues it’s
attached to, you get a headache! The vagus nerve does not transmit sensory information from the
forehead! Yet that is where the pain is felt — a good example of referred pain.
Phantom limb pain is the most exotic form of referred pain: the
sensation of pain from a limb that has been lost or from which a
person no longer receives physical signals. Virtually all
amputees and quadriplegics report phantom limb pain. It is a
fascinating phenomenon.
So, how does referred pain work? Bear in mind that there are
probably several answers, starting with “It depends” …
The dominant theory of referred pain, and the one more or less
adopted by Drs. Travell and Simons, is the “convergent
projection” theory. I’ll summarize it here — just the basics, I
promise — and it is discussed in detail in the advanced section
“I only recently learned the name for my
pain!” I met an elderly amputee. I asked
him, “Do you have phantom pain?”
(I’m never shy about asking people about
their pain — it’s particularly interesting to
me, of course, but I’ve also learned over the
years that people like being asked about
their pain. Pain is almost everyone’s
favourite subject! It’s one of those topics
that is dangerously tedious for listeners, like
talking about how you slept, your dreams,
following this one, where it is contrasted and compared with
money, your diet, and so on. But it’s my job
many other theories of referred pain.
to be interested, and it’s my job because I
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
am.)
Convergent projection theory is based on the idea that there are
He laughed merrily as though this were an
probably more nerve endings than there are receptors for them
especially clever question, and said, “You
in the spinal column. Signals from several different nerve endings
know, I suffered from phantom pain for my
all pass their information on to the same receptor in the spinal
whole life, but only found out that there
column — the “convergence.” This results in a low fidelity of
was a name for it just a few years ago!” And
pain perception, in which your brain literally does not know
he described intermittent nighttime
exactly where the signal is coming from, as there are multiple
episodes of horrible burning, stabbing pain
choices. Thus you experience a kind of “maybe here, maybe
that he’d had in his “foot” since he was a
there” pain in an indistinct fog spread out over the area of source
boy, before a prosthetist finally explained
the phenomenon to him. Decades of doctors
nerve endings — the “projection.”
had never talked to him about it, even
though they must have known — phantom
limb pain is well-documented and one of
Referred pain feels like a “maybe here,
the most fascinating areas in pain research.
maybe there” pain in an indistinct fog spread
out over the area of source nerve endings.
Psychological context is probably important to referred pain, too: if you just stabbed yourself, then
your brain can sensibly infer that, of all the possible places the pain could be coming from, it’s
probably the knife wound, and thus a sort of “simulated accuracy” is achieved.
Fun fact! How trigger point charts are made. Referred pain patterns from trigger points were
originally studied by injecting muscles with pain-causing substances. The strong pain in the muscle
quickly and clearly “lights up” the area of referred pain associated with that muscle. When the
signal is that loud, it’s pretty easy for the experimental “victim” to trace out the referred pain
pattern! In this way, it’s been determined quite accurately what the typical referred pain patterns
are for each muscle. Although there’s variation, the patterns are remarkably consistent. The studies
have been repeated many times using a wide variety of pain-causing injections: bradykinin,
substance P, 149 capsaicin (the stuff that makes chilies hot!), and serotonin. It’s been done with
electric shock as well.
They’d have to pay me quite a lot to participate in one of those studies … ��
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
3.12
Referred pain science (advanced)
Professionals and keen patients will want to dive into the science of pain referral in considerable
depth. It’s both fascinating and enlightening. Although convergent-projection theory dominates,
there are actually several theoretical models of how referred pain works. Here are four important
ones:
Four Referred Pain Theories
Convergent-projectionmany signals, one receptor
the dominant, simplest theory, but it fails to explain several key
features of referred pain
Central sensitization irritated spot in the spinal cord explains much that convergent-projection cannot, but fails in other
ways
Hyperexcitability
combine the previous two
makes sense to combine the previous two theories, but the delay
theories and throw in a long
concept only explains the slowness of referred pain in animals,
delay in sensitization
which doesn’t occur in humans
Thalamic-convergence complex brain misinterpretation plausible, probably a factor, impossible to prove
of signals
Convergent-projection is the first and still the most believable way of explaining referred pain. It
dates back to the work of WA Sturge in 1888, when he noted that attacks of angina are associated
with a persistent tenderness in the skin that remains after the attack, like an echo, and the idea has
had a rich history of development since then.
Hypothetically, there are more nerve endings than there are receptors for them in the spinal
column, although it’s a surprisingly difficult thing to prove. Signals from several different nerve
endings, with different physical locations in your muscles, all end up passing their information on
to one receptor in the spinal column — the “convergence.” This results in a kind of “low resolution”
of pain perception in which your brain simply does not know exactly where the signal is coming
from, as there are multiple choices. It’s kind of like not being able to tell exactly where a siren is
coming from. Thus you experience a kind of “maybe here, maybe there” pain in an indistinct fog
spread out over the area of source nerve endings — the “projection.”
Psychological context is almost certainly important, too (in all of these theories, in anything that
hurts): if you just stabbed yourself, then your brain can sensibly infer that, of all the possible places
the pain might be coming from, it’s probably the knife wound, and thus a sort of simulated accuracy is
achieved — sort of the way smart phones use both GPS and local WiFi signals to increase accuracy
(direct data and context).
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Not only is convergent-projection the dominant theory of referred pain, it is the explanation of
referred pain put forward by Travell and Simons in their famous texts, and then again by Simons
and Mense as recently as their 2000 text, Muscle Pain. Certainly the convergent-projection model
makes some evolutionary sense. 150 However, there are some significant problems with the
theory. It can’t explain why referred pain is often delayed by several seconds in humans, or even
minutes in some animal experiments. If the theory is correct, there’s no reason why there would be
any delay.
It also can’t explain one of the most important
features of referred pain: it only goes one
direction. Referred pain tends to spread from
the source in predictable directions (which is
useful and important to know). For example,
Convergent-projection theory can’t explain
why referred pain is often delayed by seconds.
pressing on a trigger point in the tibialis
anterior muscle almost invariably causes
referred pain that spreads distally, towards the toes; however, referred pain moving in the opposite
direction is virtually unheard of. If the theory were correct, irritating nerves at either end of the
referred pain zone should “send” pain to the other end — because the signals are all going to the
same place.
Finally and vexingly, the threshold for the local pain stimulation and the referred pain stimulation
are quite different! If the theory were correct, any pain should result in referred pain. But one of the
most distinctive features of trigger points is that a trigger point can be extremely sensitive to
pressure without causing referred pain, until you press harder.
Nothing’s ever straightforward, is it? The convergent-projection model clearly does not have all the
answers! And that’s why there are multiple theories!
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Central sensitization theory basically says that pain can drive greater sensitivity to pain — a
vicious cycle. 151 Interestingly, some types of pain may be more prone to doing this, and — so
predictable — muscle pain specifically may be one of the culprits. 152 The sensitization process is
complex, and affected by many variables. For instance, once again, mental context probably has
considerable importance: the brain can literally instruct pain receptors to be more or less sensitive
to stimulation depending on whether or not your brain perceives a threat, like turning up the
volume on an annoying radio station if you think the news might be important — or turning it
down if it isn’t. If the brain wants more information, it can ask for amplification of pain signals —
yikes!
Pain is an opinion on the organism’s state of health rather than a mere reflective response
to an injury. There is no direct hotline from pain receptors to ‘pain centers’ in the brain.
There is so much interaction between different brain centers, like those concerned with
vision and touch, that even the mere visual appearance of an opening fist can actually
feed all the way back into the patient’s motor and touch pathways, allowing him to feel
the fist opening, thereby killing an illusory pain in a nonexistent hand.
~ Phantoms in the brain, by VS Ramachandran and Sandra Blakeslee
Brain-o-centric sensitization is probably a factor in virtually all chronic pain cases. It broadly
explains the effectiveness of placebo and the importance of fear and reassurance in health care. But
there are probably also dozens of other inputs to the equation, such as the presence or absence of
numerous hormones and molecules around the nerve. The basic idea is that, if you have distressed
tissue, not only do the nerve endings at the trouble spot have the potential to get “loud,” but the
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
receptors for those signals in the spinal column may also get sensitized. In fact, an entire patch of
spinal column could get sensitized — and thus you might start getting a bunch of amplified signals
from the surrounding area.
This sensitization process would not be
instantaneous or consistent, which explains
much that convergent-projection theory
cannot — it can explain the delays of referred
pain, and it can explain the way referred pain
is only sort of predictable, and it can definitely
explain the differences in pain thresholds
Like turning up the volume on an annoying
radio station if you think the news might be
important — or turning it down if it isn’t
between the source stimuli and the referred
pain. Mild pain at the source might simply not
be enough to sensitize the spinal column, thus no referred pain until you press hard enough on the
trigger point to get sensitization rolling.
However, central sensitization leaves much else to be desired, and it still can’t explain the way
referred pain spreads in predictable one-way directions any better than the dominant theory.
Hyperexcitability is difficult to distinguish conceptually from the previous theory. If anyone can
help, please write in! �� As I understand it, it’s basically a hybrid of the previous two theories: it
says that a smaller number of spinal column receptors get converging signals from a larger number
of sources, and sensitization occurs and takes some time. It’s based primarily on animal studies
showing minutes-long delays in referred pain, which has to be accounted for somehow. It can
explain some things, but falls down flat on others. Its biggest flaw is probably just that humans do
not experience long referred pain delays! We generally get quick delivery of referred pain, within
seconds, and so — although slow referred pain in animals still wants an explanation — that key
feature of the hyperexcitability theory really doesn’t seem to apply to humans.
Otherwise, the rest of the theory is basically just proposing that both convergent-projection and
central sensitization are occurring to some degree, which is such a safe bet that it hardly seems
newsworthy. Clearly none of these theories can explain everything about referred pain on their
own, so either they’re completely out to lunch (probably not), or they exist in some combination
(pretty likely)!
Thalamic-convergence theory is an almost irritatingly simplistic way of just chalking up the whole
business of referred pain up to a brain fart, and then saying it in Latin. The thalamus is a sensory
Grand Central Station — it is believed to both process and relay sensory information selectively to
other parts of the brain. You could say that it “thinks” about your sensations, and then decides if
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
other parts of the brain have a need to know as well. So, pain information arrives (converges) on
the thalamus. If something goes wrong with interpreting it in the brain, it probably starts here. It
ups the ante of convergent-projection theory, and says that signals also converge on the brain, sort
of blurring together — summation, for you neurology geeks — resulting in the same kind of
confusion that you’d get from too many signals converging on a limited number of spinal column
receptors.
Does the brain get confused by a bunch of
pain signals and you get a not-very-clear
impression of where your pain is coming
from? Can the bewildering complexity of the
brain explain these wacky referred pains?
Maybe. Good luck to researchers who want to
prove that. Experimentally eliminating the
The thalamus “thinks” about your sensations
& then decides if other parts of the brain
have a need to know as well.
other theories, and finding evidence for this
one instead, hasn’t happened and probably
won’t. It’s unlikely, just on general principles, that thalamic convergence is The One True
Convergence, and all other types of convergence are wrong, wrong, wrong.
Bonus elaboration on the thalamic-convergence theory. The spinothalamic tract is a relatively
well-understood nerve superhighway between the skin and thalamus with nerves that are neatly
mapped to the geography of the body — somatotopic organization — and is responsible for our
ability to precisely locate superficial pain. But it has a larger, lesser-known sibling, the spinoparabrachial pathway, which is not neatly mapped (stomatopically organized). It processes much
broader receptive fields, and — this is where it gets cool — it sends those signals to areas of the
brain responsible for aversive emotions. 153 In other words, it loosely maps areas to our emotional
reaction to pain in those areas. Or in still other words: pain different areas may be associated the
same emotional reaction. You can hurt in a specific location, and yet potentially react emotionally as
though a whole area is being stimulated. Fascinating.
And that concludes my survey of the state of referred pain science. Obviously you could write a
book about this. Too bad no one has! It’s pretty interesting stuff.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
3.13
Other trigger point theories
Everything we’ve discussed about trigger points so far basically assumed that the integrated
hypothesis of trigger points is more or less correct: that a trigger point is a tiny spasm of a patch of
sarcomeres clustered around a motor end plate. But what if they’re wrong? Or even a little bit
wrong?
There have been many other theories over the decades, and many clinicians have quibbles with the
standard Travell and Simons model — as they did themselves, to be fair. 154 One notable critic
(Quintner) has gone much further and declared Travellian trigger points to be an outright fiction. I
certainly see a few obvious things “wrong” with the metabolic crisis theory myself. There are many
trigger point phenomena that are not yet explained by the existing data. Here are two particularly
good examples that have always bugged me:
1. Trigger points that seem to live in connective tissue. Many clinicians have observed that there are
sensitive points in connective tissue that behave almost exactly like trigger points. 155 If trigger
points are exclusively a product of sarcomere dysfunction, this isn’t possible — the similarity has to
be superficial or illusory. But the illusion is strong. What’s going on? No one knows. Travell and
Simons have never written about it directly, to the best of my knowledge, nor has anyone else that
I’ve ever found.
2. Trigger points can “release” in response to virtually any stimuli. Travell acknowledged this,
writing “almost any [physical] intervention” can relieve a trigger point. If the sarcomere contraction
theory is correct, there’s no obvious reason why this should be such a strong effect. It would seem
that the dysfunctional motor point is more susceptible to neurological “context” than anything the
standard theory allows for.
So, what are some of the other ideas about trigger points? Bear in mind that, like referred pain
theories, it’s entirely possible that several theoretical mechanisms for trigger points can actually coexist.
The old pain-spasm-pain theory (previously mentioned in the section about
trigger points and injury). In fact, pain does not typically cause a vicious
cycle of more spasming and more hurting. Quite the contrary, “muscle pain
tends to inhibit, not facilitate, reflex contractile activity.” 156
Dr. John Sarno’s “tension myositis syndrome.” Dr. Sarno is the author of
several popular books about back pain and muscle pain, which are excellent
in many ways. However, it’s a real source of annoyance that Sarno never
acknowledges the existence of myofascial trigger points or really anything
about the well-established science of them, and instead uses only his own
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
Dr. Sarno’s popular
books are good in many
ways, but Sarno never
really admits that there
is a well-established
theory of muscle pain
that trumps his! A
The Complete Guide to Trigger Points & Myofascial Pain (2019)
label for the same phenomenon, “tension myositis syndrome,” and attributes
them almost entirely to stress-powered circulatory restriction. He’s only got a
couple pieces of a much larger puzzle.
common problem with
myofascial pain
syndrome — too many
cooks in the kitchen.
Fibrotic scar tissue. Because the worst cases of myofascial pain syndrome can
result in chronic fibrotic changes, this has been mistaken repeatedly over the years for scar tissue —
healed muscle traumas. There is lots of evidence that this is just not the case.
Referred pain of peripheral nerve origin. “It’s the nerves, stupid.” In 1994, Dr. John Quintner
proposed that the referred pain from irritated nerves (peripheral neuropathy) is the main thing, and
not a symptom. It’s a perfectly good … unconfirmed guess. The main problem with the idea is that
it boils down to picking another tissue — irritated nerves instead of irritated muscle — and there
are clues that support both guesses. However, it’s one of the most important of the other trigger
point theories. I go into a little more detail about this in a section below.
Muscle spindle hypothesis. A “muscle spindle” is a specialized sensory nerve ending, and theory
basically states that they are the epicentre of the dysfunction, not the motor end plate that powers a
patch of super-contracted sarcomeres. Simons debates it in detail and finally dismisses the theory
in Muscle Pain, and I agree with his reasoning.
Sensory under-stimulation. A root cause of trigger points may be sensory under-stimulation,
rather than the over-stimulation/irritation of metabolic crisis. I expand on this idea below in The
Bamboo Cage as an interesting theoretical case study, exploring the depths of just how wrong the
“story” of metabolic crisis might be.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
3.14
Quintner: “It’s the nerves, stupid”
2018 — Expanded: Added substantially to the section with exploration of two examples of peripheral neuropathy that may be mistaken
for trigger points (but only if you’re not very good at this stuff).
In 1994, Australian Dr. John Quintner wrote a historically significant critique of the conventional
wisdom about trigger points — that is, Travell & Simons’ explanation for the phenomenon of
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
trigger points (the energy crisis hypothesis) — and proposed that peripheral nerve pain could be a
better explanation. Specifically, that irritated peripheral nerve trunks are “a rich source” of pain,
and may be the true nature of trigger points, rather than a clenched patch of muscle. 157
Quintner has continued to actively study and write about this subject. In 2015, he published a new
version of his original paper in 2015. 158 The two version are strikingly similar: it’s the same
argument, just with the benefit of an additional 20 years of research perspective. His criticism and
theory make for interesting reading (required, really, for professionals). It’s might a better way to
explain at least some aspects of trigger point pain, and he may be correct.
But probably not entirely correct. It is just an alternative theory, after all — and one without much
detail or support. The main point of Quintner et al.’s work is that the conventional wisdom is
wrong — not to replace it. But I see little superficial difference in the quality of these competing
hypotheses: they are both just educated guesses. Although Travell slipped into acting more like a
guru than a doctor at times, she and Simons routinely emphasized that their ideas about trigger
points were just speculation, without much experimental support. Quintner’s idea has even less.
Neither has ever been validated, and both have a mess of puzzling loose ends and logical
problems.
I can’t read Travell & Simons or Mense without thinking over and over again, “But what about
________?” Sometimes they acknowledged those gaps and sometimes they didn’t.
And that’s pretty much how I feel reading Quintner: plenty of “but what abouts.”
One specific example: Quintner suggests that the locations of trigger points correspond to the
locations of peripheral nerves. I disagree: there are lots of common trigger point locations that
don’t seem to be located on any peripheral nerve pathway (perhaps a tiny branch, of course, but
nothing you’d find named in an anatomy text). And there are plenty of large peripheral nerves that
I can massage right over without ever provoking anything like typical trigger point discomfort. I
spent a decade paying close clinical attention to trigger points and nerve anatomy without ever
noticing a correlation. I could have missed it, but that seems a little unlikely. 159
Let’s get specific: known peripheral neuropathies that can seem like a trigger point problem
When all you have is a trigger point hammer, you may see only trigger points to bash on. There are
some peripheral neuropathies that could be mistaken for trigger points. Especially if you aren’t
familiar with the neuropathies.
Lateral femoral cutaneous nerve (LFCN) entrapment on the front of the hip, AKA meralgia
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
paresthetica, causes “lateral hip and thigh pain can easily be misinterpreted and ascribed to other
causes.” 160 Massage therapist Whitney Lowe:
A client, who I will call Steve, was experiencing lateral hip pain around the greater
trochanter of the femur. Some of the pain was extending into the lateral thigh region as a
deep aching pain sensation.
One practitioner thought that Steve had trigger points in his gluteus minimus muscle and
another thought he had a joint capsule problem. Treating the trigger points via direct
pressure on the tissues gave some brief intermittent relief, but ultimately was
unsuccessful in resolving the issue. In this instance an alternative explanation seemed
necessary for Steve’s symptoms.
Meralgia paresthetica can be a serious and tricky problem. There are some books about it, or at
least one anyway. 161 But here’s the thing: as much as a therapist with trigger point tunnel vision
is likely to miss the diagnosis, meralgia paresthetica usually involves relatively obvious symptoms
of a neuropathy:
Sensations often include coldness, numbness, weird sensations (itching, buzzing).
And the symptoms tend to be very superficial, not the deeper ache that’s more typical.
And they tend to be triggered by relatively obvious physical circumstances, like (Lowe) “clothing
such as tight jeans, especially if the individual is sitting for long periods. Nerve compression can
also occur from girdles, belts, military armor, seatbelts….”
None of that is typical of a trigger point. Any competent professional, who isn’t obsessed with
trigger points being the cause of nearly everything, is likely to spot the difference!
Cluneal nerve entrapment is just around the anatomical corner and similar in character. Cluneal
nerve branches pass from the low back and sacrum over the edge of pelvis and into the buttocks,
completely surrounding a classic location of sensitive soft tissue in the middle, upper “corner” of
the butt (perfect spot for massage #12). These nerves are somewhat vulnerable to injury and/or
chronic impingement along that route. 162 When irritated enough, they may cause back, buttock,
and leg pain.
Fascinatingly, cluneal nerve impingement is even known for causing a sore spot in the buttocks,
which radiates pain down the leg when pressed… so it can do a great impersonation of a trigger
point. Maybe the classic sensitive spot at this location actually is cluneal neuropathy — if so, that
would be a perfect example of a trigger point (sore spot) that is not a micro-cramp in muscle, but a
cranky nerve trunk.
And yet cluneal complaining is not a perfect impersonation of typical trigger point discomfort: as
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
with meralgia parasthetica, there will probably be some telltale symptoms of neuropathy. Consider
this description from Aota’s case study:
Palpation on the LPSL [location of the impinged cluneal nerve] consistently induced LBP
and leg tingling radiating from the buttocks to the calves on both sides. Injections around
the LPSL were repeated every month. Each time, the patient reported reappearance of leg
tingling during the block procedure and, soon after, complete improvement in LBP and
leg tingling that continued for three days.
That’s a lot of tingling! Every bit of which is a strong clue that the problem may be a peripheral
neuropathy, and not a trigger point.
So that’s two examples of peripheral neuropathy that certainly can be mistaken for a trigger point
… but probably only occasionally, and mainly by beginners. So these confirmed examples of nerve
entrapment don’t seem unusually triggery to me, just potentially confusing for people who are still
learning.
And there are plenty of common sore spots in soft tissue that have no relationship to any known
peripheral neuropathy, and no classic neuropathy symptoms. How would we account for all of
those? That’s a lot of neuropathy that doesn’t present like neuropathy!
Why so many grumpy nerves?!
My main concern with Quintner’s it’s-the-nerves-stupid hypothesis is that it requires an
assumption of way too many inexplicably irritated peripheral nerves. Sore spots are extremely
common: are they all caused by injured, entrapped, or otherwise irritated nerves? Why would that
be happening? To practically everyone, cosntantly? Are nerves really that vulnerable? Accepting
the hypothesis means embracing a world with a baffling amount of mild neuropathy.
Quintner describes peripheral neural tissue as “a rich source of local and potential referred pain,”
but why so rich? He suggests “mechanically or chemically sensitized nociceptors within the nerve
sheath” and “damaged nociceptive afferent axons” and “entrapment or metabolic insult” and
others. Mechanical explanations (trauma, entrapment) are generally implausible because people
are so obviously quite tolerant of strong massage, and indeed many find it quite relieving — which
would not be the case if their peripheral nerves were terribly vulnerable. Even if physical insult to
nerve trunks is a mechanism of trigger pointy pain, it seems like only half an explanation at best —
for a truly satisfying explanation, we would still need to know why so many people have so many
irritated nerves.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
But educated guessing is really what this book is all about! Above I speculated in a very general
sense about why muscle tissue might tend to malfunction. Now it’s time to turn to a rather morbid,
poetic bit of guesswork about the general trouble with nerves — broadly in support of Dr.
Quintner’s ideas, despite my concerns.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
3.15
“The bamboo cage” — lessons from immobilization torture
Imagine that “trigger points” don’t exist in a physical sense, as the harshest critics have suggested.
Certainly it seems to people like muscle feels uncomfortable — stiff, sore, aching — but perhaps we
really have no idea why, or even if it’s the muscle that is actually hurting. The problem might actually
be in our minds, and not our meat. This may be more literally true than it seems: not “all in your
head,” but just a deeply neurological phenomenon. It may be that so-called “muscle pain” is a
function of the central nervous system and the behaviour of nerves, and not unhappy muscle
tissue.
For instance, consider how intensely uncomfortable it is to be immobilized. Being stuck actually
hurts — tissue responds to stagnation with discomfort and then pain, and it can become extremely
unpleasant long before there is anything physiologically wrong with your tissue. Stay immobilized
for too long, and stuckness can become torture — literally!
Actual torture by immobilization, as in a cramped bamboo cage, is the most macabre and extreme
example of how much we hate to be stuck. (There is a memorable depiction of immobilization
torture in The Bridge on the River Kwai, and unfortunately such methods are not just a Hollywood
invention. 163 ) As with relentless drops of water, immobilization can cause great pain and
suffering without doing any apparent physical harm. Why? Such extremes of human experience are
often instructive.
The same effect can be reproduced in a few minutes at home. Try this simple experiment:
Position yourself comfortably, but place one muscle group in a moderate stretch, something you
can sustain without effort (for instance, your hand bent backwards, your fingers comfortably
hooked onto something, stretching your forearm flexors). Don’t move. Wait. The stretch will
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
become somewhat unpleasant for most people within a few minutes, and bloody awful within a
half hour. Again, why? The muscle cannot possibly be damaged — not that quickly.
Now … imagine several hours like that.
Never bet against the importance of nerves and brains
More than a decade ago, Vancouver pain researcher Chan Gunn suggested an interesting
mechanism for pain that might help us to understand why stagnancy is uncomfortable, and
immobilization torturous. Here’s a translation of his idea from neuro-speak into English: 164
Tissue health depends on a normal flow of nerve impulses. If nerves are impaired, tissue
can become paradoxically super-sensitive. Once the sensitivity sets in, tissue may become
over-sensitive to all kinds of stimulation, and not just injury. Ordinary stretch and
pressure, for instance, could become painful.
Sound familiar? That is just how many people feel when they have “muscle pain”. Whether Gunn
is right or wrong about the particulars is not important — it’s this kind of thinking that may be
useful in understanding so-called “muscle pain”. If this is anything like how muscle pain actually
works, you can see quite clearly that it’s not quite right to think of it as a “muscle problem”.
Gunn used his idea as a way to explain trigger points. His explanation is outside the mainstream of
trigger point science (if there is any such thing) and was summarily dismissed by Dr. David
Simons, who wrote: “Neuropathy can be, but is not always, a major activating factor.” 165 . Simons’
dismissal was basically, “it’s not the whole story, it’s too simple,” which is always easy to agree
with. But I think his dismissal was entirely too quick, and ever since then pain science has
relentlessly affirmed the importance of neurological dysfunction and central dysregulation. 166
Basically, when it comes to pain, never bet against the importance of nerves and brains.
What is immobilization pain trying to tell us?
Gunn’s idea depended on the phenomenon of “denervation supersensitivity,” in which muscles
that have been cut off from their nerve supply become extremely sensitive to acetylcholine, the
neurotransmitter that triggers muscle contraction. They become sensitive to it because there’s
hardly any of the stuff coming from the nerve! Muscle cells literally build more receptors, coating
their surfaces with them — a vivid example of how nerves can actually change the tissues they are
attached to. 167 With all those receptors, the muscles are “listening” very carefully for
acetylcholine — they seem to be saying, “Hey, is this thing on? Where’s the acetylcholine?” And then
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
they turn the sensitivity dial up to eleven and react strongly to any that they do get. (The same
thing takes place in many different contexts: we get more sensitive to all kinds of signalling
molecules when there’s a shortage, or insensitive when there’s a surplus.)
This phenomenon occurs in response to obvious nerve injury. It’s possible — unproven but
plausible — that something analogous to denervation supersensitivity could also occur when there’s
simply a lack of sensory variety and stimulation, which amounts to sensory boredom. Muscles
might become very sensitive to nerve impulses as we stagnate, like an eager dog who lunges at the
slightest movement that might herald a ball throw. That eagerness to contract, that “itch to move,”
could become intense and start to burn like pain.
This makes good biological sense. Stillness is dangerous — a few days in a bamboo cage might well
cripple or possibly kill, and there are many more commonplace examples of dangerous stagnation
(ask any nurse). Undoubtedly it’s a good survival strategy to have nervous systems fine-tuned to
avoid it. The sensory boredom of stillness is a meaningful warning, and doubtless it’s more
meaningful still if there’s a constant drone of signals about stretch or pressure or anything
whatsoever that is more likely to do damage if sustained, even if it is perfectly harmless in the short
term.
As these signals pour in, we undoubtedly get squirmier and twitchier, literally over-eager to move,
stretch, anything. The stagnancy alarm might lead to physical changes in the muscle and its
subsequent behaviour — i.e. hypersensitivity to stimulation — or it might just be a matter of
extreme psychological distress associated with the sensations of being stuck — pain! — or all of the
above.
The urgency of that feeling — the loudness of the warning — will be dialed
up or down by our brain, modified by our knowledge of the situation, how
long we expect it to last, whether panic and thrashing about is not such a
bad idea … or if it would just ruin the meditation. 168 Sometimes people
actually practice being still, and are consciously, constructively resisting the
urge to squirm — at least for a while. And sometimes they are actually
being tortured. Or maybe they just have to work in a chair all day — which
is a bit of both. Or maybe they are cuddling with someone they’re keen on
and don’t want the moment to end.
Maybe you can’t tear yourself away from this book?
Context matters.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Breaking the cage
It’s not hard to understand how a good massage could scratch that itch to move, a stimulationseeking impulse satisfied by hands and thumbs, introducing sensations that signal the end of
stagnancy and soften the alarm.
It is often easier said than done to “use it or lose it.” Accidents of anatomy and modern lifestyle
make it nearly impossible, even for a healthy person, to keep certain places in the body adequately
stimulated — the low back, for instance. For chair-bound office workers, it is almost as though the
low back is being tortured, locked in a tiny bamboo cage. Even when we get up to move, not every
muscle is entirely stretchable, and regardless it’s hard to compensate for so many hours in a chair
(although it certainly makes sense to try).
Injury, disease and even emotional constipation can pile on and block our efforts to scratch our
itches ourselves. 169 The problem becomes much more obvious in the elderly, where these factors
have accumulated. When I worked as a student massage therapist in extended care facilities, I had
the strong impression that I was lending a helping hand, stimulating tissues on behalf of my elderly
clients, helping them do what they desperately craved but literally could not do themselves — one
fellow I remember well simply could not reach his swollen feet — or only with such difficulty and
discomfort as to defeat the purpose. Our help was, of course, an intense relief for them, like
breaking the bars of the bamboo cage that had been built around their bodies by age, arthritis,
habit, tension, and every imaginable medical problem.
This all adds up to a surprisingly non-meaty vision of how muscles might seem to hurt and why
massage matters to us. It suggests that muscle pain might be a kind of illusion, that trigger points
may not be what they seem to be, and that pressing on muscle doesn’t “fix” muscle, per se. Instead,
perhaps it “just” satisfies the organism’s intense craving for stimulation … a craving which may be
far more urgent and important than we usually imagine it to be.
I am definitely not saying that this is how the phenomenon of trigger points actually works. But it
is a meaningful detour down hypothetical lane.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
3.16
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Case study: an example of getting unstuck and feeling “giddy with joy”
This is precisely why trigger points are worth understanding: because sometimes this kind of thing
happens.
A reader with serious chronic jaw pain just reported to me that, after a few days of regular, strong
self-massage of her masseter muscles (with little direction except the basic instructions provided
here), she experienced:
… a 20 hour state of euphoria, in which I needed very little sleep, was completely pain
free, and was giddy with joy.
Wow! That’s better than any drug I’ve ever heard of.
And then the effect faded. This simple case study is an excellent example of several things. It really
demonstrates how powerful just a bit of self-massage can be. Granted, this was exceptional: selfmassage rarely has such a strong effect. “Giddy with joy” is really, really good! But the fact that it’s
possible at all is pretty incredible.
And it’s a great demonstration of how profound the feeling of stuckness can be, that being freed
from it can make us grin for 48 hours.
And it’s also a great demonstration how even the best result with trigger points may well be a
temporary one — and that tells us even more about the nature of the beast.
I normally associate such strong state-of-being changes with The Art of Bioenergetic Breathing, not
self-massage. Such effects are not surprising in
principle — it’s like anything that feels like a
refreshing change in state, from hot baths to
tickle fights with your kids and other obvious
examples of things that feel wonderfully
different than the grind of work and chores —
but the strength of the effect can be really
amazing. People may feel dramatically
rejuvenated for hours or days.
The trouble is, it inexorably fades: soon
It’s like anything that feels like a refreshing
change in state, from hot baths to tickle fights
with your kids & other obvious examples of
things that feel wonderfully different than
the grind of work & chores.
enough you’re back in your various human
ruts and habits and you don’t feel so very
refreshed any more. But this isn’t a bad thing. It’s just life!
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
On an almost poetic level, trigger points are an expression of being stuck in a rut, which strongly
suggests that temporary and/or profound relief is possible, but also likely to be temporary. I believe
that this is a terribly important basic piece of wisdom to “get” for anyone who is prone to muscle
pain.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
3.17
Muscle knots are not inflammatory: the myth of the inflamed myofascial trigger point
A routine misconception about muscle pain is that it is caused
by “inflammation,” and the term is often used almost
interchangeably with pain, as though anything that hurts is, by
definition, inflamed. In fact, by the correct definition, all
inflammation is painful, but not all pain involves
inflammation. In particular, muscular trigger points are one of
the most common of all painful experiences, and are assumed
to be inflammatory and subject to the effect of antiinflammatory medications … and yet they are not inflamed, or
not much, and anti-inflammatory medications are not likely to
Inflammation & muscle knots are a
complex stew of biochemistry. But they
are not the same stew …
have much effect on most muscle pain.
An inflammatory reaction is a complex stew of biochemistry. It occurs prominently only in
response to injury and infection. Damaged cells spill their guts into tissue fluid, signalling and
triggering many other physiological responses. Blood vessels dilate, immune cells are attracted to
the area, and dozens of molecules and substances like bradykinin, histamines and prostaglandins
flow like Guinness in an Irish pub on St. Patrick’s day. This is the chemistry of tissue damage.
Although painful, it is the result of the body trying to protect itself and heal, and it is medicated
mostly just to make it more tolerable, not to stop it.
Trigger points also contain a complex stew of
biochemistry — but it is a different stew. The
chemistry of trigger points is the chemistry of
Bradykinins, histamines & prostaglandins flow
exhaustion. There is no word for this tissue
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
state, but there probably should be. According
to the prevailing energy crisis model of trigger
point formation — which is pretty solid — a
like Guinness in an Irish pub on St. Patrick’s
day.
trigger point is “revving” metabolically,
contracting constantly and strongly, millions
of mitochondria with the pedal to the metal. The result is certainly a toxic mess of cellular waste
products — acidic and irritating, which was shown clearly in a beautiful 2008 study — but it is
definitely not the same thing as inflammation around an infection, injury, or tendinitis.
Trigger point toxicity is
mitochondrial poop
This is a mitochondria, a cell
organ. Millions of them in each
cell provide the cell with power.
The toxicity of trigger points is
caused by their waste products
— mitochondrial poop, if you
will. The chemistry of inflammation is caused by cells being broken open
& spilling their guts into the tissue fluid, mitochondria & many other
things — quite different!
This is all a great oversimplification of the chemistry, but that’s actually part of the point: we don’t
have to understand the chemistry well to appreciate that each situation is so complex that they are
certainly not alike. Each has a distinctive biochemical “fingerprint.”
Despite their differences, there is almost certainly some overlap between inflammation (which is
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
fairly well understood) and whatever it is that’s going on in a trigger point (which is not well
understood). Certainly several of the same molecules are present. At the same time, there are
obvious and striking differences. My (very) rough guess is that there is no more than 50%
meaningful similarity between the two conditions … and there may be almost no similarity at all.
Just because they share some chemistry does not necessarily mean the processes are similar. Every
process in the body shares chemistry, of course — but in many cases, so what? Immune cells turn
up in both tumors and paper cuts: that doesn’t mean that tumors and paper cuts will respond to
the same meds. So even if many features of inflammation turn up in trigger points, it doesn’t
necessarily mean much.
On the “bright” side, chemistry-driven
problems like trigger points are so complex
that they are also unpredictable. There is
probably significant variation between people,
cases, individual trigger points, days of the
The chemistry of trigger points is the
chemistry of exhaustion.
week … and so there is always the possibility
that anti-inflammatory medications might
have more or less effect, depending on unknowable factors.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
3.18
Adhesions and contracture: when trigger points freeze in place
February — Revision: A substantial editing of this topic for the first time in years, eliminating a fair bit of quaint naivete and credulity
from the good ol’ days when I still didn’t know just how deep these waters run.
Adhesions and contracture are on a continuum of soft tissue stickiness and shrinkage. A mild
adhesion is just a slight, Velcro-like stickiness between layers of tissues — easily broken by
movement or massage. Contracture is a much more permanent state of tissue being “frozen” in a
shortened position, usually caused by pathology or long-term immobilization.
Between the two is a large gooey gray area of unclear clinical importance to pain patients. This
chapter is about that spectrum and its relevance to trigger point therapy. Are trigger points related
to adhesions or contracture? If trigger points are micro cramps, do they eventually turn into micro
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
contractures?
Scar tissue is similar to contracture, but different in principle, and I’ll cover that in the next chapter.
The science of adhesions: atoms stick to each other
Adhesions are caused by hydrogen bonds. Hydrogen atoms carpet the surface of the large protein
chains that make up the primarily collagenous substance of all connective tissues. They have a
slight positive charge, and so they are attracted to negatively charged particles — such as nitrogen
and oxygen atoms, which are also extremely common in the body (in case you were wondering,
you are about 10% hydrogen, 2.6% nitrogen, and — holy wow — 60% oxygen). When atoms with
opposite charges approach each other, they are slightly attracted, like opposite magnetic poles.
That attraction is very weak. A single pair of attracted atoms barely
stick together at all — just like a single tiny loop of Velcro hook
just barely grabs on to a single bit of Velcro loop. However, there is
strength in numbers! There are a lot of these pairs of atoms on the
surfaces of connective tissues — billions of them. As more and
more hydrogen pairs bond, the overall effect is significantly sticky.
At this stage, the bonds can still be broken fairly easily. Any strong
contraction or manipulation would peel them apart with no
damage (or, at worst, only truly microscopic and trivial damage).
This is a goal of many manual therapy techniques. For instance,
instrument assisted soft tissue mobilization (IASTM) involvese strong
scraping of skin and muscles with mean-looking metal tools, and
this is partly intended to break up adhesions. Or consider skin
rolling, from Swedish massage, which specifically intended to pull
skin away from subdermal fascia and the walls of muscles.
Bizarrely, when you “roll” someone’s skin, you can often feel the
skin tearing away from the underlying muscle, like pulling up old
carpet — which is mostly less painful than you might expect.
Just like Velcro, if the bonding between layers is allowed to
“settle” — if you work the two layers “into” each other — it can
get stronger. You end up not only with many firmer hydrogen
bonds, but other physiological processes begin to compound the
problem as well, and mere adhesions eventually become
“contracture,” a much more substantial and permanent kind of
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
Hydrogen bonds form, Velcro-like,
between protein chains. The
phenomenon is exactly like any other
electrical attraction, as between the
opposite poles of magnets, or a
balloon stuck to the wall. The bonds
are weak, but there are many
of them.
The Complete Guide to Trigger Points & Myofascial Pain (2019)
stuckness…
Contracture
“Contracture” is a kind of super-tightness in which muscle that has been shortened for too long
essentially freezes in place, just like your mother warned would happen to your face if you kept
making ugly faces. The danger may have been more real than she knew!
Tissue can get literally hardened and “stuck” without movement. 170 Muscles can get locked into a
shortened position. Tendons and layers of connective tissue stick together and lose elasticity. It
would be hyperbolic to call this “contracture,” but it’s halfway there.
True contracture occurs most dramatically in people with paralysis or connective tissue diseases
like Dupuytren’s Contracture — a mysterious contracture in the palm — and progression must be
constantly battled, like a garden full of weeds, with a challenging regimen of exercise and physical
therapy. Even the most vigorous efforts may still fail, depending on the cause. Regular stretching
does not cut it for most contracture; 171 more aggressive methods like splinting might work. 172 Or
they might not: splinting Dupuytren’s contracture might help a little, but some of the evidence is
clearly negative. 173
Adhesions, contracture, and trigger points
Adhesions probably occur microscopically throughout entire muscles, between their cells and layers
and subdivisions: not just stickiness between entire muscles, but between all the parts of muscles.
Every part of a muscle is wrapped, like a sausage, in a layer of connective tissue. The entire muscle
is wrapped; several large subdivisions are wrapped (muscle compartments); subdivisions of
subdivisions of subdivisions are wrapped, and so on, like a Matroyshka (Russian doll). Even
individual muscle cells are wrapped! In theory, all of these wrappings can stick to each other a
little, and maybe it adds up.
A trigger point may in time get “locked” into place by adhesions between the wrappings
surrounding it and inside of it. Just as trigger points themselves may be “micro cramps,” a patch of
adhesions around it may be a “micro contracture.” It might be why some trigger points are more
palpable than others. (Or not — there are definitely other possibilities.)
And a muscle full of many trigger point for a long time might become more “stuck” on a
macroscopic level — less flexible, like a hardened rubber band.
These are all reasonable thing to wonder about. There's not much more we can do about it. There's
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
not a lot of relevant research. There’s no clear evidence that this seizing up process is harmful, or
even that it’s occurring to a significant degree in anyone who isn’t sick or very old and unfit, let
alone that it has anything to do with trigger points or chronic pain. Adhesions probably form and
dissolve constantly, and are mostly easily brushed away by any reasonable amount of movement,
like cobwebs.
And yet we also know, from extreme examples, that it is possible to get adhered more profoundly,
all the way into contracture — and there’s probably a wide range of severity, as there usually is
with pathology. It’s probably more aggressive in some people than others, because of subtle
pathology, genetics, or physical stresses.
The speed of stickiness
If trigger points get stuck to a clinically significant degree, it’s bound to be a slow process. Many
people worry about getting adhesions long before they need to. My guess is that it would take at
least ten years, and maybe much longer, if it even happens at all. If adhesions around a trigger
point get disturbed (broken) even once per year, they might never have a chance to become much of
a problem.
On the other hand, in the worst case scenario, a serious trigger point could, in theory, develop
meaningful adhesions in a matter of months if you did nothing to break them up — no movement,
no rubbing ever.
However, many people do live with trigger points for decades — and they may slowly harden,
thicken, and stiffen, and that may make them much more difficult to treat. There are other reasons
why old pain is more entrenched too, but this could be part of that recipe.
Can you feel adhesions and contracture?
Adhesions are probably mostly difficult or impossible to feel. There is the skin rolling
phenomenon, mentioned above — the weird sensation of breaking subcutaneous adhesions — but
that doesn’t have anything to do with trigger points.
Certainly pathological adhesions can be palpable. The knotty crud in Dupuytren’s contracture is
downright obvious.
But it depends. Some lifelong, profound contractures do not have a distinctive texture. Consider
one patient I worked with for years who had torticollis, a congenital contracture of the
sternocleidomastoid muscle. One of his SCMs was about 3cm shorter than the other, his head tilted
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
for his entire life. His facial bones remodelled themselves so that his eyes are level with the
horizon. If he straightens his neck — which feels crooked to him! — his eyes are disconcertingly
lopsided. But when his neck is bent to the side, he looks and feels quite normal — just a slightly
head-cocked posture.
And his short SCM had a normal firm texture. His short-side was tender, but so was his long-side
(and so are most people’s SCM muscles, really). If they’d both been the same length, I wouldn’t
have had any clue that they were different from their texture alone. And yet that was a truly,
obviously contractured muscle.
Naturally, many masssage therapists will claim to be able to feel adhesions, contracture and
alleged “scar” tissue (see next chapter), based on a particularly hard and ropy muscle texture. But a
ropy texture does not necessarily mean that there are adhesions, contractures, or scars — muscle
can feel that way “naturally,” just by having a high resting tone (tension) 174 and non-adhered
trigger points. A muscle with a lot of adhesions might feel that way, but it also might not.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
3.19
The scar tissue issue — are you scarred for life?
It’s a popular concept in manual therapy to “break up scar tissue” — even when there’s no scar to
be seen. Patients are sometimes actually told that they have scars they can’t see, due to “subtle” or
“internal” traumas. Therapists may claim to be able to feel scars that the patient was oblivious too
— probably because they don’t have them! Or there might be something there, but it shouldn’t be
called a scar.
I think it’s misleading to talk about scar tissue in the context of most chronic pain. It’s marketing
language, melodramatic and inaccurate. It has emotional appeal — the appeal of a clear problem
that can supposedly be solved — rather than scientific accuracy. It’s not completely wrong — some
adhesions and localized contractures are a bit like scar tissue — but they are not actual scar tissue, and
the using the term “scar tissue” to sell treatments for “breaking it up” or “softening” it is just
bullshit. It’s on about the same level as a mechanic telling an old lady whose car needs an oil
change: “Your car has rotten oil. Big job to fix.”
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
As therapists, we need to “watch our language” and talk like professionals, not salesmen.
True scarring is worse than anything most people with myofascial pain will ever face. Scar tissue is
highly disorganized connective tissue — tissue that’s been severely disrupted by trauma, and
“patched” by a messy, dense, tough bit of “gristle,” a spackle of pure connective tissue. It is nearly
impossible to fix a scar. Treatments that claim to soften or remove scar tissue are all bogus as far as
I know. It’s like claiming to be able to melt cement.
Contracture is a little more like scar tissue, but still quite different. Contracture involves large
quantities of severe adhesions and other adaptive and pathological changes spread throughout an
entire muscle or even muscle group. Muscles are significantly and permanently shortened by
contracture. Imagine if your elbow was immobilized in an extreme position, bent as far as it will
go, and you could never straighten it out ever again — that’s going to cause contracture. After six
months like that, your elbow would probably never move again.
So you can see why it might bug me when therapists casually throw around the terms “scar tissue”
and “contracture” as if they have anything to do with trigger points — it’s not a fair representation
of what’s going on. Those terms should be reserved for the people who actually have those
problems.
Adhesions are much more common than proper scarring, and potentially more clinically relevant
and treatable. Even the worst adhesions are not as tough as actual scar tissue or contracture.
Instead of large patches of dense, disorganized connective tissue, tissues afflicted with serious
adhesions are still more or less “organized,” but have lost their ability to stretch out or move
relative to each other.
Adhesion, Contracture, and Scarring Compared
Defined
What is the worst case scenario?
Adhesions “Stickiness” between layers of Almost all adhesions can be easily broken. Only clinically significant as a potential
connective tissue
but unlikely precursor to contracture.
ContractureNear permanent
Contracture is much more severe in people with true paralysis or spasticity than
fusing/shortening of soft
anything faced by people with trigger points. The most ancient and severe trigger
tissue
points could be linked to mild contracture, but even that is speculative.
Scar Tissue Extremely disorganized, thick, Mostly or entirely irrelevant to trigger point therapy. Scar tissue, by definition,
indestructible “patch” of
only forms after messy tissue trauma; it never occurs due to trigger points, no
connective tissue at a lesion matter how bad they are.
site
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
3.20
Trigger points in animals
This is an odd topic that does not clearly belong anywhere in this tutorial, but readers have often
asked about it, so I’m wedging it in here at the end of the “science” part. The questions asked are
usually: “Do animals get trigger points?” and “Can animals be helped by trigger point therapy?”
The answers I give are probably and maybe. There are also some interesting implications and
tangents. Very little of this has practical value, but I think it provides some useful perspective.
Trigger points are primarily defined as a subjective phenomenon — sensitive spots — because the
objective signs are a bit sketchy. Since animals mostly can’t tell us which spots hurt and how much,
it’s hard to know whether they suffer from this like we do. 175
However, some of the objective evidence of trigger points that we do have has been obtained by
studying animals, so there’s that. And mammalian muscle biology is all mostly quite similar.
Humans are animals! If we get trigger points, other animals probably do to. However, it is possible
that humans have much more trouble with muscle knots than other animals. Many things
distinguish us in the animal kingdom! Our psychology is a lot more complex, for instance, and
emotional stress is probably a factor in myofascial pain syndrome.
But mostly I see no reason in principle why trigger point therapy couldn’t be helpful for animals,
just as we hope it is for humans. But in practice…
I don’t trust animal therapists
I don’t trust human therapists with egos and vested interests to accurately judge how helpful they
can be. There are many animal massage therapists out there who claim to work with trigger points
in animals, for whatever it’s worth, which probably isn’t much. It’s easy for humans to succumb to
wishful thinking and selective perception, and it’s even easier when working with animals. 176
There's a maze of complications most animal therapists aren't aware of, and they tend to remain
blissfully unaware of them because they can pretty much do what they do without the slightest
critical scrutiny.
And so people who do animal massage tend to have obviously overconfident views about it. They
often fail to give credit to the animal for being very extremely suggestible, just as capable of
placebo as humans. 177 And they give themselves too much credit, failing to recognize their own
biases. They anthromorphize animal reactions to therapy, just as most people do with their own
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
pets.
Example: it’s classic animal behaviour myth that dogs feel “guilty” when they’ve done something
we think is wrong, when all they are doing is detecting and reacting to our judgement and
disapproval.
It’s impossible to palpate trigger points reliably in humans, and undoubtedly harder still with
animals. There are more variables, and stranger variables. For instance, domestic animals are super
responsive to human attention and subtle non-verbal cues, to the point of amazing defiance of our
expectations, which is bound to confuse us. The famous horse Clever Hans was so sensitive to nonverbal cues that he could get the right answer to any simple math question simply by paying
attention to the reactions of humans to his hoof taps. 178 I have no doubt at all that a dog or horse
might benefit emotionally from a hopeful human taking charge and confidently trying to help. This
is not a stretch! And that will definitely make it hard to tell if they’ve actually been helped
physically as well.
Here’s a good rule for life: give animals some credit … and give humans less. �� Animal massage
is probably a good thing for a variety of reasons, but calling it “trigger point therapy” is a bit rich.
Trigger points may get treated, but even less reliably than in human massage. What is
“experimental” and uncertain in humans is more of a total crapshoot with animals.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
Part 4
BASIC TRIGGER POINT THERAPY (MOSTLY SELF-MASSAGE)
What can you do about garden variety trigger points?
July — Improved: Extensive editing and improvements throughout all the basic treatment sections. I added many key points and tips
while staying within the scope of “basic” (a tricky balance), mining years of writing on this topic for a wide variety of refinements and
carefully boiling them down to their essentials. Several ideas I consider obsolete were also removed. The Quick Reference Guide was also
updated to match.
2018 — Revised: The Quick Reference Guide hadn’t been updated for a loooong time, and I finally got to it. It could still use more
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
modernization and careful synchronization with book content, but it is greatly improved. (Fun fact: this update also eliminated some the
final traces of branding for the old SaveYourself.ca domain name, three-and-a-half years after it was retired.)
Most of the rest of the tutorial is devoted to both basic and then advanced trigger point therapy —
several chapters for the basics, and then many chapters for advanced refinements. The basics are
good enough for most people, most of the time, but the recommendations in the advanced sections
will be of great interest to anyone who has already tried basic treatment methods and failed to get
relief — which includes a lot of people who buy this tutorial. But don’t skip ahead! The basics are
an important foundation, and very few people are doing the basics well.
Dr. Janet Travell wrote that “almost any [physical] intervention”
can relieve a trigger point — nearly any stimulation. And indeed
it does seem like most mild to moderate trigger point pain can be
relieved with a surprisingly small amount of simple self-massage
with your own thumbs, or with the help of some cheap tools. So
self-massage is usually the simplest, cheapest, and most effective
Massage “seems” effective? That seems
like weak sauce for a book that is
supposedly all about the science! There is a
full discussion of the evidence of efficacy in
the advanced treatment chapters.
intervention, and it dominates the basics of trigger point therapy.
How can such a trivial treatment work? It smacks of being a bit too-good-to-be-true, but there are
plausible explanations. The pain may be more of a sensory phantom than something wrong with
the tissue. Pain is weird, often disconnected from clear causes, and surprisingly easy to modulate
with virtually any reassurance or pleasant stimulus. If trigger points are a purely sensory
phenomenon without much pathological substance, if there is no lesion in the tissue, if the problem
is more about how the nervous system is mis-interpreting sensation in the area… then massage
might be able to easily inspire a “reinterpretation.” So not much to “fix” in that scenario — maybe
just a dysfunctional sensation to change.
Or, if trigger points are caused by slight nerve entrapments — tunnel syndromes, slight
snagging/entrapment of nerves inside their tubes, as discussed in the chapter “Quintner: “It’s the
nerves, stupid”” — then it makes sense that even very gentle, subtle manipulation might free them
up and solve the problem, and all the intense sensations are superfluous.
Or, if we work within the micro-cramp hypothesis, then vicious cycle of contraction and
exhaustion taking place inside a lesser trigger point may not be especially difficult to disrupt,
similar to taming a macro-cramp with a quick stretch. The knot may not be all that tightly
contracted in the first place. The hypothetical accumulation of metabolic wastes could be relatively
minor and easy to flush out. 179
Finally, isolated and new trigger points are generally much easier to manage — they are probably
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
neurologically simpler and/or the tissue state is much closer to normal. Adhesions are not a factor
in trigger points that haven’t been around for long (if they are in any trigger point).
So, what does basic trigger point therapy consist of?
It’s almost entirely about self-massage, which mainly consists of learning the key features of TrPs
so that you can find them, and then a few refinements beyond just random rubbing: how long to
rub, how often, how hard, with what, etc, and some common mistakes to avoid. Tools like balls
and rollers and “canes” are also a key part of self-massage.
The basics notably exclude practically everything else: getting professional help, addressing
medical factors, medications, injections, exercise therapies (especially stretch), ergonomics, and
much more. You could argue that many of these things should be included in the basics, but I think
learning self-massage for trigger points is more than enough to start with.
Downloadable quick reference guide
Starting with the basics and then moving on to advanced
treatments, there are many tens of thousands of words of
information ahead about all the possible ways that you can
attempt self-treatment of your trigger points! That’s a lot of
words — a book-sized number of words, still to come.
Fortunately, you don’t have to memorize it all.
This tutorial includes a handy cheatsheet that summarizes all the diagnostic tips, basic treatment
instructions, and advanced therapy tricks — on a single page. This is the Quick Reference Guide
(QRG) to Trigger Point Diagnosis and Treatment. The QRG is in the PDF file format, which can be
displayed and printed on any computer. Click the link or the download button on the right to get
the QRG — both links will open a new window, and this window will still be here. It’s not a bad
idea to print it out and have it handy while you’re reading through the tutorial.
The quick reference guide
condenses all key diagnostic &
treatment points, tips & tricks into
a single page. Laminate it, put it
on the fridge!
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
4.1
Basic self-massage instructions
You can’t treat it if you can’t find it, but finding trigger points is the
hardest part, even for experts. It is the exact opposite of an exact science,
as I have emphasized in detail previously in the diagnosis chapters.
However, I’m going to recap the highlights for self-massage in a practical
way. So how do you try to find trigger points?
First of all, you don’t sweat it too much: sure you try, but you also just cast
a wide and pleasant net. The first rule of massage for trigger points is that
any good massage is probably better than bad trigger point therapy.
But of course you still look for them! And mostly you just grope around stiff, sore muscle tissue
with fingers and thumbs and find small, acutely sensitive spots.
You may or may not feel a slight bump or twitch when you hit a trigger point, but those are
inconsistent and unreliable signs. Do not put much stock in them.
More importantly, the soreness of a trigger point should feel “relevant” — that is, the soreness of
the spot should feel like it is related to the discomfort you are trying to treat, rather than some
other kind of discomfort that just happens to be in the same area.
It should also feel good — a paradoxical combination of soreness and relief we call “good pain.”
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
You can limit your exploration to a fairly small area of muscle tissue around the “epicentre” of
your symptoms, but some trigger points are surprisingly far from the pain they cause, usually
closer to the center of the body. For instance, wrist pain may be caused by trigger points in the
forearm muscles up near the elbow. (But trying to figure those out is going beyond the basics.)
How do you rub a trigger point when you hope you’ve found one?
It’s not rocket science. “Rubbing” is really all there is to it. But rubbing exactly how? There are
some specifics to consider…
Rub in what way? For simplicity, either simply press on the trigger point directly and hold for a
while (10–100 seconds), or apply small kneading strokes, either circular or back and forth, and
don’t worry about the direction of the muscle fibres. Really, anything that feels good is fine. But, if
you happen to know the direction of the muscle fibres — sometimes it’s obvious — then stroke
parallel to the fibres as though you are trying to elongate them, because that might be more
effective.
Rub how hard? Massage is mostly about having a conversation
with your nervous system, so you want it to have the right tone:
friendly and helpful! Not shouty and rude. You’re not trying to
“kill” it, you’re trying to soothe and “scratch” it. The intensity of
the treatment should be Goldilocks just-right: strong enough to
satisfy, but easy to live with. Too much intensity can backfire,
and a just-right intensity may actually be a key to success. So, on
a scale of 10 — where 1 is painless and 10 is intolerable — please
aim for the 4–7 range, and err on the side of gentle at first.
Does it work? A science-fair simple
experiment in 2010 produced evidence that
simple squishing (six 30-second
compressions every other day for a week) is
“effective in reducing trigger point
irritability.” 180 In my experience, much
less is often sufficient. But the evidence is
also really minimal. I will get into more
detail below.
Beginners are often much too aggressive. (And the pros too!)
And rub very gently, too! Regardless of your maximum pressure on any point, always make sure
there’s some light pressure as well. Specifically just gentle tugging of the skin to and fro. It’s
important to include this because it might be more effective, depending on the cause. We cast a
wide net with technique as well as locations.
Rub how much, how often? Start small—a single session of about 30 seconds might be enough,
give or take depending on how helpful it feels. Five minutes is roughly the maximum that any
trigger point will need at one time, but there is not really any limit — if rubbing the trigger point
continues to feel good, feel free to keep going. As long as you aren’t experiencing any negative
reactions, you should massage any trigger point that seems to need it at least twice per day, and as
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
much as a half dozen times per day. More is probably too tedious and involves too great a risk of
just pissing it off.
Rub with what? Rub the trigger point with your fingertips, thumbs, fist, elbow … whatever feels
easiest and most comfortable to you. Simple tools are really handy for spots that are harder to
reach. And I don’t mean specialized massaging tools — just a tennis ball, or other handy household
objects. More information about massage tools is coming soon.
And what if rubbing backfires? It probably won’t. But if your symptoms worsen in the hours after
treatment … simply ease up and use less pressure, less often. In basic therapy, you can always
count on trigger points adapting to stronger pressures over the course of a few days of cautious
experimentation. If they don’t, either the problem isn’t really trigger points, or they are simply
worse trigger points than you thought!
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
4.2
How do you know it’s working? Getting a trigger point to “release”
The goal of self-massage for trigger points is to achieve a “release.” What is trigger point “release”
and what does it feel like? It mostly refers to an easing of sensitivity of the trigger point, and/or a
softening of the tissue texture.
But release is a painfully vague term with no specific scientific definition. It’s a label for the
unknown, for whatever is going on when the trigger point seems to goes away. Maybe it refers to
the literal relaxation (or even the violent disruption!) of the tightly clenched muscle fibres. Or
maybe it’s “just” a sensory adaptation, which might be a kind of healing (it just stops hurting), or
trivial and temporary (like scratching a mosquito bite).
A release may not be obvious. In fact, things could even feel worse before they feel better: tissue
might remain “polluted” with waste metabolites even after a successful release. Release might even
require some damage to the tissue of the muscle knots — that is one theory. If so, the area would
probably still be quite sensitive even if you’ve succeeded.
Again we can use the acne analogy: like popping a zit, some minor harm may be done in the
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
process of helping.
In my experience — both treating and being treated — it’s a weird mixture of these possibilities:
initially there’s a satisfying but profound sense of scratching an itch, but the tissue is actually more
sensitive afterwards, not less.
Don’t worry about the details: just stimulate the trigger point, and trust that you probably achieved
a release, or a partial release, and then wait for the trigger point to calm down.
If you were successful, you will notice a
reduction in symptoms within several hours,
often the next morning.
The role of good pain
Generally speaking, with easy trigger points,
If you were successful, you will notice a
reduction in symptoms within several hours,
often the next morning.
successful release is usually associated with
“good pain” — that clear, strong and
satisfying sensation that is somehow both painful and yet also relieving. It is positive in the same
sense that throwing up is positive: it’s not exactly pleasant, and yet your body “knows” that it
needs and wants the pressure. Usually, if you feel “good pain,” a trigger point release is likely.
On the other hand, if you are wincing or gritting your teeth, you probably need to be more gentle.
Ease and comfort is an important component of successful treatment. If you can’t massage the
trigger point without wincing, either you’re being too brutal on yourself, or the trigger point is
simply too severe. Sometimes a trigger point will feel nasty and hot and burning and still release
anyway. But often such a rotten trigger point will need more persistent or smarter treatment.
In the advanced troubleshooting sections, I will talk about other clues to watch for that indicate
that a release is in progress.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
4.3
Basic tips and tricks for better, longer-lasting trigger point release
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Trigger point massage often provides only partial and temporary relief. Here are several easy
things you can do to improve your batting average:
Timing! Treat right before sleep. Many stubborn trigger points that defy midday treatment will
yield if you follow massage by going to bed.
Treat only a few knots at a time. Be a bit focused and work only with the worst spots at first. When
you start to see improvement, expand your efforts to other areas.
Beware of excessive pressure — it’s one of the easiest ways to sabotage the effectiveness of your
treatment. Start gently and make sure you don’t have a bad reaction. If you’re fine, you can always
add more pressure the next day.
Or completely switch to gentle pressure. Above I recommend including gentle skin dragging over
the sore spot, but you can also try just switching to it entirely: a different approach based on totally
different assumptions about what’s wrong, well worth a shot and well within the scope of the
basics.
Get better balls! Almost everyone has a tennis ball around, but other sizes and hardness can be
game-changers (e.g. lacrosse ball).
Trigger points are often caused/worsened by chills. Do not use ice or an ice pack on the area (there
are exceptions, but it’s a good rule of thumb). Avoid drafts on the skin, and generally stay warm.
Use heat in conjunction with treatment. If you don’t actually do treatment in a bath (the bath trick),
consider taking a hot tub or hot bath or shower before and/or after treatment.
Avoid sudden movements and strong contractions of the muscle after treatment. No challenging
workouts for the rest of the day after treating.
Move and stretch the muscles after the release of each knot. Muscle knots like “just right”
stimulation — not too much, not too little.
Recruit (and train) amateur help from your significant other or a friend. Sometimes being able to
relax while someone else does the massaging makes all the difference. More on this below.
Some of these are the beginnings of advanced approaches that will be discussed in much greater
detail below.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
4.4
Top 5 mistakes beginners make
Often the secret to success in any endeavour is to simply avoid the mistakes made by beginners.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
In trigger point therapy, beginners routinely sabotage their own results, getting only partial and
temporary relief. There are several common mistakes in self-treatment that will undermine your
results, or actually aggravate trigger points instead of relieving them. Avoid these mistakes —
there’s a much better chance that your efforts will work much better, and your trigger points won’t
come back!
1. The wrong trigger points! Of all the things that can go wrong with your self-massage technique,
this is the most common — simply missing the trigger point entirely! Sometimes this happens just
because you lack experience identifying the feeling of trigger points (you miss them by a
millimetre) but more often because of referred pain (you miss them by a mile). But don’t feel bad!
Referred pain is a confusing phenomenon. It can baffle amateurs and professionals alike. It can
cause you to “chase the pain” instead of the trigger point — pressing on the spots that hurt, instead
of pressing on the actual trigger points. The solution to this challenge is to continue to learn and
practice and experiment — don’t be afraid to just throw a lot of massage at the problem and try lots
of spots throughout an area — and to study referred pain patterns and try to understand where the
trigger point might really be. There will be a lot more advice about how to locate trigger points in
the advanced treatment sections.
2. Excessive treatment intensity! It’s tempting to be quite savage
with a trigger point when you find it. Resist this temptation,
especially at first. Strong intensity may be appropriate later, but
work your way up to it. Or it could be the wrong approach
altogether, and you need to experiment with a completely
gentle approach.
3. Ice and chills! Getting chilled or applying ice to trigger points
may bring them roaring back. (A notable exception is that ice is
probably harmless or even helpful when you’re alternating it
with heat, “contrasting,” discussed below.) Drafts on the skin at
night, especially on the neck, are one of the reasons why “I
woke up with it” is such a common way for trigger point pain
to start, or to come back. Conversely, muscle pain mostly likes
heat, and hot baths and heating pads will often aid trigger
point treatment.
4. Overexertion! Many beginners do not give themselves
Self-sabotage! One of the most incredible
cases of self-sabotage I’ve ever seen was in a
young man with a massive, walnut-sized
knot on the top of his shoulder, in his
trapezius muscle. He had been working on
the spot with both intense heat and intense
pressure. He had actually burned himself
and was blistering, and he had severely
bruised the tissue by beating on it with a
massage tool. Yikes!
Remember that the evidence (i.e. Gulick)
shows that remarkably minimalistic therapy
may be effective in many cases.
adequate time to recover from treatment. Intense muscular
effort will usually aggravate a trigger point. The most common way that this happens is either with
overly enthusiastic “weekend warrior” recreation, too soon after relieving a trigger point, or by
going to the gym to try to “work out” the stiffness. See the footnote for another sordid tale of selfsabotage. 181
5. Awkward positions! Even just spending excessive time in a chair. Sleeping in awkward positions
with muscles spending hours in an excessively lengthened or shortened state is another very
common way that people get trigger points flaring up … or coming back soon after releasing them.
Plane rides are another one that I hear again and again.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
These factors will all come up again here and there throughout the rest of the tutorial, and I’ll
discuss other, more obscure mistakes that can sabotage treatment.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
4.5
What about massage tools?
One of my massage therapy clients once described an experience she’d
had with an orthopedic physician:
He didn’t know about using tennis balls for massage! He asked
what helped my back pain, and I told him I always lie on a tennis
ball. He looked at me like he was going to refer me to a
psychiatrist! How can an surgeon not know about the tennis ball
thing? Doesn’t everyone know about the tennis ball thing?
Ah, the humble tennis ball
Unfortunately, no: not everyone knows about the tennis ball thing. But it
is a time-honoured simple self-treatment for chronic muscle aches and
Best buddy to the common
muscle knot!
pains, running a close second to “the hot bath thing.”
A tennis ball is just a particularly cheap, handy, portable self-massage tool that you can use on
suspected trigger points. It’s like a tiny little foam roller. It’s like a more accurate foam roller.
Basic technique for trigger point massage with a ball
The basic idea of tennis ball massage, or any massage with any kind of ball, is to apply specific
pressure to a stiff or aching spot in a muscle by trapping it between your body and something else:
usually the floor, sometimes a wall, or another body part (or a few other creative options like the
back of the couch, the bottom of the bathtub, and so on). The point is to use the ball to reach spots
that you simply can’t get to with your hands, and every other kind of tool massage is a variation on
this theme.
It is in fact exactly like foam rolling, but less trendy and more
precise. Both have their strengths, but if I could only have one, I
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
Going to the wall: Most people usually
The Complete Guide to Trigger Points & Myofascial Pain (2019)
would definitely choose the tennis ball for its accuracy and
start with the floor, but for many locations
versatility.
working against walls allows much better
Tennis ball massage is usually the most useful in the muscles of
a bit of a quadriceps workout!
the back and the hips: places where you can actually lie down on
Make sure your feet have a good grip. And
control over pressure. Plus you usually get
the tennis ball, pinching it between your body and the floor or
you’ll quickly discover that a tennis ball
wall. Many other locations are awkward (especially for
may be a bit slippery for wall work, which
beginners), and you may find it difficult or impossible to apply
is why many folks graduate to other kinds
pressure effectively.
of balls.
Lie down on a tennis ball, placing it in approximately the right location. You do not have to be
precise. “Explore” by moving slowly and gently, until you’ve got just the right spot.
The limitations of tools
Tools certainly are great for those places that you can’t reach any other way, and for spots that
need more pressure than you can apply with your hands. But they aren’t perfect. One reader put it
this way:
I have every knot remover gadget on the planet: the foam roller, lots of different balls,
TheraCane, a 2-headed percussion massager, the Knobber, etc. However, in the end I find
my fingers do the best job.
— Cindy Corriveau, Calgary
That has been my experience as well: no matter how clever, massage tools can’t “touch” the
sensitivity and dexterity of your own hands. I recommend that you always try to use your hands to
reach a muscle knot whenever possible; resort to tools only when necessary.
That said, it often is necessary! Don’t worry too much about what tools to get.
Of course, it doesn’t have to be a tennis ball.
Lacrosse balls are less common and much firmer, for instance, but they have a great rubbery
texture that makes them easy to work with, and less prone to slipping. Squash balls are also nice
and “sticky,” but much smaller and more precise.
A simple selection of balls — I have had a “bucket o’ balls” around for many years now — gives
great bang for your buck, and anyone who has a tough muscle pain problem should have one.
Most of the balls in a good bucket o’ balls can be purchased in one trip to a sporting goods store
and a pet store. A bucket o’ balls and a bit of practice is like having 50% of a good massage
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
therapist on call for the rest of your life, for the tiniest fraction of the cost of therapy. A ball
certainly can’t do it all, but it’s a good start and an incredible value!
Use tools at your discretion. In the advanced troubleshooting sections, I will discuss tools in much
more detail, both commercially available tools and free or cheap tools. I will recommend several
specific ones, warn you away from pointless expensive ones, and suggest clever tactics for getting
the most out of any massage tool.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
4.6
Can you damage your nerves when self-massaging?
February — Science update: Extended the discussion of vulnerability to include “sensitization.”
Yes, you can damage nerves by massaging, but it’s rare and rarely
serious. I did it to someone just once in ten years working as a
professional massage therapist — I tell the story below. Mostly nerve
trauma is not something we need to worry about, but it’s a common
concern anyway, driven by excessive “nerve fear” in our society
(discussed above). I get a lot of questions like this one:
One thing that helps sometimes when my neck pain gets
excruciating is to really dig my fingers hard into a couple of muscle
knots in the back of the neck (not right on the spine but off to each
side, below the occipitals), or to use a Thera Cane to do the same
thing. Is there any chance of causing nerve damage from so much
pressure?
Is this a realistic scenario? Can
you damage nerves with selfmassage? Here’s the executive
summary for this section: no.
Case closed.
reader Peter Spaeth, Boston
I’m going to answer this in detail so that you have good confidence about this issue. I’ll discuss the
physical protection most nerves have, some of the potentially more vulnerable locations
(endangerment sites), the toughness of nerves, and the extra caution needed with tools.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Why nerves are not very vulnerable to massage
If you are even slightly cautious, it is nearly impossible to damage your nerves with self-massage,
because:
1. larger nerves are mostly padded well by other tissues
2. healthy nerves are not especially fragile or sensitive
3. if actually threatened by trauma, nerves produce plenty of warning sensations that will stop any
sensible person before much harm is done
Let’s look at those in more detail …
Larger nerves are mostly protected
The larger nerves and nerve roots — the only nerves of any concern — are mostly shielded by skin,
fat, muscle, and bone. It’s particularly unlikely that you could harm yourself by massaging in the
location Peter asked about, on the back of the neck (beside and behind the spine). The only
prominent nerves in the back of the neck are the nerve roots, the bundles of nerve tissue that
emerge from between each pair of vertebrae. But these are under at least a half inch of sturdy
musculature, the meaty paraspinal muscles.
But not all nerves are well-protected, of course.
Endangerment, Will Robinson!
There are a few places in the body where nerves are more exposed and can be injured by stronger
pressures. All of these sites are familiar to any well-trained massage therapist: we call them
“endangerment sites,” but the danger is minimal. Perhaps a better thing to call them would be
“unpleasant places to rub.”
Here are all of the commonly cited endangerment sites (nerves highlighted):
Endangerment sites
anatomic location (plain English)
potentially vulnerable anatomy
Anterior Triangle of the Neck (throat)
carotid artery, jugular vein, vagus nerve ; under sternocleidomastoid
Posterior Triangle of the Neck (side of the throat) nerves of the brachial plexus, proximal ; brachiocephalic artery;
subclavian artery & vein
Axillary Area
(armpit) brachial artery, axillary vein & artery, cephalic vein; nerves of
brachial plexus, distal
Medial Epicondyle, Humerus (inside elbow)
ulnar nerve
Lateral Epicondyle, Humerus (outside elbow)
radial nerve
Umbilicus region (belly)
descending aorta & abdominal aorta
lateral 12th rib (lowest rib)
kidneys
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Greater Sciatic Notch (buttocks, beside tailbone) sciatic nerve
Inguinal Triangle (groin)
external iliac artery; femoral artery; great saphenous vein; femoral vein;
femoral nerve
Popliteal Fossa (back of the knee)
popliteal artery & vein; tibial nerve
Hollow under the earlobe
parotid salivary gland, facial nerve
The endangerment sites are debatable and in some cases definitely misleading. Nerves are
everywhere, and there are many locations where they are potentially just as vulnerable to pressure
as some of the ones listed above … but no one has ever proposed them as endangerment sites. 182
The idea that the sciatic nerve is “exposed” to any degree in the sciatic notch, for instance, is a bit
ridiculous (compared to the ulnar nerve, say).
And you can easily massage the scalene muscle group (in the posterior triangle of the neck)
without ever bothering a nerve fibre. Extra caution is justified in this area, but not because the
brachial plexus is notoriously sensitive — it’s more because of the blood vessels.
If you massage these locations with reasonable caution, you might feel electrical, zappy, funny-boneesque pains, but you will feel them before there is any actual danger. Healthy nerves aren’t
particularly sensitive, but they will speak up if they are on the verge of being crushed or torn (like
any tissue).
Nerves aren’t very fragile or sensitive
Most nerves, most of the time, can be firmly squeezed without producing any symptoms
whatsoever. The ulnar nerve — the “funny bone” — is tolerant of almost any fingertip pressure,
and only produces that infamous zing with much greater force.
However, there are almost certainly circumstances where nerves can be more sensitive. For
instance, they may only be sensitive to pressure when oxygen-starved (or otherwise vulnerable).
Which may be exactly what’s going on with some of the nerve tissue in your neck — muscles rotten
with trigger points are measurably hypoxic, low-oxygen. 183
And so, one way or another, nerve roots in the posterior of the neck might sometimes be sensitive
enough that you may get some stranger, nervier sensations when self-massaging in the neck.
However, this sensation tells you nothing you didn’t already know: your soft tissues are cranky.
There is no cause for concern if the sensations are easily tolerable.
In my experience, however, blatant nerve sensitivity in the neck is rare in association with neck
cricks, even quite severe ones.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Or maybe they are naturally sensitive? But not in a “zappy” way
Another intriguing possibility is that the sensitivity of nerves and trigger points are actually the same
thing — trigger points might be the sensitivity of vulnerable nerves. This idea is thoroughly
discussed in the section, “Quintner: ‘It’s the nerves, stupid’.”
If so, then pressing on them isn’t likely to injure them, or even cause clasically zappy nerve pain:
just the familiar aching and burning of common muscle pain. The nerves are clearly vulnerable in
some sense, but probably not to injury.
There’s another sense in which nerves might be “naturally sensitive,” and more vulnerable. There
are several mechanisms by which nerves can become pathologically over-sensitive after an initial
insult, causing the pain to drag on and on. For a long time, no one had any idea why this happened
to some people and not others, and it really does seem to be a binary phenomenon: either it
happens or it doesn’t. Unfortunately, one likely explanation was identified in 2010: genetics 184
That is not great news, but it is interesting and at least a little bit useful.
So chronic pain could be due to on-going irritation of nerve tissue, but it could also be entirely due
to a malfunction of the sensory equipment itself. A fascinating possibility (and a rather bleak one).
The point: be wary of therapeutic wild goose chases looking for mechanical causes of pain.
Neuropathy, when it happens, is definitely not necessary just about physical insult, but about our
vulnerability to it.
What happens if you push your luck and push too hard on nerves?
Push hard enough, and you can injure a nerve, of course. In a 2017 incident, a woman’s radial
nerve was crushed by an aggressive massage in her upper, inner arm. It’s rare, but it happens. 185
Deliberately ramping up pressure on a sensitive nerve is hard to do, like sticking your hand into a
jar of scorpions. And yet, surprisingly, sometimes people still do it! It’s surprising what we can put
up with if we think it’s necessary, and the no-pain-no-gain attitude inspires a lot of foolishness.
Nerves can recover from a lot of abuse, up to
and including being mangled in nasty
accidents, or being pinched hard for years. For
instance, many people who have severe carpal
tunnel syndrome — years of disabling median
nerve impingement — often recover just fine
once pressure on the nerve is finally relieved
Deliberately increasing pressure on a sensitive
nerve is hard to do, like sticking your hand
into a jar of scorpions.
by surgery.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
In the unlikely event that you cause yourself a nerve injury, it would probably only result in
annoying but trivial symptoms that would take a few days to resolve, or perhaps a few weeks at
the worst. But I have rarely heard of this happening by self-massage — it’s just too unpleasant as
you approach the point of injury to actually get there.
Please beware of tools
I’m sure that there are people, somewhere out there, who have hurt their nerves with self-massage.
And I bet most of them were using a massage tool. When you use massage tools, it may be easier to
apply too much pressure too quickly … before you have that “I’ve made a huge mistake” moment.
It’s harder to control tools, and hard to tell what’s going on when you’re sensitive fingers and
thumbs aren’t involved. For example: you can easily feel the pulse of an artery when you are
massaging with your fingers, for instance, but you can’t feel it at all when you use a tool.
So if you use a tool, use it with extra caution.
That one time I injured a client’s nerves
Once upon a time I pushed my luck, and injured a patient’s cervical plexus — this area where most
people will probably never self-massage strongly. I injured him by applying strong pressures in a
vulnerable area too quickly. It was one of my more reckless moments in a decade of mostly quite
gentle massage.
He was alarmed and unhappy with me, of course, but his symptoms were minor: he had annoying
flashes of moderate pain that slowly faded over about three weeks, and probably the worst thing
about it was simply that he was less sure of his prognosis than I was. I knew he’d get better steadily,
but he didn’t know if he could trust my opinion! Fair enough.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
4.7
Don’t hesitate to recruit amateur help
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Do not underestimate the value of amateur assistance! A creative and generous amateur can be just as
effective a trigger point therapist as the average professional, certainly for easy cases — and even
for difficult ones!
A helper — spouse, partner, friend, etc. — can be an incredible resource, and many people do have
a willing helper available. Don’t hesitate to make it a family project. I often invite helpers to my
own clients’ appointments to provide basic training. Adequate therapy then continues outside my
office, and the price is sure right. Just as self-treatment is a realistic and affordable alternative to
professional trigger point therapy, so is amateur help.
A helping hand
If your partner isn’t willing to help
… perhaps it’s time for a new
partner? Seriously, there needs to
be more of this in life, with or
without nasty chronic pain
problems! In many ways, partners
can be just as effective as a
massage therapist, or even more.
Another reason that amateur helpers are an important resource is that they are often better listeners
than professionals. Whether it’s due to a lack of confidence, or simply being friendlier with you, or
both, amateurs will often be much more responsive to your requests for changes in pressure or
location than professionals are. Sadly, many professionals are too preoccupied with their own ideas
and forget that therapy is an intricate partnership. Trigger point therapy with a helper invariably
works better when there is lots of communication, because the patient can provide so much
valuable information about exactly which location and how much pressure feels the most effective.
Of course, not everyone’s partners are helpful. Many of my patients complain of partners who just
don’t want to do massage, or partners that are willing but, unfortunately, do not listen well.
Another not-so-good scenario is when amateurs are too confident, and think they know what
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
they’re doing and insist on imposing their ignorance. They may have misinterpreted ideas they got
from competent professionals, or they’ve gotten bad ideas from incompetent professionals, or all of
the above. When you encounter such a well-intentioned, overconfident know-it-all, you have to
either educate them — give them this tutorial! — or fire them and find someone else.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
4.8
A little more perspective on amateur assistance
Half the challenge of trigger points, maybe more than half, is simply recognizing their importance
in the first place — getting to the point where you accept that trigger points are your problem, or a
large part of it. Many people need a professional to help them get to that point, or a tutorial like
this, or a popular book like Clair Davies’ The Trigger Point Therapy Workbook.
Often I work with patients who have quite treatable cases of myofascial pain syndrome, but who
have been given dozens of different diagnoses over the years, many of them scary. Such patients
are unlikely to believe, at first, that just a little simple trigger point therapy may be all they ever
needed! And no amateur can help them through that process. Only a confident professional who
can assess, and persuasively dismiss, all those wrong diagnoses can guide a frustrated, cynical, and
confused patient to the awareness that it was actually a simple case from the beginning.
But once you are there … the therapy itself can be quite easy! So easy that even an amateur can do it.
As you’ve seen in the preceding sections, trigger point therapy is not difficult — most of the time
it’s just a little rubbing.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
4.9
How to get adequate professional help
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
All PainScience.com tutorials have a strong focus on self treatment, and on other solutions that
minimize cost and dependence on expensive health care. I believe in empowering patients through
education to do every possible thing for themselves. This is particularly a good idea in the case of
trigger points, because so few health professionals are well-qualified to treat them, and because
self-treatment really can work minor miracles.
But sometimes you really do need a little help. �� And in the case of trigger point therapy, it
won’t be cheap to get help: rates start at USD $60/hour in North America, and can go much higher.
You don’t necessarily need help because your case is difficult.
It can make perfect sense to seek out professional help before attempting advanced self-treatment
tactics. For instance, it may simply be a matter of an awkward spot, and a lack of a friend or family
member available to help. Or it may be a relatively mild trigger point that you simply can’t locate
— you know it’s there somewhere, but you’re having trouble figuring out where. So, even for mild
cases, you may want to seek professional help.
I will address this topic in much more detail in
the advanced troubleshooting sections below,
suggesting a wide variety of therapy options.
Sometimes you really do need a little help!
But for basic cases, my recommendation is that
you simply find any massage therapist you
like. Just as with locating trigger points themselves, you can largely trust your instincts.
Simply find a massage therapist who seems friendly, curious and responsive to your requests.
After reading this tutorial, there is a really good chance that you will actually know more about
trigger points than the therapist, so don’t be afraid to politely ask for what you want. Of course,
you should also be open to their suggestions. But the scenario you want to avoid is the bossy
therapist who puts all his or her energy into their own pet theories, completely neglecting what
you asked for — a bizarrely common scenario, unfortunately.
Also, looking for a massage therapist who does “medical massage” is a reasonably good way of
finding someone competent.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
4.10
Common medications that might make a difference (and might not)
As anyone with anything more than a mild case of muscle pain knows,
there are no over-the-counter pain medications that are going to make a
significant, lasting difference. However, ordinary pain medications are
the first line of defense for tens of millions of people. Patients often try
virtually everything at their local pharmacy, sometimes stumbling on a
medication that seems to make a difference for a while, but usually
finding that medications simply don’t do any more than take the edge
off.
The commonly used over-thecounter medications are antiinflammatories like ibuprofen,
Tylenol, codeine, alcohol &
muscle relaxants.
In the spirit of “basic” treatment options, this section will only
summarize the widely used and non-prescription drugs: ibuprofen, Tylenol, codeine, muscle
relaxants and even alcohol. None work well, and none offers anything like a cure. All of these
options are worth cautiously experimenting with. All of them are problematic and pointless in
excess.
Anti-inflammatory medications are worth trying, but rarely work any miracles, probably due to
the fact that trigger points are not really an inflammatory problem. When ibuprofen seems to work,
it may just be because trigger points often co-exist with inflammatory problems, such as some
minor tendinitis, for example. An interesting, related option is Voltaren gel: ibuprofen in an
ointment, basically. Again, it’s not likely to magically eliminate trigger points, but it’s certainly
worth a try, and is probably the safest of all medication options. See the Voltaren section for more
information.
Straight acetaminophen (Tylenol) seems to do almost nothing for muscle pain for most people,
and it’s infamously hard on the liver.
Codeine (mostly available in low dosages Tylenol 2s and Tylenol 3) won’t treat trigger points, but
seems modestly effective because it’s deeply relaxing. Unfortunately, codeine also makes people so
dopey that it’s just not useful except at the times of greatest need, and not all that much even then.
Alcohol is hard on your system in many ways, and hangovers obviously increase muscle pain.
However, anecdotally, moderate usage seems useful for taking the edge off trigger point pain,
probably via sedation and the “I don’t care if it hurts” effect. It’s hardly a cure, and you can’t go
through life drunk any more than you can be constantly high on codeine, but it can offer some
relief. Do beware of a particularly sneaky side effect: alcohol is well-known to compromise sleep
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
quality. 186
Muscle relaxants come in several varieties, but only one that is widely available without a
prescription: methocarbamol, as found in Robaxin, Robaxacet and similar brand names. A muscle
relaxant is the one drug in this section that seems to have the potential, in principle, to actually treat
trigger points (as opposed to masking the pain of them). However, they just don’t work well.
Methocarbamol is so surprisingly useless, in fact, that I’ve included it in the treatment options hall
of shame: the “Reality Checks” section. The unexpected uselessness of muscle relaxants is
explained in detail below.
There are a few other medications, or medicine-like options, that are also in the “Reality Checks”
section: the homeopathic ointment Traumeel, Epsom salts, and drinking extra water are three
popular ones that almost certainly do not have any effect on trigger points.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
Part 5
ADVANCED TRIGGER POINT TROUBLESHOOTING
What can you do about severe and persistent trigger points?
There is a groan that unites men and women, rich and poor, in any nation. These [muscle]
pains are “explained” in every culture, but the universal fact of this persistence must
mean that no adequate therapy exists.
~ Professor Patrick D. Wall, FRS, DM, FRCP, in the Foreword to
Muscle Pain: Understanding its nature, diagnosis and treatment
The basic advice given in the sections above is more than enough for most people, most of the time
to deal with their trigger points well enough. But what if your case is more challenging? The
second half of this book is devoted to troubleshooting trickier cases of myofascial pain syndrome
— even cases involving many severe, active trigger points that seem to resist all forms of treatment
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
and go way beyond “stubborn.”
What if you came to this book already familiar with the basics, but you’ve never really been able to
do much better than just temporarily take the edge off? What if the book so far is all old hat to you?
What if you already have some idea what to do about them (score one for you), but they just keep
coming back (score one for the trigger points)? This is a common deadlock.
Many people who “discover” a trigger point diagnosis are initially excited by the possibility of
relief … and then disappointed as self-treatment and therapy seem to go nowhere fast. Even when
you are “correctly” treating the right trigger points, or even getting them treated by a professional,
sometimes they just won’t go, or they come back so fast that you might as well have not even
bothered!
Trigger points seem to be much easier to deal with below some unknown critical mass of numbers
and severity. Above that line, things get much tougher. Many trigger points seem to reinforce each
other: the more there are, the faster they all get worse, and the harder it is to deal with any of them.
The tough cases feel like a sinister game of whack-a-mole.
You may get very little relief at all, or you may get good relief but only for a short time, or none of
the above. Treated trigger points may come back in a day, a week or a month. Worse yet, treatment
may even backfire — yikes! Some people do experience nasty negative reactions — aggravated
symptoms, severe bruising, nausea.
The problem of trigger points that always come back, or never really go away in the first place,
may or may not be fixable, depending on the details of your story and your body. In general, the
only way to find out if it’s possible to beat such trigger points is to try a lot of things, and that is why
the rest of the tutorial is so long. The tactical “secrets” to advanced trigger point troubleshooting
are creativity and persistence — to throw everything at the problem but the kitchen sink. There’s no
single magic bullet, but many small lessons that slowly accumulate into more of a cure than you
used to have.
I’m always reassuring readers and clients that learning to deal with your trigger points (muscle
knots) involves a long learning curve. In the vast majority of these cases, continued
experimentation can still result in longer-lasting results. No one has “tried everything,” not by a
long shot. Most people are not familiar with more than 2 or 3 treatment options out of the dozens
of possibilities we will discuss here. For instance, I got through my entire clinical career as a
massage therapist without ever once trying spray and stretch therapy — which is probably one of
the most worthwhile things to try!
Even when trigger points can’t be “cured,” it’s often possible to learn to manage them to the point
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
where they become no big deal. Compared to constant suffering, that practically is a cure. But the
only way to get there is to keep trying new things. The sections ahead are designed to give you
some hope, a sense of the possibilities, and every possible option — every tip, trick and useful
perspective I can think of, after a decade of study and practical experience and constant exposure
to extreme cases from every corner of the globe. 187
But before we get into all the tips and tricks, I
want to devote a section to another popular
trigger point self-treatment manual, The
Trigger Point Therapy Workbook, by Clair
Davies, and why it is not actually suitable for
helping many people with difficult cases of
myofascial pain syndrome …
Persistent & creative experimentation will
lead to trigger point relief that lasts longer &
longer.
5.1
A brief detour: why not The Trigger Point Therapy Workbook?
This is an abridged version of my full review of the Workbook.
Clair and Amber Davies’ popular book is well-written and has many virtues. In particular, it is
illustrated well, and offers detailed muscle-by-muscle reference material — something this tutorial
actually deliberately lacks.
I used to wonder why I even bothered to create this tutorial! Why not just recommend the
Workbook? Why reinvent the wheel?
It turns out there’s quite a good reason! More than I originally expected. Today, this tutorial offers
a lot that you can’t find in the Workbook.
The strength of this tutorial is depth: the delving into the nature of the beast, particularly the
science reporting. That strength has grown while the Workbook has fallen behind the times. The 3rd
edition, published in 2013, not only promises too much to patients, but fails to explain the
importance of many significant scientific developments and controversies.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
The Workbook promises too much & neglects relevant science.
The Workbook has always promised too much. In the first edition in 2001, Davies tried to convince
readers that trigger points are responsible for practically everything that ever hurt you or ever will,
and — even worse — he certainly gave readers the idea that self-massage is a nearly infallible cure.
That was absurd even then, 188 but it was also more forgivable eighteen years ago. The 3rd edition
should have been much more cautious and humble. It should have explained that trigger point
science has had many disappointments and problems, and that we have important new ways of
explaining this kind of pain that have nothing to do with muscle tissue. It did not, and failing to
even acknowledge the controversies is a deal-breaker in my opinion. This topic is too important for
such neglect.
Fortunately, trigger point therapy based on the conventional wisdom still seems to offer people
some relief. Massaging trigger points is no miracle cure, but it often helps. I have heard from many
patients and readers who seem to have gotten some benefit from the Workbook … but it also gave
them unrealistic and simplistic expectations. It did not help them troubleshoot their difficult cases.
(How can it, when it doesn’t even admit that there are legitimate questions about what trigger
points really are?)
My goal when I set out to perfect this tutorial was to offer people a more realistic view of trigger
point therapy — to meet the challenge of difficult cases head on, and to offer you every possible
option for treating them, and even the worst of all trigger points — even while explaining the
limitations of those options. I believe it has been doing a better job of that than the Workbook for
many years now, and it will only get better as I continue to update it and keep up with the science.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
5.2
Some important things to keep in mind about placebos
2018 — New section: A new standard chapter for most PainScience.com tutorials summarizing several key concepts about placebo.
A placebo is relief from belief: the appearance or illusion of a treatment effect that is not actually
attributable to a biological treatment mechanism. It’s a fascinating phenomenon, but its “power” is
over-hyped.
This is a standard section in most of my books, summarizing several key points about placebo that
are important context for a thorough discussion of evidence-based treatment options. I do not
support any of these points here — for readers who want to know more, there’s a more detailed
article about placebo.
Placebo is not just one phenomenon — “the” placebo effect — but miscellaneous illusions that can
collectively create the appearance of an effective treatment. Placebo is complicated!
Placebo has a special relationship with pain. Reassurance (placebo) has more potential to relieve
pain than most symptoms, because pain is entirely a product of the brain. However …
Placebo is not a magical mind-over-pain superpower, and it can’t affect injury and organic
pathology, only the experience of them to a limited extent.
Placebo can backfire. When a placebo effect wears off — as it often does — people often fear that
they must be really screwed. Placebo turns to nocebo, placebo’s evil twin (feeling worse because of
belief).
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
The potency of placebo is affected by anything that can impress the patient with the seriousness and
legitimacy of a treatment: risks, costs, size, intensity, technology and even odd minutiae like the
colour of pills. This is why we have the concept of “therapy theatre” — because so much therapy is
all about putting on a show.
One of the best ways to impress people is with novel and intense sensations, because the patient can
feel the “power” of the treatment. This is the basis of most manual (hands-on) therapies: they are
sensation-enhanced placebos (“interactive therapy theatre”).
Placebo has been hijacked and re-branded for its public relations value to alternative medicine.
“The power of placebo” is widely used as a justification for therapy that can’t beat a placebo.
Placebo does not work when you know it’s a placebo, contrary to what many people have heard
(based on a couple bad scientific papers). The idea of “placebo without deception” is bullshit.
Many snake oils supposedly work on animals, and if animals are immune to placebo then the
treatment must be legit. But animals (and their biased human observers) are definitely not immune
to placebo.
Is it okay to pay for a placebo?
Many people claim to be happy to pay for a placebo. As long as it works, who cares how? And
placebo can work! So why not? This is an extremely common sentiment.
I have no problem with people paying for a placebo as long as their eyes are wide open, but the
wider your eyes get the less likely the benefit. And there are very strict limits to what placebo can
do. And paying for things is never completely harmless.
Treatments with unknown efficacy but some plausibility and low risks are the least objectionable
placboes to pay for. I’ve tried many such treatments, knowing full well that any effect I enjoy is
probably just placebo (or regression to the mean, or natural recovery)… but it might be an actual
effect, and I’m willing to pay a little for that chance. But, for me, the plausibility has to be there.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Cartoon by Loren Fishman, HumoresqueCartoons.com.
Above all, what I want readers to take away from this is that placebo is not therapy. It’s mostly just an
over-rated curve ball that accounts for an awful lot of temporary “success” stories.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.3
Fundamental limitations of trigger point therapy, and how to take advantage of them
Trigger point therapy can be pretty much hit or miss. If you do it yourself, you may be less
effective than a professional, but at least you won’t go broke trying. It’s best not to pay upwards of
a buck a minute for trial and error when you can experiment on yourself at no charge, and safely.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
This is the raison d’etre of this book (and all of PainScience.com), actually: in situations where the
professionals are nearly as unreliable as you are, save yourself instead of paying for professional
shots in the dark. Obviously there are limitations to self-treatment — some spots you just can’t
reach! — just as there are limitations to professional therapy. The only really dramatic difference
between professional care and self-treatment is the cost.
The beauty of trigger points is that you can use the worst things about them to your own
advantage. They may be tricky and stubborn and weird, but you have time to mess around. You
can wait. You can experiment. You can fiddle. For free. For years, if necessary — as long as there’s
evidence that you’re gaining ground.
This section covers the three most basic problems with trigger point therapy and how selftreatment is a generally good solution for them. (And some good examples of pointlessly expensive
therapy are provided in the footnotes.) Two more sections after this cover more specific challenges
with self-treatment: common mistakes, and more serious common barriers to success. But there are
three really fundamental limitations to trigger point therapy to consider first, for both the pros and
their patients:
1. Locating trigger points can be tricky, and it’s hard to treat what you can’t find.
2. Even when you’ve found trigger points, they don’t necessarily go away just because you squish
‘em, stretch ‘em, heat ‘em, or any of the other common treatment themes.
3. And even if they do go away, they usually don’t stay away: trigger points have a nasty habit of
coming back.
Fumbling around with diagnosis. Trigger points are really not at all easy to confidently locate, and
(as discussed far above) research has clearly shown that even the professionals cannot really be
counted on to find them for you. Thus, hunting for trigger points invariably involves a certain
amount of expensive fumbling around. As a Registered Massage Therapist, I am painfully aware
that $1.67 is flying out of my patient’s pocket every single minute as I hunt around for their trigger
points — I had better be damned good to justify that, and the sad truth is that sometimes I’m
not. 189
The right professional may be able to “fumble better,” and give patients a lot of good treatment
ideas. But, as your own patient, you definitely have an advantage: you literally have all day to find
the right spot.
Fumbling around with treatment. And then there’s the mystery factor, the overall scientific
cluelessness about why trigger points form in the first place — not what they are, but why they
happen — the impossibility of being confident about exactly what flavour of treatment is going to
make them go away. Professionals are definitely not privy to the magic trigger-point-begone
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
formula, and while extensive hands-on experience undoubtedly leads to somewhat higher quality
experimentation, it’s experimentation nevertheless, and — once again — our experimenting is
expensive. 190 But patients can and should experiment with different approaches willy nilly. As a
patient doing self-treatment, you might or might not get results, but at least the insult of a great
expense is not added to your injury.
Fumbling around with perpetuating factors.
The third basic problem with trigger point
therapy is that a trigger point comes back, like
The Cat in the Hat. The forces that tended to
lead to them in the first place routinely result
Professionals are definitely not privy to some
magic trigger-point-begone formula.
in their resurgence. Even “successful” trigger
point therapy is notoriously prone to being
temporary. But, once again, we can snatch victory from the jaws of defeat thanks to the logic of
self-treatment: if your benefits are going to be brief, better that they also be cheap!
It’s also largely up to patients to make changes in their lives that make them less prone to persistent
trigger points. A good therapist may have excellent suggestions for things to try, but an educated
patient is nearly as capable. How hard is it, really, to guess that your crappy, uncomfortable office
chair may be the reason your trigger points just keep coming back? If stress seems to be a factor in
the stubbornness of your muscle pain, that’s not particularly difficult to figure out — certainly not
after doing a bunch of reading on this website — and it’s also a deeply personal problem to solve,
and the solution likely doesn’t have much to do with physical therapy or massage therapy. 191
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.4
Several more treatment mistakes and problems (that you can fix)
In the basic self-treatment sections, I introduced the five most common treatment mistakes and
reasons why self-treatment often fails. Unfortunately, it’s possible to avoid all of the most obvious
errors and problems and still fail — because there are all-too-many ways to fail, some of which you
can control (this section), and some of which you can’t (next section).
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
I will now introduce some more fixable mistakes and
manageable problems. All of these will be discussed in more
Quick Review What are the most common
detail throughout the rest of the tutorial, and you can cherry pick
treatment mistakes?
and read more carefully about the issues that are most important
1. missing the trigger point
to you.
2. excessive pressure
Poor massage technique. I’m sorry to say it, but your selfmassage skills may simply not be up to par yet! This problem is
neither common nor uncommon. Good technique is actually not
very important, because you can get away with poor technique
3. using ice or getting chilled
4. exercising muscles too hard or too soon after
treatment
5. sustained awkward positions after
treatment
when treating most mild to moderate trigger points. They just
aren’t that picky — any kind of rubbing will do. As Dr. Janet Travell wrote, almost any kind of
stimulation has the potential to help your trigger points.
But the other side of this coin is that, unfortunately, there is just not much scientific evidence to
guide us in determining exactly what will work the best for most people, most of the time. Some of
those trigger points just won’t respond to sloppier technique. And when mediocre massage tactics
meet more severe trigger points, failure is almost inevitable. Figuring out what works for you is a
personal matter of trial and error … sometimes quite a lot of trial and error. One of the main goals
of the advanced troubleshooting sections is to upgrade your massage skills.
Too many trigger points. Remember, a trigger
point is just a trigger point — but when you
have a lot of active trigger points all at once,
we call it “myofascial pain syndrome.” It’s the
excess of trigger points that makes it a
syndrome. In more serious cases of myofascial
pain syndrome, trigger points may be so
Figuring out what works for you is a
personal matter of trial & error … sometimes
quite a lot of trial & error.
numerous that treatment becomes a logistical
nightmare. Where do you start? It isn’t an
impossible situation, but it does require more effort and tactical savvy than dealing with an isolated
trigger point.
Slavish devotion to techniques that haven’t truly earned your
love. This one is from the Department of “If I Had a Buck For
Every Time ______.” Irrational and excessive devotion to an iffy
self-treatment technique is extremely common. With mild trigger
points you can get away with it — your iffy self-treatment
method of choice does the job temporarily … sorta … kinda …
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
Another example of slavish devotion to an
ineffective technique is the corestrengthening and postural school of back
pain therapy. Patients really get hooked on
this idea that if they are stronger in the gut
and have a nice “neutral” lumbar curve,
The Complete Guide to Trigger Points & Myofascial Pain (2019)
and you’re happy to have even a little relief. But too often I see
people just hammering away on a more serious trigger point
that will solve all of their back pain
problems. The devotion to the concept is so
problem and not getting any meaningful results. Stretching is the
strong and apparently emotionally
single most common therapy that people choose to devote
addictive that I have routinely encountered
themselves to even when it doesn’t actually work. “I have a
patients who simultaneously believe that
regular stretching routine that works really well,” patients will
say. “Really?” I reply, trying to be gentle. “Has it solved the
problem? Why are you still having regular episodes of severe
pain? How effective is the stretching really?” If you have a pet
self-treatment technique, and you still more or less have a
significant trigger point problem, please face the obvious: it ain’t
the therapy “works” and yet still suffer
regular episodes of severe low back pain
and are constantly hypervigilant about
protecting themselves from their backs
“going out.” If that’s an effective therapy,
I’d hate to see their idea of a failed therapy!
that good a technique!
Negative reactions and anxiety about them. If you have any ominously bad responses to selftreatment, and especially if it freaked you out, it can be difficult to get good results in the future.
Fear and anxiety are powerful aggravating factors. If you don’t understand negative reactions or
have any way to control them, there’s no way to deal with the fear, and everything is more
difficult.
Avoidable perpetuating factors — Trigger points often quickly regenerate for the same reasons
that you got them in the first place. These reasons are called “perpetuating factors,” and
eliminating them is often the holy grail of trigger point therapy. This theme is spread out
throughout the rest of the tutorial. There are many possible perpetuating factors, things such as
insomnia, stress, and awkward working postures, or your entire job or career. Many of these are
avoidable — even your career! The solution is to learn what causes and aggravates your trigger
points, and work hard to eliminate those forces from your life.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.5
More serious barriers to success
This is a depressing section, but necessary — and hopefully fascinating and strangely reassuring to
those of you who feel like you are facing invincible trigger points. There’s just no getting around it:
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
sometimes, trigger point therapy is not effective at all, or barely. The only thing worse than not
being able to release your trigger points is not understanding why, not knowing what your chances
are, not having a realistic view of the situation (see the sidebar for more about this). Here are some
more reasons that therapy fails that you may not be able to do anything about:
Inaccessible trigger points. There are plenty of muscles in the
human body that are simply not accessible without a scalpel, or
some other extraordinary effort. Sometimes, muscles that are
difficult to access can be reached by a skilled therapist with
specialized skills. Massage inside the mouth, for instance, is not
that exotic a technique — but it could be a real challenge finding
a therapist with some experience with it. 98% of us can’t — for
all my knowledge, I rarely “go there” with my own patients. A
Cold comfort — could this be the most
important paragraph in the tutorial? Many
times I have encountered people who are,
tragically, never going to get rid of their
severe trigger points, because they face
several of the kinds of problems described
in this section. However, even these people
can get some relief. Why? How? It’s simple:
more dramatic example: some of the muscles of the pelvic floor
most of them weren’t sure whether or not
are nearly inaccessible, unless someone actually inserts a finger
their problem was really trigger points, and
through your anus. This is a real thing. I am not making that up.
were living in a haze of doubt and fear as
And for a few people with pelvic pain, this is a vital medical
service. (The rest of us might prefer to “unhear” that.) But there
really are some muscles in the body that simply cannot be
reached, by any means, through any orifice. If you have trigger
point pain coming from one of these muscles, there may never be
a way to prove it or to treat it yourself, or even with medical
well as pain. Many people face both trigger
points and years of frustration with
misdiagnosis, expensive wild goose chase
treatments that never work, and never
having any confidence about what’s really
wrong with them. Can you imagine what a
relief it might be for people in this position
intervention. Sometimes this is the explanation for trigger point
to finally, clearly understand that, yes, it
therapy that simply does not and cannot work.
probably really is “just” trigger points, even
if they are untreatable? That the problem is
Adhesions and mild contracture. Quick review: after a few years
painful and unpleasant but … benign? It’s
of clenching, trigger points may literally “freeze like that,”
cold comfort, but it’s a lot better than living
welded into place by connective tissues that have lost their
with both pain and diagnostic confusion for
elasticity and no longer slide freely across each other (see the
main adhesions section). It’s much more difficult to treat such
gluey trigger points. They literally can’t “let go” — not
physically. It’s not an invincible problem, but it almost is, and it
certainly is for self-treatment in awkward spots — in such cases,
the techniques required will require an extra pair of skilled
hands.
Trigger points caused by another health problem. In some
the rest of your life. It’s the lack of this kind
of realism that really disappointed me when
I read Clair Davies The Trigger Point Therapy
Workbook — you have to be realistic. Even
bad news can be good news when it helps
people get on with their lives. I’ve been told
by some people that this concept is the most
valuable thing they learned from this
tutorial — there’s a deep thought, eh?
people, trigger points are simply a symptom of something much “bigger” going on in the body,
such as fibromyalgia, Parkinson’s disease, or an autoimmune disease. Obviously, if trigger points
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
are being generated in this way, there may be little that you can do to treat them, or you may have
to deal with numerous other more basic health problems first. Insomnia is a good example of an
underlying problem that can make trigger point treatment virtually impossible until it’s treated. A
serious disease like ankylosing spondylitis — an autoimmune disease that slowly destroys the
spine — is a classic example of a health problem that generates so many secondary trigger points
that it is simply not possible to deal with them all. The relationship between trigger points and
some other diseases will be covered.
Unavoidable perpetuating factors. Some things that predispose people to trigger points are
effectively or entirely unavoidable. Health problems are an obvious possibility, but we’ve just
mentioned that separately. What I’m talking about is basic features of your life that you can’t
change or won’t change because the cure would be worse than the disease. I will counsel people to
consider changing careers and make other drastic changes that might help their myofascial pain
syndrome. Almost anything you do with your life is theoretically avoidable or changeable, but
there are limits to what people are willing to do.
The most straightforward example of an unavoidable perpetuating factor is always parenthood,
which can directly and indirectly aggravate trigger points in a dozen different ways — stress,
insomnia, and piggy back rides, for instance. Yet parenthood is a burden that is nearly impossible
to put down. Families sometimes actually disintegrate under these pressures, but most people, of
course, will not and should not leave their children just to make it easier to cure their trigger
points.
The majority of severe cases of myofascial
pain syndrome occur in people who are
trapped in circumstances that set them up for
failure. Insult is added to injury by therapists
who continue to offer false hope, and charge
for the trouble. In these ways, advanced
trigger point therapy can go way beyond
Most people will not & should not leave their
children just to make it easier to cure their
trigger points.
“technique,” and involves challenging
personal, social, and even philosophical
issues.
But don’t give up too easily. There are so many things to try that might still work. Let’s now dive
into an almost ridiculous number of tips and tricks!
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
5.6
Massage efficacy according to science
Trigger point therapy is experimental, as I have emphasized repeatedly throughout this book. There
may be some half decent science about the nature of the painful phenomenon, but when it comes to
proof that the little monsters can actually be fixed it’s all about as nailed down as the Loch Ness
Monster or Sasquatch. But just like the cryptozoology cranks who believe in those critters, in this
section we will make a mountain out of the molehill of evidence that we do have. For fun and
edification.
This section is about the massage evidence specifically and exclusively. What little science there is
about using other techniques to treat trigger points is covered in sections devoted to those
techniques — and it’s usually just a study or two, except for needling/acupuncture, which is the
only category with a fair bit of research.
Even more specifically, this is section is about the science of applying direct pressure to trigger points.
Pressing them, like little buttons. This has always been the main massage technique for treating
trigger points, and it is the most basic and important method recommended in this book (specifics
on technique will be explained below). In life, and in a massage therapy practice, it seems obvious
that sore spots in muscles often get less sore when you poke and prod ‘em. Alas, what seems
“obvious” to the fallible human mind is often surprisingly wrong. You have to check carefully, in
controlled conditions, eliminating as many variables and sources of bias as possible — a clinical
trial, in other words. Science!
But it’s never been checked properly. There’s not enough science.
And so, despite using and recommending pressure on trigger points since the late 90s, I actually have
had no idea if it’s truly an effective way to get rid of a trigger point. For shame.
Even regular (Swedish) massage for back pain is understudied, the most basic and popular
massage treatment of them all, with only a few dozen mostly terrible studies available to review,
and a true “more study needed” non-conclusion 192 — and that’s as “good” as it gets. Why so
little? The main problem is the massage profession doesn’t have a research culture, and other kinds
of scientists don’t have the interest. The professionals who have studied massage are usually
setting out to prove that massage works, a strong bias that often wrecks a trial. 193
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
16 mostly shabby little studies
As of mid-2017, I am aware of only 16
scientific tests of trigger point squishing that
one might cite. I have read and reviewed all of
them. I will describe a few below thoroughly,
highlighting some common issues and
problems. The section concludes with a
Maybe someday there will be enough
evidence for a real conclusion here, but I
doubt that will happen in this decade or the
next, not even if we’re lucky.
complete list of them, with links to my
analyses of every single one — for the truly
keen reader!
So what does all that half-arsed science say? What’s my impression, after having my head down in
those weeds for many, many hours?
It says little. My impression is “meh.”
All of these studies have serious flaws. All show signs of a high risk of bias. All claim to be positive
… and yet the actual data isn’t so sure. Most report only minor effects, a couple are clearly negative,
and just a single one (Aguilera et al ) reports a more robust effect … but that was based only on a
single measurement taken immediately after treatment (an effect that could evaporate within
seconds for all we know).
If you squint optimistically, you could call some of this evidence promising. You could say that
where there’s smoke, there’s fire. But it’s like the smoke from last night’s campfire — more of a
smokey smell than a smoke that can hide any fire.
Dial up even a mild cynical impulse, and the evidence collectively looks more like a damning
failure to produce any clearly good news.
But mostly there’s just no conclusion at all, and I am not writing about these studies because they
actually add up to anything. I’m doing it to fulfill one of the basic promises of this book: to
rigorously, thoroughly, and critically examine the science of trigger points, such as it is. And
because I’m an obsessive dork. Maybe someday there will be enough evidence for a real conclusion
here, but I doubt that will happen in this decade or the next, not even if we’re lucky.
So, a few selected examples …
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
2002: A controlled study without the control
Let’s start with the oldest test of the efficacy of pressure for trigger points that I’m aware of, a 17year-old Chinese randomized controlled trial of 119 people with “palpably active 194 myofascial
trigger points.” 195 They checked simple pressure alone at two intensities and three durations
(nice variety), measuring changes in pain, sensitivity, and range of motion (among other things).
They detected a barely statistically significant effect from some of the intensity/duration
combinations, and none at all for others (the lighter, briefer doses). They concluded:
Ischemic compression therapy provides alternative treatments using either low pressure
(pain threshold) and a long duration (90s) or high pressure (the average of pain threshold
and pain tolerance) and short duration (30s) for immediate pain relief and MTrP
sensitivity suppression.
Sounds good on its face! But where’s the “control” in this supposedly controlled trial? They did not
compare these treatments to anything neutral. A control group was present in the other part of the
study, where they tested combo treatments, but it was absent from the “does pressure work” part
of the study we care about. The researchers treated this part of the study as if the efficacy of
pressing on trigger points was a given and they only wanted to nail down the details. That’s a bad
assumption that makes for bad science!
A controlled trial compares treatment to non-treatment (either no treatment at all, or a fake
treatment like pressure near the trigger point). In this trial, all they did was measure the sensitivity
of trigger points before and after applying pressure to them. Even if everything else was just right,
this would nuke the validity of the study. But not everything else is just right.
They also split their subjects into so many little groups that each one of them was like its own
underpowered experiment. From that data, they got results that were technically “statistically
significant” — that is, the results were not a fluke (oversimplification) — but only just barely (Pvalue <.05) — which is a perfect example of why “P-values” have gotten such a bad reputation.
Even if the results had been more statistically
convincing, they still lacked clinical
significance: that is, the actual improvements
were trivially small. For instance, the largest
improvement in the entire data set for pain
was a drop of about 2 points on a 10-point
pain scale. That is just not enough. The best
number should be better! This flips their good-
You want your numbers to be as large as
possible before you start listing all the reasons
why they may not actually be as good as they
look.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
news conclusion to a bad-news conclusion. I
really would have liked to see quite good
numbers here. They might not have been trustworthy good numbers for the other reasons
discussed here, but you at least want your numbers to be as large as possible before you start listing
all the reasons why they may not actually be as good as they look.
And here’s the last nail in the coffin: before this study and several times since, it’s been established
by other studies that identifying trigger points by feel is unreliable. So there’s really no way to be
sure that they were actually testing treatments on trigger points in the first place. If they could have
been far more accurate somehow, perhaps they would have gotten better results. But we’ll never
know.
Too many problems! This study tells us nothing except that brief bouts of pressure did suspiciously
little to a bunch of putative trigger points.
2008: pressing this-a-way instead of that-a-way
Hugh Gemmell, Peter Miller, and Henrick Nordstrom — three UK chiropractors — seem like
unusually competent researchers to me. Their 2008 paper 196 is both readable and expert, and is
admirably focused on clinical significance (an important concept neglected by most researchers,
which exasperates me). I was also charmed by the way they pointed out the glaring flaws in other
similar studies done to date (echoing many of my own thoughts about other studies in this section).
Seems like these fellas actually understand something about science!
And yet I still think they put a face-saving spin on results that were actually bad news.
They were interested in testing two hair-splittingly different ways of applying pressure to a trigger
point:
1. Ischemic Pressure — Sustained deep pressure for 30-60 seconds or when there is “decreased
tension” or its “no longer tender,” whichever comes first. This is the technique originally
recommended by Travell and Simons. Reminder: “ischemic” is “low-oxygen.” The idea is to starve
the trigger point of oxygen, to shut it down.
2. TrP pressure release — Slowly increasing painless pressure up to a “tissue resistance barrier,”
holding until that barrier softens, and then adding more pressure, repeating for up to 90 seconds or
until there’s no more sensitivity. This is the method T&S recommended in the second edition of the
Big Red Books. 197
I have never endorsed one of these methods over the other because I think the difference is silly.
That was my opinion before and after reading Gemmell et al . Trying to feel a “tissue resistance
barrier” when pressing on a TrP is hopelessly vague and unreliable. There is no way that different
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
therapists will ever find the same barrier at the same “place” (pressure) in the same patient — it’s
just too vulnerable to palpatory pareidolia (feeling what you want/expect to feel, like seeing faces in
clouds).
But Gemmell, Miller, and Nordstrom decided to put it to the test, and that’s the scientific spirit:
why not just find out? They measured the immediate effects of both methods on forty-five
chiropractic students with non-specific neck pain and shoulder TrPs. They divided the students
into three groups of fifteen — rather small, unfortunately, but small sample size isn’t a deal-breaker
in itself — and compared each of the two pressure methods to sham ultrasound. A decent control
group, hallelujah!
Another way the study stands out is that their
“primary outcome was clinical improvement,
which was defined as a reduction of 20 mm on
the visual analog scale for pain.” Bravo again!
They baked the idea of clinical significance
right into their experimental design, which is
refreshing to see.
There is only one fair plain language
interpretation of this: treatment did not work
at all.
Except, uh oh, in this case, the difference
between the improvements in each group was clinically significant … but not statistically
significant, so the clinical significance doesn’t matter. One might even cynically wonder if this is
why they decided to take the unusual step of reporting clinical significance (because otherwise the
answer would have been a straight-up negative). Regardless, the raw data is just all bad news.
There were no important differences between the two treatment methods and sham ultrasound.
There is only one fair plain language interpretation of this: treatment did not work at all. Neither
type of pressure worked better than the other, and neither worked better than sham. But the
researchers soldiered on, pluckily framing their conclusion in terms of “improvement” and
“number needed to treat,” in a gambit to say something, anything nice about their results:
In patients with non-specific neck pain, a single treatment with ischemic compression to
an active upper trapezius TrP is superior to sham ultrasound. For one patient to improve
with a single treatment of ischemic compression three patients would have to be treated
compared to sham ultrasound. A patient treated with ischemic compression is five times
more likely to improve compared to a patient treated with sham ultrasound.
That sounds like something, but don’t be fooled. They got there
by using the numbers of people who “improved” (by their
definition of a minimum 2-point drop on the pain scale), and
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
Interesting side note: their data was a great
example of why a control group is
necessary. The students who received sham
The Complete Guide to Trigger Points & Myofascial Pain (2019)
ignoring exactly how much they improved. In all groups, some of
the students improved, even the ones who just got bogus
ultrasound.
Ischemic compression: 9 improved
TrP pressure release: 7 improved
Sham ultrasound: 4 improved
The difference in those numbers was attributable to statistically
insignificant differences in more detailed measurements. In other
words, those who improved were almost identical to those who
did not. But by categorizing each subject as either improved or
not improved, of course everyone fell just slightly to one side of
that threshold or the other … and there happened to be more on
ultrasound improved! Study subjects who
get bogus treatments usually do improve,
because the “active ingredient” is only one
of many factors that affects how people feel
after getting treated. People like to be
treated. They like being touched, listened to,
asked for their opinion, and so on.
Attention, compassion, and medical
equipment are all reassuring, and
reassurance has real effects on pain. But
things like this are part of every treatment,
so you have to factor them out to find out if
your “active ingredient” is actually doing
anything.
the happy side, and suddenly you’ve got a difference that looks
much better!
This is a really excellent example of how statistics can lie convincingly by misleading without being
technically wrong. Their conclusion is one legitimate way to interpret the data. But it’s lipstick on a
pig! This is a negative study, folks. Pressure just failed. Boo.
(And yet this study has been cited extensively as evidence that massage works for trigger points.)
2011: Tool assisted knot squishing looks good in one small study
In 2011, Dr. Dawn Gulick of the Widener University Physical Therapy Department compared the
sensitivity of trigger points both with and without a simple treatment of pressure 198 — squishing
them, that is. It’s about as direct and focused a trial of trigger point therapy as you could hope for.
It’s a good design. This is the kind of experiment I think we need — now we just need more and
bigger, better versions of this.
It’s particular notable because Dr. Gulick et al. tested the effect of treatment applied repeatedly over
several days. It was also controlled to some extent: a second nearby trigger point was left untreated
for comparison. They measured the sensitivity of these TrPs before and after in 28 people,
specifically “the minimum pressure required to cause pain.” The results:
There was a significant difference between the pre- and post-test sensitivities of the
treated and non-treated trigger points. The results of this study confirm that the protocol
of six repetitions of 30-second ischemic compression with the Backnobber II rendered
every other day for a week was effective in reducing trigger point irritability.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Sounds great. Now for the inevitable enthusiasm reducers …
Of course it has one of the main problems one faced by all trigger point studies: it’s so tricky to
accurately locate them in the first place that it’s hard to be sure that they were actually testing real
trigger points. I think they did a good job of trying in this case, 199 but it’s still a blight of
uncertainty. Especially with such a small group of people.
Worse, there is not one word in the paper about clinical significance — a stark contrast with the
rare papers that do (eg Gemmell et al.) — and the authors place a predictable emphasis on
“statistical significance” but not the actual size of the treatment effect. This is nearly synonymous with
saying “technically we found a difference, but it’s a not an exciting one.” I have rarely, if ever, seen
an exception to this rule. Failure to report a big effect size almost always means there was no big
effect size to report.
And, sure enough, the actual difference is modest.
For the treated TrPs, pressure tolerance improved by about 12 Newtons, give or take 13 N (2.7
pounds-force). In untreated TrPs, the improvement actually got worse by a couple N on average
(give or take several times as many N) — so we can basically just round that to zero and conclude,
as expected, that not treating a trigger point has no effect.
12 N of increased pressure tolerance was about 38% improvement for those patients. Since pressure
tolerance is essentially a fancy way of saying how sensitive a trigger point is, you could also say
“38% less irritable.” That’s neither bad nor good. 200 And there was a lot of variation, from
actually bad in the worst cases, to definitely good in the best cases.
My conclusion? They found modest, highly variable improvements in trigger point sensitivity.
Slightly encouraging.
And this is small-scale science, and funded by “industry” no less — an obvious (though minor)
conflict of interest. 201
2013: Barely improving ankle ROM with trigger point therapy (or stretching, it’s hard to tell)
Another small but promising test of pressure was published in a 2013 paper. 202 This is a much
less useful experiment than Dawn Gulick’s trial, smaller, only considering ankle range of motion
(not pain), and unwisely testing both pressure and stretch. But it is still interesting, because it was
looking at the immediate effect of a brief treatment on people who have tight calves right now.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Rob Grieve and colleagues found twenty-two recreational runners with limited ankle range of
motion, supposedly caused by tightness by the calf muscles, which also supposedly had latent
trigger points, which were in turn presumed ot be the cause of the limited ankle ROM. Half of
these runners got a very brief, 10-minute sessions of trigger point therapy — pressure while
stretching, basically — and their ankle range of motion was measured right before and
immediately after.
The other group simply got nothing. After identifying their restricted motion, they just sat there for
ten minutes with the researcher — “supervised rest” — and then their ankle ROM was measured
again.
Treatment seemed to work better than doing nothing. Maybe, kinda, sorta.
Importantly, ankle ROM measurements changed even after doing nothing. Imprecision and actual
changes produced an average increase of 3˚ more range, with no treatment. The largest changes
were 6˚: three people had that number, and four more changed by 5˚. Meanwhile, treatment
increased the range by … about 4˚. The largest changes in ROM from baseline were a couple people
who got a 9˚ boost, but the mean difference was just a single degree more than the mean difference
after ten minutes of sitting there.
Whoop-de-doo!
And … they were also stretching. That’s quite a confounding factor. That factor really confounds!
Absolutely no way to know if the tiny difference — if it wasn’t statistical noise — was made by the
stretching or the trigger point pressure.
Based on this data, I do not think the authors’ rather cheery conclusion is justified: “The findings
suggest that a possible treatment method for runners and non runners with reduced ankle
dorsiflexion could be the MTrP therapy approach.” I think the findings suggest the opposite. Or
nothing. The study has so many flaws — some acknowledged by the authors, plus several more
that are not even mentioned — that I don’t think it’s capable of suggesting anything.
2017: Turns out pain relief is relaxing
Let’s start with a small 2017 test of treating trigger points associated with neck pain, using thumb
pressure. 203 Superficially, this is just the sort of study I’d like to see. But dig in a bit, and it turns
out to be weirdly convoluted. In addition to pain, Morikawa et al measured “prefrontal
hemodynamic activity and autonomic activity based on heart rate variability (HRV) were
monitored by using near infrared spectroscopy (NIRS) and electrocardiography (ECG),
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
respectively.” In other words, they were looking for biological signs of relaxation, basically.
They might have jumped the shark there.
Did I mention this study was small? So small it hardly seems worth bothering. Treatment was given
to just ten patients. Their pain was modestly reduced compared to 10 control patients, and their
relief correlated with increased parasympathetic nervous system activity — relaxation — which
Morikawa et al measured in a couple of ways (brain blood flow, heart rate variability). They were
testing the interesting but daring and dubious hypothesis that
compression at MTrPs induces pain relief through inhibition of sympathetic activity,
which (1) might increase the peripheral blood flow and subsequent removal of noxious
substances, and (2) might block the excessive release of acetylcholine.
Translation: trigger point therapy works by relaxing you, which flushes trigger points with extra
circulation and dampens the release of acetylcholine. There’s so much wrong with that hypothesis
it’s literally not worth getting into, because it doesn’t really matter. Their study wasn’t designed to
show causation, and their idea is implausible for one simple reason: it’s obvious that relaxation
rarely puts a dent in trigger point pain. Probably all this study does is confirm in highly technical way
the common sense observation that “pain relief is relaxing.”
Which is actually kind of worth knowing, even though it’s also quite obvious. Forget the fancy
hypothesis that relaxation is somehow the actual mechanism of trigger point therapy: that’s just
window dressing. The take-home here is that there were measurable signs of relaxation in these
subjects, which is cool.
Unless there weren’t, because this study was tiny and had a risk of bias off the charts. Have never
yet seen a study of 10 subjects that proved anything.
All together now
There’s more science, but not enough, and you’ve already got the picture. Despite all the sweat and
tears that undoubtedly went into them, these experiments simply do not actually answer the main
question.
The table below summarizes all the studies of any kind of massage/pressure on TrPs that are
remotely worth mentioning. Click on the name column to read the summaries in a new browser
window/tab.
Studies of massage (mostly ischemic pressure) for trigger points
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Hanten
Hou
Hodgson
Fernández-deLas-Peñas
Gemmell
Kostopoulos
Aguilera
Gulick
Cagnie
OliveiraCampelo
Grieve
Takamoto
Ameloot
Ravichandran
Sohns
Amin
Morikawa
200040-subject trial of self-treatment with ischemic pressure in stretching, supposedly positive but
unconvincing
2002uncontrolled test of a range of intensities/durations of pressure on 119 TrPs
2006study of pressure on upper trapezius trigger points, 37 subjects, unusual algometer, positive results,
effect size unknown but likely small
2006uncontrolled pilot study showing tiny improvements from both compression and friction massage in 40
subjects with neck pain
2008clearly negative result with positive spin; good quality, controlled test of two kinds of pressure on 30
shoulder TrPs
2009superficially positive test of pressure, stretching, and pressure+stretching, but uncontrolled (for bogus
ethical reasons)
2009small short term effects of both ultrasound and pressure on 66 latent traps TrPs compared to
2011simple, positive test of ischemic pressure on a TrP in the upper back, controlled by an untreated TrP
2013small, uncontrolled trial of pressure on neck, shoulder TrPs, several outcomes measured, 6m follow-up,
improvement in pain just barely clinically significant
2013overly complicated trial of pressure for shoulder trigger points; supposedly positive results, but no
substantiating data published!
2013badly flawed study of the effect of TrP massage and stretch on ankle ROM
2015allegedly positive trial of trigger point therapy for acute low back pain with serious problems
2016small, “positive” test of tapping, an implausible treatment method for low back TrPs, with clinically
insignificant results
2016small negative RCT of pressure+stretch vs ultrasound+stretch, significant but equal effects
2016odd, tiny, negative trial of trigger point compression for shoulder pain (includes interesting opinion on
centralization)
2017small test of spray and stretch versus progressive pressure, no control, mixed results, poorly written
paper
2017small, odd study of relaxing effects of pressure on TrPs in neck pain patients
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.7
Upgrade your self-massage technique
“Just rubbing” often doesn’t cut it for difficult cases. Here are some miscellaneous minor
improvements to your technique that could make a difference. These are followed by several more
detailed sections, each focusing on technique and troubleshooting tips that need more discussion
than we can cram into a paragraph.
Experiment with pressure. If at first you don’t succeed with massaging your own trigger points,
you should first attempt to reduce the pressure. “How much pressure?” is one of the most common
questions about massage, but unfortunately there are no firm rules, just rough guidelines and
playing the odds. Stronger pressure may be exactly what you need, but put your money on
“gentler” at first, because most people with difficult cases will usually get better results from a
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
softer approach, and there’s less risk of negative reactions. Try dropping your self-treatment
pressure to about 75% of what it feels like you crave, or 75% of what you were doing. Consistently
use that pressure for at least 2–3 days — you have to give it a chance! If you still aren’t getting
results after that … then it might be time to try stronger pressure. Self-treatment can be a really
good way to experiment with higher intensities, rather than spending quite a lot of money on
professional massage that may be much more painful and no more effective. Occasionally I’ve
successfully treated one of my own trigger points by beating the crap out of it! I never would have
wanted to pay for therapy like that, but I was willing to take the risk myself, and self-treating gave
me good control over the experiment.
Experiment with dosage and frequency. Experience has taught me that most people get the best
results from frequent but fairly brief dosages of pressure, up to several 1–5 minutes sessions per
day. But there’s only a little science — just the Gulick study discussed in the previous section —
and a bit of common sense, to guide us in prescribing an effective “dosage” of self-massage, and
the “ideal” is probably quite different in different people, cases, muscles. And if you find yourself
using stronger and stronger pressures, you will probably require longer rest periods between
treatments. So, you have to just experiment. But you could certainly start by duplicating the dosage
and frequency that Gulick et al found to be effective: “six repetitions of 30-second ischemic
compression … every other day for a week.” Note that this wasn’t their recommendation — another
dosage might have worked better. But at least we know that it did work for the 28 people in that
study — that’s a good starting place.
Experiment with less awkward positions. There’s usually a paradox in self-massage: you’re trying
to relax muscles, but you’re also straining to reach them and press on them, using muscles to treat
your muscles. It’s not always possible to be relaxed, but with creativity and determination you may
find a way to press on a trigger point without tense or awkward contortions. Here’s a great example
of a small positioning adjustment that can make a big difference: when trapping a massage ball
between back and floor, most people need to tense many of their trunk muscles in order to “steer”
the ball around the back, which can be somewhat purpose-defeating. But if you put your feet up
(on a chair or an ottoman, say), you will be amazed at the greater ease and precision you will have
— in that position, it’s much easier to steer and stay relaxed while doing it. These are the kinds of
refinements that make all the difference over the years.
Experiment with time of day. I have clients who only come at a certain time of day.
I don’t get massage therapy at night because sleeping really reduces the value of the
treatment for me — I get all loosened up and then immediately seize half-way up again
overnight.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
But others feel precisely the opposite: that sleep is exactly what they need to “consolidate your
gains.” Time of day, and emotional/physical context, seems to be important to massage results.
There may be no point in tackling the challenge at certain times. Try to figure out what
circumstances in your day help, and which ones are like a head wind.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.8
Don’t get hung up on anatomy, and be persistent
It is amazing how much poking around it can take to find the right spot. Many times I have almost
given up the search for one of my own trigger points, only to finally get that rush of “triggery”
sensation that tells me my persistence paid off. “There we go,” I will mutter to myself. “I knew it
had to be there somewhere!” And it was. But it took a lot of experimenting with different angles
and pressures and just trying of lots of spots.
Of course, I have experienced the same thing while treating patients many times as well.
I go through this process of experimentation even though I have advanced knowledge of the
anatomy (I am pretty much a walking muscular anatomy textbook). But I still have to grope
around, a bit awkwardly and blindly, looking not only for the right spot, but also the right method
(angle, force, tool, body position, etc). It can take quite a while!
One of the most common mistakes I see in self-massage is that
people become too hung up on locating a specific piece of muscle
anatomy. Patients become preoccupied and frustrated with this
technical challenge, and usually have no way of knowing if
they’ve succeeded. Anatomy is not the key to finding trigger
points.
So … don’t look for anatomy. Look for the sensations of a trigger
point (there’s more about sensations in a section coming up
below). And keep looking until you find them.
Thoroughly explore all muscle tissue in a problem area, until you
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
Care for a quadriglutator massage?
Remember that we live in a world where
some people believe that ketchup is a
vegetable … and anatomy is much harder
than food identification. I often hear people
talking about the anatomy of injuries with
great ignorance and confidence — a nasty
combination. They believe pain is coming
from a part of them that literally doesn’t
exist, or not in that neck of their woods.
Many lesser-trained massage therapists
make so many mistakes that it’s clear that
The Complete Guide to Trigger Points & Myofascial Pain (2019)
find a spot that feels “important” or “relevant” to your problem.
Look for that strong, clear good-pain signal that tells you that
you have landed on a trigger point (and who cares what muscle
they could not pass an anatomy exam …
like one I saw who based his treatment of
me on a completely imaginary muscle, a
it is). The vast majority of the time, all that matters is that it feels
weird hybrid of two others, like the
like the right spot.
quadriglutator or the sternobiceptoid. It’s
Don’t give up easily. Keep trying.
overconfidence of these anatomical fantasies
one thing to be wrong, but the
really tickles my funny bone. The point: if
you don’t actually know anatomy, don’t
pretend to!
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.9
Focusing on one trouble spot versus “a little bit of everything” — which is the better
strategy?
Readers often ask me whether trigger point therapy should be focused on a key area, or if it’s better
to work on “a little bit of everything.” Focus is usually the superior strategy, for two simple,
practical reasons:
1. The most obvious trigger points are often “primary” trigger points that are actually driving the
formation of other trigger points throughout the region, and in adjacent regions. Helping them may
help a lot of the others — a pretty big win. If you can help the worst trigger point, numerous
secondary trigger points may well simply disappear, or become so much less bothersome that they
are much easier to treat, or don’t even need to be treated.
2. It’s emotionally important — often critical — for patients to experience progress. With focus, the
chances of enjoying definite progress in “only” a single area are greatly improved. Having proven
that progress is possible, patients can then proceed with additional therapy with much greater
confidence.
The value of focusing on a primary is easy to grasp. But that second point is under-appreciated,
and particularly critical for both patients and professionals to understand. The effectiveness of
working with trigger points must be established — or it must be eliminated as a therapeutic option
— as quickly as possible. Respecting that economics and psychology are major factors in recovery
from pain problems, there is no time to waste in therapy! It is in everyone’s interest to see results as
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
fast as possible, even if they are “only” in one area.
The sooner you see results, the sooner you can make better, more confident decisions about how to
proceed with therapy.
In contrast, one of the most reliable ways to fail at trigger point therapy is to do “a little bit of
everything,” trying to scratch a dozen itches in every appointment, once every week or two. It may
feel nice at the time, but it tends to make progress slow and subtle at best, and completely
impossible at the worst. Massage therapy patients often feel slightly better for a few hours after
each treatment, but never make any substantive progress. The persistently positive reactions
encourage both therapist and patient to continue, but substantive recovery remains elusive. And
then, three years later, the patient is not only still in chronic pain, but also (rather tragically)
mistakenly believes that they have tried and eliminated massage therapy as a therapeutic option!
Of course the truth is that such patients were simply never treated properly in the first place …
despite the large investment! Ouch.
Focused treatments that deliberately, strategically neglect lower priority trigger points, are the best
antidote. If you make progress with the top priority first, you can much more confidently justify
continued efforts.
How focused is focused? Please note that
“focusing” a treatment does not necessarily
mean that massage or self-massage is
annoyingly pointy and completely neglects all
other tissues. Therapists should not spend an
hour poking one spot! That’s too much focus!
(And, yes, I’ve seen it done that way.) Even a
focused treatment still spreads out some.
“Focus” means that roughly 80% of a
Massaging “a little bit of everything” may feel
nice at the time, but it tends to make
progress slow & subtle at best & completely
impossible at the worst.
treatment is devoted to a small area, but with
regular detours to “make nice” with surrounding tissues, or just take a break and do something
else entirely (foot rub!).
So, therapists, make sure your patients are relaxed and happy in general. And, patients who selfmassage, make sure you give some massage to other muscles in the area.
To sum up: to focus you should relax the region and then zoom in on the most important spot you can
identify. That will give you the best chance of seeing some real progress.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
5.10
More information about exactly how to rub (moving strokes)
In the basic section, you learned how to rub a trigger point with simple circles or back and forth
movements, possibly with the fibre direction, or to simply press and hold. That’s good enough most
of the time. However, it’s a bit ham-handed to just rub in circles with your thumb and fingertips.
This section will discuss three improvements for moving strokes:
1. Massage along the length of muscle fibres.
2. Push tissue fluids towards the heart.
3. Prepare the muscle with broad, easier pressures.
Remember you can also just hold a trigger point — see the next section.
About muscle fibre direction. For more effective trigger point release, determining and working
with the direction of muscle fibres may be helpful. Trigger points are contracted along the long axis
of muscle fibres. To elongate them — to push the sarcomeres apart — you want to push along the
length of the affected muscle cells.
How do you determine muscle fibre direction? In superficial muscles, just under the skin, you can
either feel it easily, and/or determine it logically. It’s easy in long muscles — the fibres usually
more or less run the length of the muscle! The fibre direction in the biceps muscle, for instance, is
pretty obvious: it parallels the long bone of the upper arm, the humerus.
Another great way of figuring out fibre direction is to find the tight strap of muscle that contains
the trigger point you’re after. Trigger points are always located inside a tighter section of muscle,
which feels like a cord or rope inside the muscle. That ropy texture is what makes therapists say
things like, “You feel really tight!” And it’s always a dead giveaway of fibre direction: it parallels
the ropes! Find the rope, and then instead of strumming across it, slide along it. Think of flattening
the trigger point, steamrolling it!
Push towards the heart. In fact, when you stroke along the
length of a trigger point, you want to limit yourself to a single
direction — push tissue towards the heart, not away. Although
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
What’s “towards the heart” in the back?
There are several places in the body where
massaging “towards the heart” is basically
The Complete Guide to Trigger Points & Myofascial Pain (2019)
the most microscopic vessels in and around the muscle knot run
in every direction, the larger ones often lie parallel to the muscle
fibres, nestled amongst them. The vessels that carry
deoxygenated blood and excess tissue fluid back to the heart all
have one-way valves — that is, they let fluid through on the way
impossible. In the limbs, it’s quite obvious:
slide towards the trunk. In the head and
neck, push downwards. But in most places
in the trunk, especially the chest and upper
back, it’s pretty hard to tell which direction
back to the heart, but they don’t let fluid go backwards towards
is “towards the heart,” and it doesn’t matter
the tissues it came from. Therefore, as long as you’re squishing
a lot. In the lower back, give some
tissue fluids around, you might as well work with that system
preference to pushing muscle tissue
instead of against it. Random squish will still work — but you’ll
upwards.
be more effective if you push towards the heart, and/or along the
direction of fibres.
Prepare the muscles. Don’t just rush in with focused pressure with the fingers or thumbs (what we
call “poking”). If possible, prepare the area first by pressing and kneading with the palm or heel of
the hand, or simply by starting slowly. You can prepare the muscles for two minutes … or for two
days, or for two weeks. If your trigger points are extremely sensitive, don’t “poke” them at all —
instead, massage them with broad surfaces and softer tools only for a while. It’s a rare trigger point
that won’t get at least a little bit easier to approach after a few days of this!
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.11
Yet more information about exactly how to rub (pressing and holding)
May — Edited: Clarified, modernized, and expanded a little bit, especially integrating new information about the effect of massage of
tissue fluids and circulation.
Your trigger points may respond well to either kneading strokes, or to simply being firmly pressed
with an unmoving thumb or finger or tool.
Pressing and holding a trigger point like this is called ischemic pressure or blanching, and it’s the
method of trigger point release used by most professionals. In a previous chapter, I explained that
the scientific evidence that this method actually works is inconclusive. In this chapter, I explain in
more detail how to do it anyway. We’re deliberately embracing an experimental treatment here,
which is just fine as long as it’s not misrepresented as “proven.”
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
“Ischemia” is an inadequate blood supply to tissue. For a simple demonstration of what “ischemic
pressure” does to circulation, just pinch your fingernail: it will go white around the pressure. When
you release the pinch, assuming your heart is beating, the blanched tissue will quickly turn pink
again as the blood returns to the tissue.
Hypothetically, when you press firmly on a trigger point, the same thing occurs to some extent in
the deeper muscle tissue: swampy tissue fluid is pressed out of the trigger point … and then
hopefully it refills with fresher, cleaner, more oxygenated blood. This highly localized tissue fluid
flushing could be the mechanism by which this method works (if it works), but there are also
several other possibilities. It could be the sustained and highly localized stretch of the fibres of the
trigger point, for instance, or just a change in sensation, or a neurological “reset” effect. It could
even be that ischemic pressure starves the trigger point of oxygen even more than it already is, the
stress of which could help, in theory. But no one knows (of course).
In theory even a very brief application of pressure should be enough to squeeze the stagnant tissue
fluids from a trigger point, but in practice no one seems to think that it actually works. As a general
rule, sore spots do not stop being sore simply because you press on them for a couple seconds. So
common practice is to press and hold a trigger point for at least 20 seconds, and it’s not unusual for
professionals to apply pressure for much longer (2-3 minutes). There’s no clear justification for
such long holding except a very basic “more is better” impulse. An experiment in 2002 showed
some benefit to both quick, intense bursts of ischemic pressures and longer, more gentle
holding. 204
One advantage of a long hold is longer, gentler holding is that it may give an opportunity for both
patient and/or provider to feel changes: reducing sensitivity, and perhaps a shift in the texture of
the trigger point.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.12
Using “press and hold” to identify a trigger point release in progress
One of the best things about using still pressure on a trigger point is that it can help you identify a
trigger point release in progress. In the basic treatment sections, I recommended a simple “wait
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
and see” method — you treat your trigger point, and if it feels better a few hours later, you know
you must have “released” it.
That’s not good enough when you need to get serious about trigger point therapy. You need to
know if you’re releasing the trigger point while you’re working on it.
As you press and hold a trigger point, the sensitivity of the
trigger point will almost always ease up. This indicates one of
two things: either you are achieving a release, or you are simply
neurologically adapting to the pressure (i.e. your brain is starting
to “ignore” it as it becomes “boring”). In fact, it’s possible that
adaptation actually aids trigger point release! (Pure speculation,
that — I don’t know.)
So, here are some step by step instructions:
Hot burning trigger points! Trigger
points with a hot, burning, sharp
pain quality — I think of them as
“hot burners” — are generally slower to
release than trigger points that have a deep,
aching, “good pain” quality. If you’ve got
yourself some hot burners, brace yourself
for being more patient.
1. Find the trigger point.
2. Apply enough pressure to get a “clear signal” — clear but easily tolerated intensity, hopefully
“good pain” with some referral.
3. Wait up to 3 minutes for the intensity of the sensation to fade at least 50%. This indicates release
and/or adaptation.
4. Increase your pressure to bring up the intensity to what it was before.
5. Repeat steps 3 and 4 at least twice.
In other words: add pressure and wait for release … add pressure and wait for pain to ease … and
so on.
And what if it doesn’t ease up? It usually will. However, if it doesn’t, don’t be alarmed. Trigger
points don’t always release on the first try, or the fifth try. If you have a trigger point that isn’t
releasing, try again about twice per day, for about five days. If it still isn’t backing off at that point,
you can start to feel sure that something’s wrong and it’s not going to give.
Unfortunately, there’s no one explanation for a “non-fader.” It might be fibromyalgic tenderness
instead of a trigger point; it might simply be too severe, you might be “missing” it by a few
millimetres; it might be a “satellite” trigger point that is constantly regenerated even as you try to
release it by a more “primary” trigger point nearby. And so on.
There’s no defense against a non-fader except to just experiment with other strategies. Sometimes a
trigger point that wouldn’t release at all last month suddenly starts to become responsive this
month, thanks to known or unknown improvements in other factors.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.13
Identifying your trigger points by feel
This topic was covered thoroughly above, see Identifying your trigger points by feel: tissue texture
and other palpable signs. Rather than duplicating it here, where it is relevant once again, I’m just
linking to it for the sake of readers who use the tutorial like a reference instead of reading straight
through.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.14
Referred pain is not a diagnostic feature of trigger points!
This finer point is one of those things that “separates the men from the boys” in trigger point
therapy. A skilled, knowledgeable therapist knows this: there are far more points that produce
referred pain than there are actual trigger points.
I didn’t know this myself for the first half of my ten-year clinical career. For quite a while, I treated
my patients (and myself) with the assumption that “referral = trigger point.” There was no specific
cure for my ignorance — it simply started to become clear as I studied, learned and practiced. Now
that I have a strong grasp of the science of referred pain, it’s simply “obvious.” (And then, later, I
also discovered that this principle is stated outright by David Simons, somewhere in his text,
Muscle Pain.)
Referred pain is a feature of the human body’s pain system, and not specifically of trigger points.
Anything that hurts can cause referred pain. If you push on a healthy muscle hard enough, it will hurt,
and referred pain may occur in the pattern typical of muscle.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
So just because referred pain is occurring does not necessarily mean you are pressing on a trigger
point. For high diagnostic confidence you need the big three: (1) exquisite sensitivity, (2) pain
resembling symptoms, (3) local twitch response. Not referred pain.
It’s easy to get fooled, because referred pain from healthy tissue and trigger points will be similar
— they are all part of the same muscle, which has a single pattern of referred pain. You run the risk
of pressing on something that isn’t a trigger point, but is intensifying the same pattern of referred
pain that’s also being caused by the trigger point.
Fortunately, there’s also something working in your favour, even in ignorance: pressing on a
trigger point is much more likely to produce referred pain, for the simple reason that trigger points
are more painful than healthy tissue. Remember from the referred pain science section, referred
pain has a higher threshold than local pain — referred pain only gets rolling after provoked tissue
has already started to hurt. Thus, if you’re massaging here and there in a muscle, the healthy tissue
is relatively unlikely to hurt much and cause referred pain — but the trigger point is. So, generally
speaking, both therapists and patients are much more likely to choose to focus on actual trigger
points, because they stand out.
This is one of the good reasons, by the way, why therapists shouldn’t use brutally intense pressures
everywhere: you may provoke pain and referred pain in perfectly healthy tissues, creating the
illusion of “trigger points everywhere”, when in fact you’re just causing a lot of pain and 90% of
your effort is not actually affecting trigger points. Especially during the diagnostic phase of
treatment, skilled trigger point therapy is characterized by cautious pressures not only to avoid
negative reactions, but also specifically to help distinguish between healthy tissues (which will feel
mostly painless with moderate pressures) and the trigger points (which will stand out in contrast).
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.15
Don’t be fooled by “reverse referral”
As if referred pain wasn’t confusing enough! Every time referred pain has come up so far in this
tutorial, I have described it in terms of a trigger point in one place causing pain in another area, like
this:
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
For most cases, this is the important relationship to understand — that the pain in Area B may be
coming from somewhere else. But it can also work the other way around! Pain in the referral zone may
actually represent a problem in the referral zone, something actually wrong with the tissues in that
location. It’s not always wrong to look for a problem right where it hurts. Sometimes you are hurt
right where it feels like you are hurt!
So, “reverse” referral doesn’t mean that pressing on the referral zone will cause pain where the
trigger point is: it means that the causal relationship is complex. Depending on which tissue is
actually worse off, treating the trigger point may or may not solve the problem. Area B may
actually be in more trouble than Area A! “Referred pain” is causing the trigger point, rather than the
trigger point causing the referred pain. Sort of.
Or … could it be both? Could there be a vicious cycle? Suppose there’s tissue damage in Area B,
and then a trigger point gets fired up in Area A, and refers pain back to Area B. Not only is this
plausible, it’s probably common — there are probably many scenarios where it’s hard to tell which
area was in trouble first or worst.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Every trigger point has this vicious-cycle relationship with its referral zone. Recall that referred
pain happens because the brain can’t quite tell where internal pain is coming from — we’re not
wired for it. When Area A has a trigger point, the brain gets confused and thinks maybe the pain is
coming from Area B. But what if Area B is actually injured as well? Well, then Area B really feels
like it hurts!
Here’s another way to think about this: instead of thinking of the
“direction” of referral or causation, simply think in terms of
which area is in more pain. Which problem is the “real” problem,
or the bigger problem? If there is a blatant injury in Area B,
there’s not going to be any confusion. Area B is damaged, plain
and simple.
Confusion will arise when Area B is damaged in a non-obvious
way. And this absolutely happens! For instance, a mild tendinitis
in the shoulder can be difficult to tell apart from referred pain.
The infraspinatus muscle on the back of the shoulder blade can
How is this different from trigger points
becoming a complication of an injury? It’s
not, really. It’s another (deeper) perspective
on the same problem, with some new
wrinkles. Earlier in the tutorial I explained
that trigger points will form in response to
an injury, and then go on to hurt more and
last longer than the injury. This section
focuses on some other scenarios: what
happens when the injury is not so obvious
and is never actually superseded by the
refer dramatic, well-defined pain into the front of the shoulder.
complicating trigger points? What if both
And so can inflammation of the biceps tendon! A therapist can
trigger points and injury continue together?
easily be fooled into thinking that the problem is coming from
the infraspinatus muscle — all the more so because the referred pain from infraspinatus seems so
intense. But, in this scenario, the intensity of the shoulder pain is not caused by the severity of the
trigger point, but by the actual tissue problem in the referral zone.
A problem in Area B will make the trigger point in Area A feel all the worse. That’s “reverse”
referral. And this is exactly how a lot of pain cases go unsolved.
Quite the head trip, eh? Well, yes and no. Yes, if you try to wrap your head around the neurology
of it. But it’s not so confusing if you just realize that Area B may or may not have its own problems,
and the referred pain from area A may or may not actually be the main problem.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
5.16
Beyond the tennis ball: commercial massage tools
Tennis balls are the most commonly used self-massage tool (mostly everyone has one, and they
work pretty well), and I’ve already said that everyone should have a “bucket of balls” in their bag
of tricks. Over the years, I have become convinced that such a nice selection of balls is, collectively,
by far the best of all self-treatment tools for muscle pain, because it’s an easy collection to work on,
cheap and endlessly useful, adaptable and portable.
Two years ago, I wouldn’t have recommend a selection of balls as a big deal in particular. I was
enamoured with (and experimenting with) many of the other massage tools described here, many
of which I still like. But balls “win” — ultimately, you just can’t do better than a nice selection of
balls! No one prone to muscle pain should be without their balls.
So, start your massage tool collection with a bucket of balls. Some particularly excellent balls, and
balls with special purposes, will be described below.
But there are other tools in my bucket!
There are, of course, countless massage tools out there. I advocate working with the simplest and
cheapest first, but there is also an incredible array of commercial self-massage tools on the market:
sticks and widgets, rollers and thumpers and vibrators, wooden thumbs, and on and on. And
many of these are useful. Some of them are useful for only a single thing, but that’s okay —
sometimes that’s just the thing you need!
Here are some of my favourites:
The Jacknobber
A better example of a
“knobbly hand tool”
than the cute novelties
like the Octipet.
Jacknobbers, Index Knobbers, Octipets (a popular octopus-shaped novelty tool) and other misc
knobbly hand tools. There are countless tools on this theme: something you hold in your hand
that has hard, knuckle-like projections. There are so many different variations on this theme that
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
it’s impossible to recommend just one, or even ten of them — it comes down to personal taste. But
the concept is, of course, simple and useful, and most of them are pretty cheap.
The Knobble II (second edition) is yet another knobbly tool, but it is the best
of them and deserves a special mention. It has stood the test of time, and it is
the tool I grab from my boxes more often than any other except a plain ball. By
happy coincidence, I used mine to save myself from a nasty headache within
24 hours of its arrival in the mail (see Perfect Spot No. 1). Its grippy handle
and radial symmetry makes it more versatile than other knobbly tools. More
The Knobble
in my full review of tools made by Pressure Positive.
The Zubo, handmade by Allan Saltzman of YogaTools.com. This is another
superior variant on knobbly tools: a short stick! Your first impression might
be, “$20? For a piece of dowel?!” But I admire the simplicity of it, and my first
impression was, “I need that.” The Zubo is (as you can see) a wooden dowel
with rounded ends. That’s it. But you can do a lot of good self-massage with a
wooden dowel with rounded ends. Sure, make one yourself — if you happen
to have a wood file handy, and a half hour to kill. Or just say twenty bucks
worth of “thanks” to the small businessman who thought of it first. Mr.
Saltzman also sells some other handy tools that are not so easy to whip up
yourself, such as his spinal rollers (see below).
The Zubo
Massage tools don’t
get much simpler
than this.
What’s this?
Starving brain sucker!
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Brain suckers — vibrating head massage tools. Remember that old kid’s joke? You “suck” on
someone’s head with your fingers and say, “It’s a starving brain sucker!” Well, my friend, brain
suckers are real. And they are relaxing. This is not quite exactly a “massage” tool in the sense of a
tool that you apply pressure with, but it sure can feel nice! It’s a great way to relax yourself before
treating trigger points with pressure.
Massage sticks. The TheraCane® is probably the best known of these tools,
but The Backnobber is my favourite. Massage sticks are mainly about getting
at hard to reach places, and they are indeed very good at reaching those spots
— but less good at actually massaging them. They tend to be clumsy. When you
want some kind of pressure, any kind of pressure, on a hard-to-reach spot,
reach for the massage stick. But if you need precision and quality pressure,
you’re either going to need a lot of practice and experimenting with the stick,
or another tool altogether.
The Backnobber
The best of the
massage sticks. Best of
all? It breaks down for
easy storage.
Examples of
foam rollers.
Foam rollers. It’s just a handy thing — soft tubes. There’s a million kinds of ‘em! Don’t spend too
much, because there are plenty of cheaper ones. Note that pool noodles also work, and may be
even cheaper. They’re especially handy for side of the hips, as pictured — balls are often too
“pointy” for the sensitive trigger points in the gluteus medius and minimus muscles there. With a
foam roller, it’s easy and more comfortable to just settle your weight onto the roller. Most are
variations on such a strong and simple theme that there’s really nothing to distinguish them.
However, there are a couple unusual ones, such as Allan Saltzman’s spinal rollers and the Tiger
Tail (see next items).
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Foam rollers work particularly well on the
side of the hip.
Spinal Rollers, another handmade tool from Allan Saltzman of YogaTools.com. Basically just an
extremely sturdy foam roller, padded with a dense, rubbery foam. I also have one of these. The
USD $50 price tag is fairly steep (and the larger ones go up to $80), but I do not know of a better
way to apply long, firm strokes of pressure along the spinal muscles so effectively. A foam-only
roller can also work, but they are a bit too soft for me, and many other pressure-lovers.
Allan Saltzman’s well-made “spinal
rollers”
Much sturdier than a foam roller &
superb for strong pressures along the
whole length of the muscles along the
spine & for back cracking. Available at
YogaTools.com.
The Tiger Tail Rolling Muscle Massager is sort of a foam roller with handles
— or a specialized rolling pin, made for squishing muscle instead of dough.
There is no question that I thought of (and tried) using an actual rolling pin on
myself long before I heard of the Tiger Tail. But a rolling pin tends to be too
hard, too broad, and too fragile (the handles tend not to be sturdy enough,
unless you’ve got a really good quality rolling pin) for most
massage purposes. The Tiger Tail solves these issues: it’s got a foam cover on a
narrow cylinder, and it’s extremely sturdy. Its applications are fairly limited to
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Tiger Tail Rolling
Muscle Massager
The Complete Guide to Trigger Points & Myofascial Pain (2019)
“rollable” spots, primarily the legs and the forearms, but it does those spots very well, and it’s
perfect case study in how the right tool can make all the difference: it’s easy to apply and control
plenty of pressure.
But Caveat emptor! Commercially available massage tools are nearly always more expensive and
not necessarily any more effective than improvised massage tools adapted from freely available
objects and cheap devices not originally intended for massage (like dog toys), and so on. Coming
soon below, I’ll discuss some commercial massage tools I don’t like.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.17
Thumping trigger points with vibrating massage tools
The Thumper is a sturdy example of a vibrating massage tool, a class of massage tools that
deserves a little more attention. There are many gadgets like the Thumper, but I am fond of the
Thumper brand: a well-designed device built here in Canada. I’ve had my Thumper for about 15
years now, and it works as well today as it did the day I brought it home. I used it routinely in my
clinic for many years (a favourite part of the treatment for many clients), and mainly as a selfmassage tool ever since, but it’s also a nice easy way for my wife to give me a quite a bit of massage
for minimal effort. 205
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
The “Thumper Maxi Pro” is the thumpingest of all vibrating massage
tools. (Except for the one built for horses.)
The difference in the tone between a big one and a little one is substantial. The big one (the Maxi
Pro) is heavy by design, so much so that it would be hard for some people to handle, especially
trying to apply specific pressure in awkward areas, but their heft also delivers more satisfying
thumps that make other vibrating massagers feel more like “tapping.” Physics is physics, and sheer
mass counts for a lot here: insert obligatory “size matters” joke. Some people may even prefer the
“Equine Pro,” designed for horse massage to offer “even more power and strength”! There are
days when the Maxi Pro, as substantial as it is, doesn’t seem like it offers enough thump for me.
But if you can’t reach the spot you want to thump,
obviously a lighter model with a handle is the best you can
do on your own.
A Thumper is not cheap, so there ought to be a good reason
to get one. Fortunately, it offers a lot of value regardless of
therapeutic effect, just as massage does generally, but
probably even more so: for those who enjoy them, vibrating
massagers can deliver a lot of pleasant stimulation super
conveniently for a long time. It may cost up front, but over
the long haul it’s quite economical.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Thumper Mini. Size matters! And
sometimes you need smaller.
The Complete Guide to Trigger Points & Myofascial Pain (2019)
And then there’s the possibility that it helps trigger points, on top of that.
Why does vibration feel so good?
Vibration is inherently relaxing for most people, assuming it isn’t applied too suddenly or intensely
or in an uncomfortable location. I think there are a couple reasons for this:
1. Proprioceptive confusion. Proprioception is the sense of position or movement, our under-
appreciated “sixth” sense. If you move or shake the body at random, the cerebellum gets a deluge
of nonsensical proprioceptive data, sensory information about movements that the brain did not
plan. Assuming a safe and healthy emotional context, the nervous system, overwhelmed by the
flood of stimuli, willingly “gives up” and stops resisting the movement — an unusual state.
2. Sensory novelty. Fresh and unusual sensations are the bedrock of massage therapy: when we get a
good massage, we experience many sensations that are unique to that context, and that is half the
appeal. But vibration delivers especially strong and distinctive sensory novelty: it feels like nothing
else, and it feels like the opposite of feeling stuck and stagnant. Like splashing cool water on your
face when you’re hot, vibration feels like a natural antidote to the sensation of stiffness.
The case for treating trigger points with vibration
Thumpers are not reputed to be good for trigger point pain specifically, and there’s no direct
scientific evidence. 206 I’m not aware of any strong biological rationale for why vibration in
general would work for trigger points, let alone why any specific frequency or intensity or other
specific approach would be optimal.
To the extent that vibration is relaxing and pleasing to the nervous system, it may also help with
trigger points — as with any kind of pain. Vibration might have a bit of an edge given the potency
of the sensations it can produce — very relaxing, and very pleasing for many people — but this is
more about relieving symptoms than treating the problem.
There are some other intriguing possibilities,
however. This is pure speculation now …
Vibration has a fascinating effect on flexibility.
If you just add some vibration, even already
Gymnasts can get an “astonishing” boost in
flexibility — just add vibration.
flexible gymnasts can get a surprising boost in
flexibility, even an “astonishing” increase
according to Sands et al . This has been shown in three different experiments. 207 208 209 Shaking
appears to actually improve the range of people who already have great range! That is almost
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
certainly a neurological effect on muscle behaviour, a rare “hack.” And since trigger points might be a
misbehaving patch of muscle … well, hey, maybe something cool and good can happen that way.
It’s not a strong reason to try it, but it’s not a bad one either reason.
This effect may simply be deep muscle relaxation, suggesting that the relaxation induced by
vibration might be more meaningful than just feeling still and quiet: it may reduce muscle tone to
levels we cannot readily achieve by any other means.
For this reason, when you thump a trigger point, I recommend simultaneously elongating the
muscle it is in, if practical. Stretch on its own is not a good treatment for trigger points (see the
stretching summary), but stretch+vibration could be.
There is also the vague possibility that vibration has a mechanical effect on tissue fluids in trigger
points, which are probably swampy with waste metabolites. A large number of pressure waves
pulsing through the trigger point could conceivably facilitate cleaning it out and a return to
homeostasis. And I also think this is a bit of a reach.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.18
Commercial massage tools to avoid
The moment something is labelled a “massage tool,” it’s price magically doubles to about twice
what you’d pay for an object like that if it had a more ordinary purpose.
Sticking to my relentless theme of do-it-yourself-as-cheaply-as-possible, I strongly recommend that
you practice a healthy skepticism about all commercially available massage tools, especially if they
are sold as part of a “system” or “package.” For example, the Acuball …
The Acuball debacle. Consider the chiropractor Michael Cohen’s
invention, the “Acuball” (promoted at Acuball.com). You can pay
too much for the ball itself at $30, or you can pay twice that much
and get it as part of a kit containing another smaller ball and some
instructional materials. Cohen actually sent me a free sample of the
whole kit, giving me the opportunity to discover that I’m glad I
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
didn’t buy it. The DVD was produced on the cheap, the book was
amateurishly written and published and contained too many
pseudoscientific and unjustified claims to count. In particular, I was
amazed to see a section claiming that stretching will cause weight loss.
Wow! Really? 210
Not recommended
The Acuball is a great example of
an overpriced massage tool sold as
part of an over-priced “system,” all
of which is of dubious value.
But the real problem was that the ball itself just didn’t work well. It’s
got this great concept: that you can heat it up before applying it, which sounds like a nice idea, but
it takes a significant amount of boiling (5 minutes) to heat it up thoroughly, and then it’s too hot at
first but then cools down fast, and the point of contact between you and the ball is pretty small so
there’s not that much heat transfer anyway. In fact, the ball doesn’t even have a smooth surface,
but is covered by tall knobblies, which will minimize skin contact and maximize heat dissipation
(d’oh, simple physics). And then to add insult to injury, the knobblies also pinch mildly as you
move the ball: as the surface of the ball compresses, the knobblies bend towards each other,
grabbing skin and pulling a little uncomfortably as the ball moves. Not a horrible flaw, but why is
it a flaw at all? It’s a nearly useless design, for 30 clams.
River rocks, by contrast, are free.
In the same vein, a Texas company called Trigger Point Technologies alleges that their massage
tools are made of a “special” substance that is especially good for self-massage. (“Special
substance” reminds me of the ancient Saturday Night Live sketch, Happy Fun Ball [YouTube, 1:35,
a remake because the original isn’t available].)
I’m not really concerned with whether or not the claim is accurate. The problem is that it doesn’t
matter! There are many cheap and easy ways to self-treat your own trigger points, so there’s really
only so much need for a “special” and expensive tool for this job. The effectiveness of selftreatment for muscle knots is limited primarily by completely different factors, many of them
uncontrollable … not by the quality of the substance your massage tools are made of.
Special? Or just expensive?
Supposedly made of a
‘special’ substance, it’s really
just another ball. You’re just
as likely to find something
equally useful at a pet mart
or a dollar store.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
I’m not opposed to the idea of spending money on a massage tool that is especially handy or
effective, it’s just not that high a priority. By making the substance their massage tool is made of a
focus of their marketing, Trigger Point Technologies fails to persuade me that they understand
either massage therapy or trigger points.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.19
Massage tools: 7 free (or very cheap) and tools from objects not originally intended for
massage
Here’s a list of my favourite clever, interesting massage tools that are cheap or entirely free, and
charmingly adapted from objects that were not originally conceived as a massage tool.
Lacrosse balls are really firm — too firm for many people — but they have a
great rubbery texture that makes them easy to work with, and less prone to
slipping, especially when they are pinned between backs and walls. They
are also a bit smaller than tennis balls, and therefore also a little more
precise. For patients/muscles that tolerate the harder texture, they are just
terrific. They’re very cheap, of course, and it’s well worth having one in
your massage tool kit.
River rocks. Here’s a massage tool that “rocks,” har har — a therapist I
Even rocks can make
good self-massage tools!
know collects smooth river rocks, and gives them away to patients as selfmassage tools. It’s a great idea! Although hard as rock (too hard for many
patients and situations), they’re perfect for certain self-massage challenges. For instance, they
might be ideal for firm “scraping” of the muscles of the forearm — a muscle group which can
really take a beating in some people.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Squash balls are softer &
smaller than tennis balls,
which makes them ideal
for massaging some
hard-to-reach spots, like
the back of the shoulder.
Squash balls. I love my squash ball. It’s ideal for self-massaging in the upper back, where trigger
points are often too intense for harder tools. Its stickiness makes it highly “steer-able” when
pinched against a wall. Its size makes it quite accurate. It just has nice properties for self-massage!
They also come in a range of textures (indicated by the dots on the ball).
Dog KONG® (classic). (Note: not actually cheap. 211 ) I have been treating people with myofascial
pain syndrome for eight years now, studying and writing about it constantly, and the more I learn,
the more I believe that you can get some of your best massage tools at … your local pet store? Yep.
A KONG dog toy is another great massage tool that a lot of people have handy, or that they can get
easily. With its pyramidal shape and hardness that varies depending on how you use it, it’s even
better than a tennis ball!
The Classic
KONG® dog toy
is an amazingly
good selfmassage tool.
Dog KONG® (ball). The Classic KONG® with the funny shape is
terrific in some ways, but not ideal for every situation. The simple ball
version of the toy is a great companion tool: its softball size is ideal for
certain locations where other balls get “lost” (i.e. the small of the back).
It is as hard as you’d ever want a massage ball to be, yet still has a little
rubbery give. Its rubber surface means it doesn’t slide around too much.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
And it’s perfect for “the bath trick.”
Sock ball. (This is different than the “sock trick” described below.) A
sock ball — socks rolled into each other, as most of us have in our sock
The KONG® dog ball is also
ideal for massage.
drawers — is a perfect massage tool for more sensitive trigger points.
It’s the tool to switch to if you need to work your way up to stronger massage.
Rolling pin. Ah, sweet simplicity — there are hundreds of different “foam rollers” on the market
for self-massage, and I actually like foam rollers. However, often a rolling pin is just as good, and
already in the house. Of course, a rolling pin is hard — and while that’s just fine for some
applications (the tibialis anterior muscle, shin splints), and the quadriceps, it’s obviously too hard
for others. However, there’s nothing stopping you from wrapping something soft around it —
either a temporary solution, or something more permanent if the rolling pin is going to be your
best friend and permanently recruited for muscles instead of pie crusts.
Foam rubber balls. This kind of ball has a particularly nice texture, and can be anywhere from very
soft to very hard. Finding them is a bit tricky. I used to have recommended supplier for this type of
ball, but I just discovered (Jun 26, 2019) that they are gone now.
Advanced tips and tricks continue relentlessly in the next two sections, with a pair of tool-using
tricks I particularly like …
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
5.20
The sock trick
Whether you work with a tennis ball, a KONG® dog toy, or even a rock, most massage tools can be
put into a long sock or stocking, allowing you to dangle it down your back into those hard-to-reach
places. This can give you much finer control over the exact location of your tool.
Of course, if you don’t have unusually long socks — and not many of us do — there are other
solutions along the same lines. KONGs can be tied to a rope or string. A tennis ball can be put in a
long, soft sack … or in a short sack.
The truly enthusiastic self-massager — you know who you are — may wish to actually craft their
very own custom “massage tool sock.” You can easily sew one yourself, or go to any seamstress
and pay probably less then $10 to get them to make you a long, narrow sock of sturdy fabric.
Amaze your friends!
I have a pile of pantyhose in my
drawer that I do not wear. They’re
cheap & perfect for “the sock
trick,” a fun gift for my massage
therapy clients.
What parts of the body is the sock trick especially good for? Use the sock trick to reach muscles
from the upper back down to the lower back. It will save you considerable time as you work your
way from top to bottom (or bottom to top), systematically applying pressure to the full length of
the paraspinal muscles.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
5.21
The bath trick
From the Department of Why Didn’t I Think Of This Before: the bath trick! I discovered this while
working on my own muscle knots, trying to tame an episode of low back pain, which is a neverending job — they are always under control, more or less, but always threatening to come back,
under the onslaught of chair work that I have saddled myself with by making a living as a writer.
This is what trigger points do, of course — they come back. It’s in their nature. And that’s why I’m
always working on them — both my client’s trigger points and my own — and always discovering
new ways of doing it. It’s a creative challenge that never ends.
The Bath Trick
Run a hot bath & trap a ball between your body & the bottom
or back of the tub to rub your back muscles — your buoyancy
allows for excellent control over moderate pressures.
The bath trick is a “together at last” trick: it came from combining two other classic tactics for
releasing your own trigger points: the heat of a bath, with the pressure of a ball. But the result is
more than the sum of the parts, like chocolate and peanut butter, and it works better in some ways
than anything else I’d come up with before. Suddenly I’m using the bath trick regularly myself,
and recommending it to every other patient.
Absurdly simple instructions for trigger point release in the bath …
1. Simply run a hot bath …
2. climb in and get nice and warm and comfortable …
3. and then bring in a ball! Trap the ball between your body and the bottom or the back of the tub, and
cheerfully crush your trigger points with relieving pressure.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Why bother?
The bath trick works particularly well because the pressure is mostly quite easy to control, and
easier still if your tub is equipped with hand-holds.
Often people find that the full weight of their body trapping a tennis ball against the floor is simply
too much — the pressure is too intense, and they’re unable to achieve a relieving sensation. But in
the bath, you are much lighter! You have much better control and a moderate intensity of pressure.
But pressure caution is still required! I think the heat of the bath can mask the intensity of the
pressure. I have bruised myself even when I thought I was being careful. Bruising is not cool and
not therapeutic. Please be careful not to overdo it, especially at first!
While the heat relaxes you, your buoyancy in the water allows finely tuned control over moderate
pressure on your trigger points. Applying a little more or less pressure is as simple as rising up in
the water a little, or submerging more of yourself. You can also raise or lower the water level for
additional control over your buoyancy — many people will find that they are too bouyant and are
basically floating over the ball rather than pressing down on it. Fix that by draining off a little of
the water.
What sort of ball should you use? Some balls are better for the bath
than others. Either a lacrosse ball or a KONG® brand rubber dog ball is
perfect. (Not the pyramidal KONG with the hole through the centre, but
preferably the ball, which is made with the same dense rubber.) These
balls don’t get soaked, and they have a nice neutral buoyancy — they
don’t sink or bob up to the surface — so it’s nice and easy to move them
around underwater, trapping them right where you want between your
body in the bathtub.
Tennis balls, generally so useful for self-treatment, are not especially
The KONG® brand dog ball is
perfect for the bath trick.
good for the bath trick. Wet ones are kind of a pain outside the bath,
and they like to pop up to the surface.
What parts of the body is the bath trick especially good for? The muscles of the back and low
back are the most obvious targets. However, one of the best things about the bath trick is that it’s
one of the few tool-massage methods that’s quite effective for the neck and upper shoulders.
Regular tennis ball work, with the ball pinched against the floor or wall, is quite awkward in this
area. In the bath, the sloped back of the tub and your reduced weight make it much easier to apply
strong, well-controlled pressures to this area. Great!
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Another fantastic location to apply the bath trick is the sides of the hips. Simply turn on your side
in the bath, and it’s possible to get quite relaxed onto the ball in a way that’s not easily achieved
outside of a bath.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.22
Introduction to non-massage self-treatments for trigger points
We have now covered self-massage methods in exhaustive detail. But self-massage is only the best
treatment most people can apply to their trigger points, not the only one. There are three other
major helpful methods, and some of them may be more effective than massage for some people —
it depends on the case. There are many other therapies — but these three are the primary self
treatments.
Stretching feels good and may help some trigger points some of the time, but it’s generally overrated, and sometimes stretching can actually do harm. Yoga classes injure people often enough that
it’s a fair question whether there’s even an overall benefit. Stretching is such a complex topic that
it’s covered in great detail in its own chapter after the advanced treatment tips are wrapped up.
Mobilizing, or “massage with movement.” Mobilization — rhythmic contraction and elongation of
tissues — is a concept of my own invention. Mobilizing is routinely more effective than stretching,
and it can be particularly helpful eliminating trigger points associated with tissue stagnancy.
Mobilization is summarized in more detail below, and discussed in great detail in the article
Mobilize!
Heat therapy. Trigger points love heat: hot baths and showers, hot tubs and Jacuzzis with their jets,
saunas and steam rooms, heating pads and hot water bottles and microwaveable bean bags and gel
packs … you name it, if it’s hot, your trigger points will like it. Using heat on your trigger points
gets its own section below, and there’s also a good general article on heat therapy elsewhere on
PainScience.com.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
5.23
Stretching (executive summary)
This section is an executive summary of a much larger batch of sections below. Stretching is such a huge topic that I
felt it interrupted “the flow” to have a big stretching discussion in this part of the tutorial. Read the basics here; later
on, you can read much more in the main stretching section. Note: this summary deliberately lacks footnotes and
substantiating detail.
The anecdotal evidence that stretching “works” for stiff and aching muscles is substantial.
(Ominously, so is the anecdotal evidence that it can backfire.) There is also some scientific evidence
suggesting that stretching is helpful for common musculoskeletal problems, such as neck and back
pain (but it’s also a complicated, incomplete, underwhelming mess). Stretching doesn’t seem to
come close to “curing” anyone, but darned if it doesn’t also “take the edge off” enough to make it
worth trying. So people in pain stretch, and sometimes they feel a little better for a while.
Stretching as a treatment for trigger points has some expert endorsements. In the weighty text
Muscle Pain, researchers Dr. David Simons and Dr. Siegfried Mense wrote that stretching “by
almost any means is beneficial.” This depends on chain of assumptions and theories about how
trigger points work: the micro-cramp is metabolically exhausting, like an engine revving in the red,
producing waste metabolites that pollute and irritate the surrounding tissues, causing pain and
more contraction. In theory, a trigger point cannot burn fuel if it is fully elongated, which would
give the energy crisis a chance to abate — a vicious cycle breaker.
If they are right, then stretching works about
the same way that stretching out a calf cramp
works: you win the tug-of-war with spasming
muscle, just on a smaller scale. This sounds
great on paper, but there are several major
problems in both theory and practice. Simons
and Mense also emphasize that it has “not
been firmly established” that stretching trigger
points is helpful, and that stretch works
How can we pull apart a powerful contraction
knot — a tiny segment of muscle fibres in full
spasm — with anything less than pliers, a
vice & a glass of bourbon?
primarily for “newly activated, single-muscle”
trigger points … leaving out a lot of trigger points that are serious problems. There are many
circumstances in which you cannot realistically hope to win a tug-of-war with a strong one,
because it would be too anatomically awkward and/or too painful.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
How can we pull apart a powerful contraction knot — a tiny segment of muscle fibres in full spasm
— with anything less than pliers, a vice, and a glass of bourbon? We almost certainly do not have
the leverage or pain tolerance required, especially if the muscle fights back with a defensive
contraction (which may account for the cases that backfire). That trigger point is like a knot in a
bungie cord: all we’re going to to do is stretch the hell out of the bungie cord on either side of the
knot. If it works at all, it probably mostly only works on the milder cases that don’t matter much in
the first place.
And then there’s the possibility that Simons and Mense were just wrong, and a trigger point is not
like a tiny cramp at all. If there is no metabolic “revving,” no energy crisis to interrupt by pulling
muscle proteins apart like kids fighting on a playground, then it’s back to the drawing board:
either stretching doesn’t work at all, or we just have no idea how it works. Which is possible.
It’s not a very promising treatment method, but the hope is not going away either: it feels good
even when it fails, and partial and temporary successes will keep most of us trying. Just beware of
wasting your time! For most people, other treatment methods are probably more useful.
See below for the full discussion of stretching for trigger points, which gets into the nitty gritty
details.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.24
Mobilizations: massaging with movement and the Goldilocks zone
Can you exercise to help beat trigger points? Yes. But you have to enter
…
… The Goldilocks Zone.
To qualify as an advanced trigger point troubleshooter, you have to do
better than simply avoiding a few common things that piss trigger
points off: you have to actively pursue the ideal alternatives. So, in various
ways before now in the tutorial you’ve learned that both overexertion
and tissue stagnancy (getting stuck) are irritating too.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
Doo doo doo doo, doo doo doo
doo …
The Complete Guide to Trigger Points & Myofascial Pain (2019)
So, what’s the alternative?
Regular, easy exercise. Exercise intensity that is “just right.” Just enough stimulation to keep muscles
warm and happy … but not enough to irritate them.
Anyone struggling with trigger points must (must, must) embrace life in the Goldilocks Zone. You
have got to constantly but gently stimulate your body. Weekend warriors need to let the ski slopes
go for a while and take up a walking habit instead. Hardcore power yoga bunnies need to switch to
a gentler class. Office workers have to learn to “microbreak.” Gym rats have to ease up on the “reps
to failure.” And so on.
You can easily take the idea of the Goldilocks Zone and run with it. It’s not hard to understand in
principle. But there are many details.
Chair warriors, for instance — office workers stuck in chairs all day every day — can learn a great
deal about how to cope with their predicament, how to work “defensively” and prevent severe
muscle tissue stagnation. For much more information, see The Trouble with Chairs. Strength
training enthusiasts can read all about the relationship between strength training and trigger points
in the next section, “Trigger points at the gym.” And yoga practitioners and stretching enthusiasts
need to learn that stretching can also irritate trigger points. Stretching can be a pleasant Goldilocks
Zone activity.
But the idea that absolutely everyone needs — the ideal embodiment of the Goldilocks Zone — is
the idea of “mobilizations.”
“Mobilizations” are rhythmic, repeated movements that alternately stretch and contract
musculature and other soft tissue — massaging your tissues with movement. I prescribe at least
one or two key mobilizations to nearly every client, usually in preference to stretching.
Mobilizations are more “neurologically interesting” than stretching and stimulate more metabolic
activity in the tissue while remaining gentle. They are more practical and efficient than stretching
in many ways, especially because they can affect more tissues more quickly, and because they
constitute both a better warm up and a better warm down for more intense activity.
See Mobilize! for more information.
And they are ideally suited for efficiently, accurately stimulating — but not-overstimulating —
muscles with trigger points. Don’t just think of mobilizations as an exercise that is compatible with
trigger points. They are also a therapy for trigger points. 212
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
5.25
Case study: mobilizations prove to be crucial factor in recovery from neck pain that started
in the 1970s
Trevor Elliott is a self-made man: entrepreneurial and good at it, a gentleman farmer and
commercial real estate investor, he could easily retire but doesn’t seem particularly interested in
doing so. A gregarious Irishman with an enthusiastic handshake, he’s always getting into a project
… and getting into trouble.
In 1971, the trouble was that he fell off a motorcycle in Ireland. He savagely wounded his neck, and
never really recovered. Although bones and ligaments healed, Trevor was left with a severe,
apparently permanent “crick” in his neck. It was so severe that all who knew him knew his habit of
wrenching his neck constantly, almost like a tic, trying to wriggle free of the grip of his pain — for
decades.
For more than 35 years Trevor tried every
possible therapy, especially chiropractic
adjustments, but never in all that time had any
lasting results. Interestingly, his anterior neck
musculature had never been addressed by any
therapist in any way in all that time — “no one
has ever rubbed me there!” — although this is
Trevor’s pain was so severe that all who knew
him knew his habit of wrenching his neck
constantly, almost like a tic.
a likely place for trigger points to form, persist
and torment.
Trevor had ten treatments with me between February 23 and May 31, 2006. In that time, he
improved to the point where he began doing things he hadn’t been able to do for many years,
friends and family commented on the change, and he felt substantial and lasting relief from the
feeling of his neck being “out.” He wasn’t “cured,” but his symptoms were down a good 80% — far
more than he had ever dared hope for. He had expected to go to his grave with this pain.
Trevor’s relief has continued, thanks largely to mobilizations. Although he occasionally sees me for
a “tune up,” he now effectively manages occasional flare ups of pain with neck circles — a direct
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
simple mobilization exercise consisting of nothing more and nothing less than rolling the head
around … and around … and around … .
Again, Trevor’s not “cured,” and probably can’t be cured. But after some trigger point release that
was 35+ years overdue, and a regular habit of neck mobilizations, his trigger points are quite well
controlled — and while that may not be a cure, it is a rather major improvement. To this day,
whenever he drops by, Trevor usually thanks me specifically for the neck circles prescription!
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.26
Trying to squirm your way out of trigger point pain? Don’t do it! Consider a little more
method in your madness
Here’s a useful perspective, another way of thinking about mobilizations that may make a lot of
sense to you. Imagine this scenario …
You’re sitting at your desk. As usual. You’re reading this, or something — you’re always
reading something, typing something. Without even noticing, you tilt your head to the
side, and then wrench your neck into rotation with a grimace. You quickly turn it the
other way, and there’s a soft pop that gives you a little relief. Until the next time. It’s
going to be five minutes, tops, before you’re at it again. Might be seconds.
Sound familiar? Almost everyone has this problem. This kind of reflexive effort to escape stiffness
and pain with a brief, exasperated stretch and/or joint pop — squirming, basically — may happen
dozens or even hundreds of times per day. It is most common in the neck, followed closely by the
low back, but can occur in virtually any body part. Argh.
“The squirm” is a response to an instinctive desire to move — to mobilize! Answering the instinct
is definitely the right idea. Stagnancy is definitely a problem, and movement is a solution.
Unfortunately, done in this way it will never do any better than just “take the edge off.” As
symptoms increase in severity, this twisting and squirming becomes more intense and frequent —
and even less effective.
Imagine this scenario:
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
You’re sitting at your desk. As usual. You
feel an impulse to squirm, but instead of
squirming, you move more mindfully
Stagnancy is definitely the problem &
movement is the solution.
and properly. You take a 30 second break,
stand up, and roll your head in a full
circle just five times — easy, quick. Then swing your hips around a few times.
That’s better!
In other words, squirm more thoroughly! And in a more positive frame of mind. A microscopic
yoga break. The movement involved will be a good order of magnitude greater than a brief,
reflexive squirm. The difference in mental attitude is subtle, but incredibly important over time.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.27
Strengthening: should you take your trigger points to the gym?
Executive summary. People with trigger points often feel
weak, but we don’t know if they actually are. Strength
training is very healthy in general — much more than most
people give it credit for — but we have no idea if it’s good
for trigger points, and it has the potential to both help and
harm. Moderate intensity contractions pose minimal threat
to muscles “sick” with trigger points, and the moderate
stimulation and the increased circulation might be helpful.
If you like lifting weights, and you want to try to treat your
trigger points that way, I encourage you to “go for it,” but
If you must take your trigger points to the
gym, watch out — there are potential
hazards. But also opportunities to heal.
please be more cautious than you normally would: baby
steps, allow for extra recovery time, avoid maximal and eccentric loading, include more endurance
training (higher reps, lower loads).
If weight-lifting is not your style, no worries: you have my blessing to carry right on not lifting
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
weights. But please do consider it as a healthy activity that has some potential to also help your
muscle pain.
•
The contents of this section can mostly be inferred from your guru-like knowledge of trigger
points, which you’ve acquired from your reading so far. For instance, in the previous section we
were discussing the importance of moderation, gentle exercise, and the Goldilocks Zone — so
you’re not exactly going to fall over with surprise when I tell you that lifting heavy weights at the
gym with your muscles full of trigger points may not be the best idea you’ve ever had.
Yet a lot of people want to do exactly that. Many independent,
motivated people in pain will go to the gym hoping to “bury”
their pain, only to discover that it isn’t quite that easy. A few
enthusiastic people will succeed and become gym-therapy
evangelists, which is a problem for the many people who either
fail or actually get hurt. So there’s a need to tackle the subject
head on. Mostly we’ll talk about the most manly gym activity,
strength training, but we’ll also compare and contrast it with the
main alternative, endurance and aerobic training.
Is strengthening even therapeutic? Strength training is weight
Quick review of the science We don’t
actually know if trigger points truly make
muscles contract less powerfully, or just
cause a sickly sensation of weakness. If a
muscle’s power is truly sapped, it’s
probably because sarcomeres in the trigger
point are already maximally contracted, and
adjacent sarcomeres are somewhat overstretched making it difficult for them to get
a contraction started. Review above.
training, bodybuilding, pumping iron. It means “high load, low reps” — lifting heavy weights just
a few times. Its most obvious goals are to make muscles bigger and stronger, which works really
well, but it has much more general health benefits than most people realize, and it’s safer and more
efficient than people think too.
But there is also a common belief out there that strengthening is the way out of all kinds of injuries
and painful problems. “Core strengthening” is especially overhyped: it’s probably the most
popular pair of words in exercise therapy for the last couple decades. Strengthening is often
prescribed as a therapeutic exercise to help people recover from all kinds of injury and pain
problems. Many manual therapists see exercise and “active” therapy in general as being the future,
and “passive” therapies — doing things to patients — as old school nonsense.
Strength training has some risks for people with chronic pain however. And is it even worthwhile?
Can you actually treat anything by throwing weights at it?
In some cases, probably. But not for most people, most of the time. The evidence is overwhelming
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
that strength training is underwhelming as a therapy for specific painful problems. For example, in
2006, Smeets et al concluded that it was “more promising” to study “the interplay between
biological, social and psychological factors” in back pain than to bother with more studies of
lumbar strengthening. 213 A 2016 study showed that there was no difference between high load
lifting and low load motor control exercises for back pain. 214 Those are just a couple of
representative examples. It’s a huge topic, which I am just glossing over here — I’m covering it just
enough to emphasize that the benefits are not clear at all.
It’s not that strength training never works as therapy. It’s just considerably less impressive or
consistent than you might think. Particularly given the risks, you might want to ratchet down your
enthusiasm for curing yourself with weights.
And there are risks!
The physiological changes associated with
strength training and “gettin’ huge” occur
when you exhaust a muscle by lifting
The evidence is overwhelming that strength
training is an underwhelming therapy.
something heavy over and over again. Recent
evidence has shown clearly that it doesn’t
matter much how heavy the weights are or how many times you lift it, just as long as you are good
and worn out at the end. 215 If you’re not doing this, you’re doing some kind of exercise, but it’s
not strength training, not really. “Exhaustion” has a meaning in strength training beyond simply
being tired. Exhausting muscle tissue completely, or close to it, is called taking it “to failure,” is
essential for building strength — but also potentially a problem for trigger points and pain. That
intensity can mess with people with chronic widespread pain, 216 especially in fibromyalgia
patients. Maybe pissing off trigger points is one of the reasons that happens. No one knows.
But maybe you can get away with it? Hey, you never know.
Taking your trigger points to the gym and exhausting them is
definitely not necessarily going to be a disaster. It could go either
way. It could even feel great! Rehabilitative strength training
does aid rehabilitation in many cases. Two recent scientific
papers have shown that both strength and endurance training
Muscles strains are one of the risks of lifting
heavy weights, and the risk may go up
because of the awkwardness caused by the
sensations of stiffness and weakness
associated with trigger points.
were effective for treating neck pain, 217 218 which likely
involve a lot of trigger points. This suggests that almost any activity, even strength training, could
be better for trigger points than no activity.
Nevertheless, I hear a lot of stories from people whose strength training efforts at the gym came to
tears, or simply failed to help the problem. Some people predictably experience significant
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
aggravation of their symptoms every time they try to strength train. Many more simply experience
mild symptom exacerbation and underwhelming results — their problem isn’t helped, and the
strength training doesn’t work very well either.
And latent trigger points can really interfere at the gym — long before you are aware of any
problem! Ironically and somewhat tragically, people with latent trigger points may still suffer
rotten consequences at the gym, even if those trigger points never actually flare up into activity.
Some people almost certainly misinterpret poor strength training results for years on end —
strength training is supposed to be difficult and exhausting, and discomfort afterwards is normal,
right? How can you tell the difference between the normal challenging sensations of strength
training and the dysfunctionally excessive discomfort of strength training with a bunch of latent
trigger points making you feel weaker, quicker to exhaust, and more sore afterwards?
Strength training should be hard, but it shouldn’t be that hard. Not everyone can get results at the
gym, probably because of genetics … but perhaps also because so many people are walking around
with a crop of latent trigger points that make strength training rather difficult. 219
The more relevant trigger points are to your case, the more likely it is that the strength training will
be uncomfortable and difficult, fail to build strength, and/or make no difference to your problem,
or make things even worse than they were.
Endurance training to the rescue? Gentler, more repetitive usage of the muscle — lower loads,
higher repetitions, less exhaustion — is the general solution to all of this. If you have active trigger
points and are in acute discomfort, mobilizations are even gentler than endurance training, and
often more appropriate. But endurance training is simply a terrific way for enthusiastic weight
lifters not just to safely continue training, but to actually help to relieve the trigger points and get
back to strength training all the sooner.
The low loads of endurance training simply
minimize the risk of aggravating trigger points
or tearing some muscle, while the high
repetitions provide plenty of stimulation and
metabolic activity. No tissue can thrive
without some stimulation! A good endurance
workout creates a significant metabolic
Endurance training can actually help to relieve
the trigger points so that you can get back to
strength training.
demand, which increases circulation more
than any massage ever could. 220
Injury rehabilitation is all about taking “baby steps.” Understanding endurance training gives you
another step — a way of using the gym without banging your head against a brick wall. Good luck!
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.28
Thermotherapy
Advice to “avoiding ice and chills” and “try heat” is about
as far as I go when training beginners. But for advanced
students … ah, we need to talk! You need to become a heat
connoisseur — you need to experiment with actively and
extensively using heat as a way to prepare for and support
other trigger point therapies, and as a trigger point therapy
in itself.
Muscles simply love heat. There is a strong and predictable
Heat is the most predictable source of (at
least temporary) relief from the pain of
trigger points.
reduction in muscle tone underlying heated skin — a fairly
straightforward neurological effect, a reflex. And every
reduction in muscle tone helps to relieve trigger points. And practically everyone with serious
trigger points says something like, “Well, heat is one thing that does actually seem to help.”
I don’t know of any case, ever, that could be cured with heat
alone — it’s a powerful aid, not a cure — but I do know of many
cases where heat was a critical factor in recovery. Here are
several tips and tricks for how to get the very most out of heating
your trigger points.
Distinguish between systemic and local heating. They both
have their uses. Systemic heating is full-body heating in baths, hot
tubs, showers, saunas and steam rooms. The advantage of
systemic heating is that it addresses a lot of tissues at once, and
— done properly (i.e. avoiding headaches) — can add a powerful
relaxation component to the treatment. Local heating is heating
of specific regions of the body with heating pads, gel packs, bean
bags, soaking in sinks or buckets, and so on. Local heating
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
Do not heat recently damaged tissue , such
as ankle sprains or muscle tears. For the
same reason, many people also incorrectly
steer clear of heating low back pain, but this
is an exception: low back pain should
almost always be heated, never iced,
because it is almost never an “injury,” per
se. See (Almost) Never Use Ice on Low Back
Pain! for details.
Another caution is to avoid over-heating.
Burning is obviously to be avoided, but
that’s not what I mean. I’m referring to
heating that isn’t welcome: like a heating
pad on your neck on a day that’s already
The Complete Guide to Trigger Points & Myofascial Pain (2019)
methods can be more intense in an area that needs it, and are
unpleasantly warm and the AC is busted.
often simply more convenient for repeated/frequent treatments,
Your body usually likes heat, but only if it’s
which is often quite important during a phase of intensive
actually pleasant in context. Thus, hot
trigger point therapy. Use both systemic and local methods for
summer days are often actually poor
different reasons at different times.
choices for thermotherapy.
Take a better bath. Sadly, many people don’t care for a hot bath, but mostly because they’re doing
it wrong. How can you do a bath “wrong”? Surprisingly easily! Many people make it too hot
(which is more stimulating than you think, and can keep you awake at night), fail to keep their
head cool (which can lead to headaches), and don’t drink enough water. (Dehydration can really
sneak up on you in a bath. No, really! Watch out.) For complete details on how to bathe properly, see
Hot Baths for Injury & Pain.
Get a Thermophore. For specific/local heating, I particularly
recommend seeking out a large-sized (14 × 27) Thermophore. Vastly
superior to drugstore heating pads, Thermophores are the Rolls Royce
of heating pads: large, heavy, thick, and with “a special tightly-woven
fleece blend cover which retains moisture from the air” — which really,
really works. If you leave a Thermophore on a plastic surface, there will
be beads of water under it five minutes later. The moisture captured
from the air by the Thermophore conducts heat far more effectively
than a dry heating pad. Luxurious! Both genuine Thermophores
(roughly USD $50-100) and knock-offs (cheaper and probably nearly as
Thermophore
The Rolls Royce of
heating pads
good) can be ordered online from Relaxus.com, and are also usually
available in medical supply stores. Of course, Amazon has them, too,
and probably cheaper.
Contrast! The main goal of heating for trigger points is relaxation of the muscles that contain
trigger points. But another goal is to increase circulation, to aid in “washing” out the stagnant
tissue fluids that may be the reason trigger points hurt, and to do so without subject the muscle to
any exercise stress. In the limbs particularly, you can get a much more powerful effect on
circulation by combining heat with cold. This is called “contrasting.” Contrasting is a free, safe, easy
self-treatment for a wide variety of conditions that can benefit from an increase in circulation (i.e.
practically anything except acute injuries). Contrasting involves alternating between soaking in hot
water and soaking in cold. Always finish with cold. Use a double-sink, a pair of buckets, a
detachable shower head ... or whatever arrangement you can dream up. Please see Contrast
Hydrotherapy for more detailed information and instructions.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
5.29
Breathing deeply is free, safe, and possibly good therapy for trigger points
Deep breathing while doing trigger point release is a bit of a no-brainer: it may be an extremely
effective aid to trigger point release, and even if it doesn’t it is free, safe, and has some other clear
benefits similar to what you might get from meditation. Let’s start with an overview of what kind
of breathing I’m talking about.
For more than twenty years I have been practicing, teaching, and exploring an unusual form of
therapeutic breathing called “bioenergetic” breathing (a.k.a. “round” breathing). It is a potent tool
for the stimulation of healing and personal growth (which is not a claim I make lightly). When a
therapist tells you to take a deep breath, there’s more to it than you think, and often more to it than
they think. It’s the tip of an iceberg most people have never seen or heard of.
This is probably the “flakiest” advice I have for trigger point patients, but I have confidence in it as
a therapy. It has a sound rationale. You can read more about it in the article The Art of Bioenergetic
Breathing.
“Bioenergetic breathing” has its origins in the bodywork philosophies
that emerged originally from Alexander Lowen’s interpretations of
Reich and Jung. 221 So when I teach this kind of breathing, I stand on
the shoulders of giants. I learned about bioenergetic breathing from
Joanne Peterson and Drs. Jock McKeen and Bennet Wong at Gabriola
Island’s renowned Haven Institute for Professional Training.
But what about the effect of breathing on trigger points?
Earlier in the tutorial you learned that recent scientific research has
shown that there may be irritating metabolic wastes floating in the tissue
fluids of trigger points: “ … not just 1 noxious stimulant but 11 of them.”
Yuck. The same research showed that trigger points are also acidic. “The
milieu [of the trigger point] is strongly acidic,” Simons writes. “The
amount of these [acidic] substances was very significantly and
consistently greater in active MTPs than latent ones.”
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
Ah, deep breathing! So
mystical! And possibly great
for your blood acidity.
The Complete Guide to Trigger Points & Myofascial Pain (2019)
This discovery is satisfying for me because, several years ago, I guessed
that it might be the case. I often told my patients that trigger points were “acidic,” because it
seemed likely to be true and because … well, it just sounded good, I guess! In those days I was not
as scientifically literate as I am today, and I hadn’t noticed that I was being intellectually dishonest,
presenting a sketchy theory as though it were a meaningful fact. Naughty therapist! Fortunately,
the scientific evidence now actually does support my opinion.
Trigger points really are strongly acidic. And breathing hard — outside of an exercise context —
reduces blood acidity to the outer limits of the normal range, or a little beyond: minor, transient
respiratory alkalosis. Respiration is the main way that we aggressively, quickly regulate blood
acidity. 222 Which means that it is plausible that deep breathing could be relevant to trigger point
treatment. One of the likely goals of massage therapy is to “flush” trigger points by pushing
stagnant tissue fluids out. Perhaps if blood arriving in the area is significantly less acidic, the
trigger point will recover more easily? Perhaps?
It’s certainly possible!
But far from proven. And these days I know much better how much I don’t really know, so I’ll stop
with just the suggestion. ��
Meanwhile, there are other benefits to vigorous deep breathing. The most obvious is that it tends to
be deeply relaxing via a kind of “blowing off steam” effect. This isn’t slow, meditative deep
breathing we’re talking about here: it’s fast and strong, even hyperventilatory. 223
How to breathe bioenergetically for trigger point therapy. Bioenergetic breathing is basically just
fast, deep breathing. Specifically:
It emphasizes inhalation, which is assertive and full.
It does not pause at the top or the bottom of the breath, forming a smooth sine wave.
The mouth and throat are open wide, removed from the path of the breath, never shaping or
controlling the movement of air.
In a full bioenergetic breathing session, you might work up to a vigorous pace of breathing in the
space of a minute or two, continue for five to ten minutes, and then wind down again. This much
bioenergetic breathing is optional for trigger point therapy. You can also simply:
1. Take just 10-20 deep, fast breaths before starting trigger point therapy.
2. Continue to breathe deeply and steadily during therapy.
3. And then optionally add another one, two or three short sessions of 10-20 breaths in the hour after
treatment.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Once again, for people interested in trying this kind of breathing, I strongly recommend reading
the full article about it: The Art of Bioenergetic Breathing.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.30
Neutral positioning: find a comfortable muscle length and rest there
Like breathing, here we have another treatment approach of unknown value, but it is entirely free
and harmless. This is a short section for a simple idea.
One of the diagnostic characteristics of a trigger point is pain on stretch and contraction. Some
muscle positions and states are more comfortable than others. We often seek out those positions
instinctively, to escape the pain. However, we can do so more carefully and deliberately — as
therapy. Just as deliberate, thorough mobilizations are quite a different experience than
“squirming,” deliberate neutral positioning is a different experience than unconscious, erratic
avoidance.
Consider neck pain caused by postural stress at a desk. The victim may feel quite a bit better with a
simple forward tilt of the head, and can be seen to do this many times per day, seeking relief.
However, the position of greater comfort is never sustained — not once. It is merely a reflexive and
rather desperate and disorganized avoidance of the pain. What if that person were to take a ten
minute break and rested, head supported, relaxing in a position where the pain is the mildest, or
even absent? Is it possible that they might emerge from that rest feeling far better?
You bet your boots it is.
As natural as it may be to seek out a position of greater comfort, it’s unlikely that someone will do
it as thoroughly or as well as they could with a little effort.
That’s neutral positioning therapy: unproven but sensible. It exploits the idea that a trigger point
may be more of a sensory phenomenon than a “thing” in the muscle. Pain is fundamentally a threat
alarm (whether there is really a threat or not). It is more likely to work with muscle pain than with,
say, a broken arm, because trigger points may involve more alarm than fire. Repositioning may
persuade your nervous system that the threat is reduced. A true injury will quickly resume hurting
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
when the comfortable position is abandoned and damaged tissue is disturbed. A trigger point may
not resume hurting again — or not so fast — because there may not be much wrong in the tissue to
disturb.
Note that neutral positioning is a curious mirror image of mobilizations: stillness instead of gentle
movement, but both with the goal of gently reassuring the nervous system and “practicing” being
pain free. Neutral positioning is also interestingly related to stretch, because sometimes the most
comfortable position is a stretch. To the extent that stretch occasionally seems to help treat pain,
this may be why.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.31
An introduction to medicating muscle pain (hint: not a great option)
The next few sections expand on ideas already presented in the basic
medications section, and also discuss medications that aren’t available
without a prescription (such as Oxycontin).
“No non-narcotic medication is known that is specific for the pain
generated by central myofascial trigger points. The new understanding of the
pathophysiology of trigger points opens the door to identifying drugs that specifically
inactivate the trigger point mechanism.”
~ Janet Travell, David Simons, and Lois Simons, Myofascial Pain and
Dysfunction: The Trigger Point Manual, 1999, p147
Alas, although the door has been opened, no such drug has yet
been identified. There is no “muscle knot medicine.” For now,
the options are limited to the usual pain-killer suspects — antiinflammatories, opioids, and muscle relaxants. None of those are
particularly likely to impress you with their effectiveness, and
some of which are surprisingly ineffective (I’m looking at you,
muscle relaxants — their comeuppance and references lie
below).
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
What’s in a name? Drug jargon is a
hopeless maze: narcotic, sedative,
tranquilizer, opiate/opioid, analgesic,
steroidal, yada yada yada. The same drug
can be described many different ways, and
the same thing is often marketed under
different brand names in different countries
(or even in the same country). There are
The Complete Guide to Trigger Points & Myofascial Pain (2019)
If you experiment with medications, bear in mind that it’s
countless variants and classifications.
possible for them to actually backfire: not only to fail to treat
I’ve gone overboard trying to be clear and
your problem, but to make it worse. Because trigger point
thorough and to write in terms of familiar
physiology is complex and mysterious, it’s hard to deny the
possibility that certain medications might interact unpleasantly
with it. More straightforwardly, there is a phenomenon called
“analgesic rebound” which is a common cause of pain: basically,
you become more pain sensitive when you stop or reduce painkilling drugs.
drug names and concepts, while still
organizing the information in a way that’s
consistent with chemical reality.
Throughout these sections I will use drug
brand names when they are familiar, or
drug class and chemical names otherwise.
Undoubtedly I have a bias towards brand
names that are more familiar in North
America, and I do apologize for not
including many other brand names familiar
to readers elsewhere. For instance, North
Americans know Tylenol, but Panadol is the
same stuff and known to everyone
everywhere else.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.32
Anti-inflammatories and Tylenol
Anti-inflammatories like ibuprofen (aka “Vitamin I” or Advil and Motrin) and aspirin can be
wonderful for controlling the pain of inflammation in the aftermath of a trauma. Unfortunately, as
discussed above, trigger points are not particularly an “inflammatory” condition, so antiinflammatories don’t seem to have a strong effect on them. The biochemistry of inflammation is
probably only partially similar to the biochemistry of trigger points. Therefore, there is only so
much that medications like aspirin and ibuprofen can do. It’s somewhat analogous to trying to
treat painful acne lesions with ibuprofen: it might take the edge off by masking the pain a little bit,
but basically it’s just not that relevant to the problem. 224
Voltaren gel, basically ibuprofen in an ointment form, deserves its very own section (see the next
section).
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
I’m including this diagram for the second time, to
emphasize that the biochemistry of trigger points is
different than the biochemistry of inflammation.
Nevertheless, since biochemistry is insanely complex, it’s also unpredictable, and some people
seem to luck out and find that anti-inflammatory medications actually do work somewhat well for
trigger point pain — which makes them worth experimenting with. And treating myofascial pain
syndrome is all about experimenting until you find the thing that works.
Another fairly obvious way that anti-inflammatory meds can be effective is if they successfully
reduce the inflammation of some irritated structure that is driving trigger point formation: if the
pills can reduce the irritation significantly over the course of a few days or weeks, the trigger points
might ease up!
And yet, in practice, only a small fraction of patients get lucky with this approach — maybe 10% —
and these drugs can also be pretty hard on your guts (ibuprofen is a gastrointestinal irritant).
Between their low overall effectiveness and the people who find the side effects intolerable, there’s
hardly anyone out there successfully self-treating their myofascial pain syndrome with vitamin I.
Acetaminophen (Tylenol and Anacin in the US, Efferalgan and Doliprane in Europe, Panadol in
many other places) seems to have little effect on trigger point pain … and they are now also
infamous for being hard on your liver. It’s become clear over the last few years that it’s a little more
dangerous than most people realize. 225 Except for a brief test of moderate dosages, I don’t
recommend trying to treat muscle pain with this drug — and definitely check with your doctor or
pharmacist about dosage and correct usage. (Note that acetaminophen is often combined in a pill
with codeine 226 , which is a whole different deal.)
Here’s comedian Louis CK satirizing a doctor talking about the pain-killer dilemma: “Oh, it’ll do
some intestinal damage after a while. But you’ve just got to weigh that against how much you like
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
your ankle not hurting!” And that’s assuming the drugs help! If they don’t, it’s not much of a
dilemma. The (hilarious) excerpt from Louis CK’s show, Chewed Up:
Incurable Shitty Ankle: Stretching & Pain Killers
1:00
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.33
Voltaren® Gel, an intriguing new option
Voltaren® Gel is neat stuff: an anti-inflammatory ointment that can be applied
only where it’s needed, delivering a dose of NSAID medication to exactly the
right spot, and only there — minimal, targeted dosing is the key to safety. It’s
an intriguing treatment option for trigger points — probably not much more likely to work
miracles than any other medication, but intriguing because it might work and it’s safe and cheap to
try. Available for years in Europe, but only approved by the FDA in 2007 for treating arthritic
joints, I think this is one of the best bang-for-buck treatment options for muscle pain.
In general, Voltaren® Gel will probably fail to amaze and delight you for the same reason that
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
other anti-inflammatory medications do: because trigger points are not an inflammatory problem.
On the other hand, it could also succeed for the same reason that ibuprofen occasionally does:
either your trigger points are more inflamed than other people’s trigger points, or you successfully
treat some inflamed and irritated tissue that is the real root of the problem.
The medicine gets into the trigger point by
soaking in through the skin and tissues. This is
both an advantage and a disadvantage. On the
one hand, the accuracy of delivery is one of
the things that makes it safe: you don’t have to
soak your entire system in medication in order
to get an effect. That makes it far safer than
taking the same medication orally. 227 You
might even be able to deliver a fairly large
dose of medication to the target tissue with
In general, Voltaren® Gel will probably fail to
amaze & delight you for the same reason
that other anti-inflammatory medications do:
because trigger points are not an
inflammatory problem.
multiple applications. Conceivably, this
concentrated and focused delivery — almost
like injecting the stuff 228 — could even have a therapeutic effect that a pill cannot, while still
remaining quite safe and not exposing your entire system to a high dose of medication.
On the other hand, deeper tissues are much less likely to be affected. Some trigger points in the
gluteal and low back musculature, for instance, may be a full inch or two under the skin — I am
not at all confident that an adequate dose of the medication would get there at all. But the very
common trigger points on the back of the forearm muscle (Massage Therapy for Tennis Elbow and
Wrist Pain) are just under the skin, and so they are an ideal place to experiment with Voltaren.
Although the effect of Voltaren on trigger points has not been studied — and probably never will
be — and it is not officially approved by anyone for this purpose — I think it’s worth trying, and an
interesting and potentially effective addition to your options. It’s not that I think Voltaren® Gel is
all that likely to be effective for muscle knots. But the cost-benefit analysis comes out pretty clearly
positive. Muscle knots are so common and so frustrating that every safe, cheap option that has the
slightest chance of helping is worth a shot.
Voltaren® Gel Review A useful rub-on anti-inflammatory medication for arthritis, tendonitis,
~ 3,250 words
bursitis, runner’s knee, and muscle strain
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
5.34
The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids
Opioids are the nuclear option for pain: codeine and more serious “hillbilly
heroin” (Oxycontin, Percocet, etc) can all induce deep relaxation, euphoria,
and making you “not care” about pain. (Opioids do not include the
infamous benzodiazepines, like Valium, discussed below in the muscle
relaxants section.)
Opioids are dangerous. Extremely dangerous. But, as with cars and
mountain climbing, some risks are worthwhile, and there is a vigorous
ongoing debate about how opioids should be used. For each patient, it
depends, and you need to talk to your doctor about it.
Ripening seed head of an
opium poppy.
Prescription opioid [DrugAbuse.com] abuse is causing so many deaths by
overdose that, in early 2016, the American Centers for Disease Control and
Prevention (CDC) decided it had to do something. They made many
© Albert Bridge, Creative
Commons Licence,
image cropped.
recommendations, including that opioids should not be considered an
option for chronic musculoskeletal pain. 229 That certainly includes the pain of trigger points.
The CDC’s position is strongly opposed by pain patient advocacy groups, because opioids
obviously do help many people. More cynically, perhaps they don’t want to lose funding from the
drug companies that make prescription opioids.
The danger can’t be overstated: it’s been called
the “opioid crisis” [Google search] repeatedly in
recent years, because deaths from opioid
overdose have tripled (in the US). 230 In fact,
since 2014, more Americans have died from
opioid overdoses than from car accidents — the
first time in decades that car accidents haven’t
been the number one cause of accidental
death.
Since 2014, more Americans have died from
opioid overdoses than from car accidents
— the first time in decades that car accidents
haven’t been the number one cause of
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
As if all the extreme danger wasn’t bad
accidental death.
enough, opioids just don’t work all that well.
It’s not that they don’t work at all, just not
nearly well enough or in the right ways for enough people. As with all drugs, the effects are
unpredictable. Some people are actually immune to (oral) opioids: they can’t get high that way at
all! 231 The scientific literature on this topic is a litany of disappointing results. The questionable
efficacy should be a major point of concern when discussing the opioid option with a doctor.
Demonizing”an entire class of drugs is usually a bad idea. It just might be in this case, given the
serious dangers, but not everyone gets addicted and nothing is all bad. Opioids still have an vital
place in pain management for some kinds of patients, especially acute traumatic pain, the
terminally ill, and unusually extreme pain where addiction is the lesser of evils, like some
neuralgias or complex regional pain syndrome.
But probably not for trigger points.
Opioids and myofascial pain syndrome specifically
The risks of opioids are probably greater for people with “mere” myofascial pain syndrome.
Myofascial pain syndrome does not rank high in the world of chronic pain. There are much more
savagely painful conditions, like pancreatic cancer, rheumatoid arthritis, or complex regional pain
syndrome. Although myofascial pain syndrome can be serious, very few cases, if any, are in the
same league as the really painful diseases. You should definitely be cautious about thinking that
you might need opioids to manage MPS: it rarely warrants the risks, and maybe never.
That said, opioids might help muscle pain in two ways:
1. they lower muscle tone overall, which may actually have a direct therapeutic effect on trigger
points
2. they tend to make you feel good about life, the universe, and everything … which could have a
therapeutic effect by reducing some of the stress that is an aggravating factor for so many trigger
points
The potential benefits are just speculation. Anecdotally, people report to me that opioids are
somewhat helpful. Scientifically, no one has any idea.
What about really severe myofascial pain syndrome?
Really severe myofascial pain syndrome is basically indistinguishable from fibromyalgia. As
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
discussed in the introduction, they may or may not actually be different. But if they are the same …
fibromyalgia is notoriously unresponsive to opioids. If your particular case of “myofascial pain
syndrome” involves other classic symptoms of fibromyalgia, especially serious fatigue and mental
fog … probably best to stay away from opioids. (For more detailed information about fibromyalgia
symptoms, see A Rational Guide to Fibromyalgia: The science of the mysterious disease of pain,
exhaustion, and mental fog.)
If you don’t obviously have other fibromyalgia-ish symptoms, then they might be worth the risks. If
you still want to consider trying opioids for your pain, find a doctor who respects opioids as a
powerful tool to be used with extreme caution, if at all. Consider refusing a prescription from any
doctor who does not raise the serious concerns.
This section is a simplified version of a more detailed article about opioids:
Opioids for Chronic Aches & Pains The nuclear option: “Hillbilly heroin” (Oxycontin), codeine
~ 4,000 words
and other opioids for musculoskeletal problems like neck and back pain
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.35
The surprising futility of muscle relaxants such as Robax-whatever, Valium and other
benzodiazepines
“Muscle relaxant” is an odd category of drug. There are several drugs of other types that reduce
muscle tone — like alcohol, say — but they are not considered “muscle relaxants” because they are
not interfering with muscle contraction. A true muscle relaxant is essentially a poison that messes
directly with muscle physiology.
If you think about that for just a moment, you’ll realize that you really don’t want too much muscle
relaxant. Amazonians used a muscle relaxant … on their poison arrows. Curare poison relaxes you
to death. European explorers encountered the stuff early in their visits to North America, and it led
to some of the earliest scientific studies in pharmacology.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
The most famous muscle relaxant is diazepam — aka Valium, a benzodiazapene — along with
several other well-known drugs like Klonopin, Ativan, and Xanax. Like the opioids, the benzos are
another “nuclear option” — they interfere with muscle contraction, 232 but they also interfere
with a great deal else: like consciousness! And, like the opioids, they are also highly addictive due
to the intense feeling of well-being they cause. Like the opioids, the benzodiazepines are complex
drugs with many effects, both known therapeutic effects and unwanted side effects.
There are also muscle relaxants that aim to
reduce muscle contraction without doping you
up. Such muscle relaxants are only widely
available without a prescription in the form of
methocarbamol, best known in
Robaxin/Robaxacet and their sister drugs, all
of which are mixtures of methocarbamol with
Amazonians used a muscle relaxant … on
their poison arrows. Curare poison relaxes
you to death.
some other pain-reliever, such as
acetaminophen or ibuprofen. The point of
methocarbamol is muscle relaxation without drowsiness.
There are also some prescription muscle relaxants, none of which are all that familiar to consumers:
carisoprodol (Soma), cyclobenzaprine (Flexeril), metaxalone (Skelaxin), and methocarbamol. Some
of these are marketed specifically as remedies for muscle pain. 233 For instance, King
Pharmaceuticals claims that Skelaxin produces “fast relief for muscle spasms and back pain.”
And then there’s Botox — the infamous face-paralyzing drug of the stars! Botox is a special case,
quite different from the other muscle relaxants. Like curare on poison arrows, Botox is
outrageously toxic and doesn’t “relax” muscles but outright paralyzes them, even in small doses. I
discuss Botox in its own section.
The relevance of a muscle relaxant to trigger points seems obvious: a trigger point is a zone of
intensely contracted muscle, ergo muscle relaxation should help it. Right?
Wrong! Alas, apparently it’s not that simple. (Is it ever?) Drs. Travell and Simons comment rather
emphatically on this, sternly concluding “we see no rationale for muscle relaxants in the treatment
of myofascial pain caused by trigger points.” 234 Clinical evidence is damning as well as expert
opinion. Robaxin 235 and Skelaxin do not produce “fast relief for muscle spasms and back pain” to
any meaningful degree. Botox does not appear to either, despite its good reputation for exactly that
purpose. There is “strong evidence” that muscle relaxants do some good … but only a little tiny bit.
Some are probably a bit better than nothing
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
(better than a placebo) — which is certainly
worth knowing — but not by a lot, and
certainly not all of them, and that’s the takehome message. For instance, although on the
one hand there is some good research showing
that muscle relaxants provide a modest benefit
in conditions where muscle pain is probably
often a significant factor (i.e. neck and back
pain), it’s a really minor benefit, shown by
Drs. Travell & Simons comment rather
emphatically on this, sternly concluding “we
see no rationale for muscle relaxants in the
treatment of myofascial pain caused by
trigger points.”
other good research that muscle relaxants
aren’t even as effective as ibuprofen, or no
more effective. 236 A medication that can’t outperform ibuprofen is basically a waste of time,
because obviously ibuprofen is no cure for any of the common chronic pain problems.
A 2008 physician tutorial in American Family Physician 237 sums up the blah state of the evidence:
Skeletal muscle relaxants are widely used in treating musculoskeletal conditions.
However, evidence of their effectiveness consists mainly of studies with poor
methodologic design. In addition, these drugs have not been proven to be superior to
acetaminophen or nonsteroidal anti-inflammatory drugs for low back pain.
And “skeletal muscle relaxants should not be the primary drug class of choice for musculoskeletal
conditions.”
But the case against muscle relaxants gets even stronger and even stranger: how much does the
effect of a medication depend on what you are told about it? Quite a bit, apparently! A strange and
fascinating 1999 study in Psychosomatic Medicine showed that a muscle relaxant actually increases
tension when the patient is told (lied to) that it is actually a stimulant — the information actually
results in the opposite of the intended effect of the drug. But the reverse was not true: subjects did
not actually enjoy any notable benefit from the muscle relaxant, even when they were told that it
was relaxing. They relaxed, but no more than people who had taken a placebo, and in some cases
the placebo was more relaxing. 238 All of this strongly emphasizes that your central nervous
system is the boss of your muscle tone, almost no matter what is circulating in your blood stream.
Even deep anasesthesia can’t over-rule your brain on muscle tone — it is a (fascinating) myth that
muscles are actually paralyzed by anaesthesia. 239
(That study contained many other gems of lovely weirdness, such as the bizarre fact that quite a lot
more muscle relaxant was found in the blood of people who had been told that the muscle relaxant
was a muscle relaxant. It appears that they literally soaked up more of the stuff from the GI tract
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
when they believed that it was a relaxant! Cool! And yet it still didn’t actually relax them much.)
If muscle relaxants help pain problems that involve trigger points, it should be dead easy to prove
it. The lack of such evidence is damning. It’s also damning that there doesn’t seem to be much
difference between muscle relaxants: “Comparison studies have not shown one skeletal muscle
relaxant to be superior to another.” So we have a class of drugs that shows little sign of effect, no
matter which flavour you use. Whoop-de-do!
Some speculation about why muscle relaxants don’t seem to work all that well:
Trigger points are extremely contracted: perhaps far too much to be touched by a modest reduction
in overall muscle tone. Suppose a muscle relaxant reduces muscle tone by 20% on average — a
huge number, probably far more than you would actually want. Yet a 20% reduction in the tone of
a trigger point still leaves you with 80% of an agonizingly toxic trigger point!
Trigger points and muscle tone are only related concepts. It might actually be possible to have low
overall muscle tone, and yet still have full-power muscle knots.
Even if muscle relaxants significantly reduced contraction within trigger points, they might have
little to no effect on their local toxicity: a temporarily relaxed but still toxic patch of muscle tissue
would probably start contracting again as the drug wears off.
To the small extent that muscle relaxants help common painful conditions, it’s probably due to
miscellaneous effects that have nothing to do with trigger points. For instance, they may relieve
some true, painful muscle spasm associated with trigger points. Or the euphoria caused by a benzo
like Valium may relieve stress and reduce pain perception.
But then there’s the side effects: “Adverse
effects, particularly dizziness and drowsiness,
are consistently reported with all skeletal
muscle relaxants.” My emphasis.
Oh, and they are all potentially addictive, too.
To the small extent that muscle relaxants
help common painful conditions, it’s probably
Especially the benzos!
due to miscellaneous effects that have
The bottom line? As with most of the
nothing to do with trigger points.
pharmaceutical options discussed in this
section: it might be worth a careful try with
physician supervision, but keep your expectations low for the muscle relaxants.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
5.36
Lidocaine patches
Lidocaine patches allow lidocaine to seep through the skin, rather than being injected.
Unfortunately, they have not been proven effective for anything, let alone trigger points. 240 They
are mainly used to treat post-herpetic neuralgia, but do not clearly seem to work even for that.
Lidocaine works by suppressing electrical activity in nerves — sodium channel blockade — and
this might be relevant to trigger points, which may show abnormal electrical characteristics. It’s a
reasonable reason, but also quite this. As always with medicine, you simply have to test it …
As of 2016, there are only three half decent trials — which is
practically nothing, really — of lidocaine for myofascial pain
syndrome. 241 242 243 They are all technically positive, but not
remotely decisive: Linde concluded that “probably superior to
the placebo patch,” but I’m not sure why, based on their data;
Firmani et al think their results “support” lidocaine patches, but
again they seem surprisingly optimistic; and Affaitati et al
declared them “effective,” but based on modest improvements
Patches give good placebo Bear in mind
that patches (as a delivery system for any
drug) can undoubtedly drive a potent
placebo effect, because they seem like
“targeted” medicine. While not quite as
serious as an injection, they are more
precise than a pill, a “special delivery” of
hope right to the site of the trouble.
that were statistically but not clinically significant.
So, “meh.” This is how it almost always goes with treatments that researchers study in a wishfulthinking way.
But lidocaine patches are fairly safe and reasonably cheap, so I see little harm in experimenting
with them, if you can talk a doctor into prescribing them for this purpose.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.37
Combination treatments: why and how to throw everything at it but the kitchen sink
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Applying pressure to trigger points is the only self-treatment method that we’ve discussed so far
that actually has a respectable potential to single-handedly release trigger points. All of the others
will fail on their own, most of the time. So, enter the combo treatment. The ol’ one two. The ol’ one,
two, three, four, five …
Serious trigger point therapists must combine partially effective strategies for a total effect that is
more potent. Here are three quick examples of combination therapies:
The bath trick, previously described: don’t just massage — massage in a hot bath.
Mobilizations and then stretch and then pressure and then more stretching and then finish with
mobilizations — the “wiggle, stretch, rub, stretch, wiggle” combo.
One minute of bioenergetic breathing, then five minutes of meditation, then five minutes of selfmassage.
It’s easy to imagine how those combinations could be more effective than any isolated treatment,
isn’t it?
Some combinations are so powerful that they should probably not be considered “combinations”
so much as simply good technique. In the same sense that boxing without combinations is not
really boxing, self-treating trigger points without at least some combinations is not really selftreating. For instance, consider breathing: you should probably always breathe deeply when you’re
releasing trigger points, as opposed to optionally throwing it in.
Test individual components of effective
therapy individually, and over time rate their
effectiveness. If you seem to get quite good
bang for buck from stretching, but
mobilizations never seem to do much for you,
Self-treating trigger points without at least
some combinations is not really self-treating.
then include stretching in your combos but not
mobilizations — or vice versa if you have the
opposite results.
This simple concept of combining treatments is what nearly every patient who’s “tried everything”
has not yet tried. Most people, even experienced patients, haven’t even tried half the things
recommended in this tutorial. Almost none of them have gotten into combinations seriously —
maybe just a little, almost a coincidental effort, as in the case of people who have a hot shower in
the morning and then feel naturally inspired to mobilize. That’s a combo treatment, and they
probably see the benefit of the combination, but don’t think of the combination as a strategy that
they can elaborate on.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Almost 10 times out of 10 that I’m coaching patients on how to self-treat their trigger points, it
turns into “let’s review the key self-treatments … and now you need to combine them.”
“Oh!” they say. It’s always a little bit of a surprise for some reason! “Okay. I guess that makes a lot
of sense.”
Now, go combine.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.38
Troubleshooting referred pain: the referred pain field guide
As established already in several ways, referred pain can completely fool both you and the best help
you can find. “Advanced troubleshooting” for trigger point therapy means nothing if I don’t equip
you with some knowledge and tools for beating it. For an amazing great referred pain story, see the
extra section after this one.
It’s routine, even for trigger point therapists, to waste energy and your money barking up the
wrong tree, massaging where it hurts instead of where the pain is coming from.
To be a self-treatment expert, you have to have some idea of how to find the real source of pain.
There are two basic methods, and you should use both:
1. Look it up.
2. Make an educated guess. (Guidelines below.)
Note that these are the same methods I use. In fact, they are the same methods every trigger point
therapist uses.
There are many medical charts on the market that show common
referred pain patterns in detail. And Clair and Amber Davies’ popular
book, The Trigger Point Therapy Workbook, is a muscle-by-muscle, regionby-region reference — that’s its primary advantage over this tutorial.
But, remember, I’ve deliberately left reference material out of this
tutorial.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
And you should also just “guess.” Referred pain can seem very strange,
but it tends to follow some patterns. Here are some guidelines and
principles (which is what this tutorial is all about):
Trigger points are usually inside the pain pattern. The trigger point is usually located somewhere
inside the area that actually hurts. This is very helpful to know. It means that you can usually count
on a trigger point being located somewhere in the area that hurts, probably about 9 times out of 10. It
may fool you by not being at the epicentre of the problem — it may be way out on the edge as in the
“heart attack” story previously discussed — but it will usually be somewhere in that zone.
Trigger points are usually on the same side as the pain pattern. Referred pain does cross the
midline of the body. However, it’s unusual. At least 90% of the time, you’ll find both the trigger
point and your symptoms on the same side of the body.
Trigger points are usually medial to the pain pattern. That is, they are more likely to be closer to
the centre of the body than the pain. If they are inside the pattern, they are much more likely to be
in the inside half rather than the outside half.
Trigger points are usually proximal to the pain pattern. “Proximal” means “closer to the trunk”
than something else. Your elbow is “proximal” to your hand. Your hip is “proximal” to your knee.
The opposite term is “distal” — your toes are the most distal parts of your body. Referred pain is
almost always distal to a more proximal trigger point. Here’s three quick examples:
1. Trigger points in the forearm refer pain down the forearm and into the hand and fingers.
2. Trigger points in the low back and hips refer pain down into the legs.
3. And a trickier one: trigger points in the neck often refer up — distally, away from the trunk — into
the head. However, it does get confusing in that area. Some neck trigger points always refer
downwards.
These guidelines can be pretty powerful! You can save a lot of time if you know that, in a case of
knee pain, it’s virtually pointless to look for trigger points below the knee — there are no trigger
points that refer up the leg. With these guidelines, you can avoid wasting time looking for a trigger
point in the biceps as a possible cause of your head pain — that would be extraordinary.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Nothing seems to be impossible with referred pain. Over the years, I’ve observed a few “freaky”
referred pain patterns that break all the rules — a left foot trigger point that refers pain into the
right shoulder (seriously, I’ve seen that). However, the vast majority of the time, referred pain goes
by the book. As long as you know “the book,” it’s not all that hard to track them down.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.39
Case study: referred pain causes a “heart attack” and completely fools dozens of
professionals
James is a jolly registered nurse in his forties with a massive, bear-like physique. He is so big and
thick that it’s all I can do to apply enough pressure to his muscles that he can tell I’m doing
anything. I can basically beat on him with all my strength, and he’ll still say things like, “Could I
get any more pressure on that spot? If you can.” He’s tough.
But one morning James woke with sickening, vicious pain in his upper, lateral chest and spreading
down his left arm — classic heart attack pain. He called an ambulance and spent forty-eight hours
in a hospital, ministered to by his baffled colleagues. He was not having a heart attack. His doctor
finally sent him home, saying, “We don’t know what’s wrong with you, but, whatever it is, it’s not
going to kill you today.”
Except it was “killing” him — the pain hadn’t let up one bit. It was still like the pain of a heart
attack, just without the heart attack! By coincidence, he had an appointment with me the next day,
which he came to, looking pale and exhausted. He told his story, without the slightest expectation
that I would have any professional input.
I did have professional input.
“Sounds like it could be a trigger point, James,” I said. “Mind if I have a look?”
In less than a minute, I had my finger on a tiny, exquisitely sensitive nodule along the length of a
taut band in his medial pectoralis major muscle. The muscle twitched violently when I hit it, and
James jumped like I’d given his heart a shock.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
“Holy %$#@*!” he cried out. “That’s it!”
With only gentle pressure applied, severe sickening pain spread out from the trigger point like a
toxic waste spill. The epicentre of the pain was several centimetres lateral to the trigger point. The
trigger point itself was sensitive when pressed, but there was no pain in that location — just the most
medial fringes of his symptoms reached the actual location of the trigger point. 99% of the pain
generated from that spot was elsewhere — the side of the chest, the shoulder, the arm.
The trigger point released quickly. It was nasty, but new, not well-established enough to pose
much of a problem … as long as you knew where to look for it. In twenty minutes we reduced the
“heart attack” pain by 80%. The next day it was gone, and two years later it had still not come back.
What would have happened to James if I hadn’t known to look where I looked? As a regular in my
office, with mid-back trigger points that I can’t get rid of in twenty minutes, he was no stranger to
trigger points, but he failed to even identify the pain as a trigger point problem, let alone which
trigger point. In three days of agony, his instincts had not led him to try pressing on his medial
pectoralis major muscle. Would he have tried in another three days?
Maybe. Maybe not.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
5.40
Troubleshooting negative reactions to treatment
Unfortunately, negative reactions are a common problem with treating more cantankerous trigger
points. Just as trigger points have the potential to respond positively to virtually any stimulus, they
also have the potential to get worse in response to nearly anything. One of the most common
concerns I hear from my patients and readers goes like this:
I’ve tried to self-treat my trigger points, but every time I do it I end up feeling like I’ve
been beaten up.
lots of people
Intense massage therapy can do some harm. 244 But do not panic! Most negative reactions are
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
probably not so bad after all, and may even be a counter-intuitively good sign. It is still possible to
make progress in trigger point therapy even if you are getting nasty reactions. The trick is to know
when to ease up or give up, and when to press on. And for that you have to have a reasonably
good understanding of what’s going on, and some decent thumb rules.
Some kinds of bad reactions to massage are quite typical. These should not be overly discouraging:
mild wooziness, headaches, fatigue and malaise are common responses to massage
a mild bruised feeling, similar to the soreness following an unusually hard workout, is common
and harmless when you’re not used to being massaged
moderate short-term aggravation of symptoms — the trigger points actually getting slightly worse,
instead of better — occurs in about 50% of cases in the early stages, and doesn’t necessarily mean
anything
bruising is fairly common, but doesn’t usually mean much
Most of those symptoms can be generally explained by a slightly toxic state known as
rhabdomyolysis, or just “rhabdo” — the mild cousin of a much more serious medical condition.
Massage is not a detox treatment. If anything, it’s the opposite! Post-massage soreness and malaise
(PMSM) is probably caused by mild rhabdomyolysis (“rhabdo”). True rhabdo is a medical
emergency caused by muscle crush injuries. But milder stresses cause milder rhabdo — even just
intense exercise can do it. And massage! We know this from a good formal case study, several
informal ones, common exertional rhabdo, and the similarities between PMSM and ordinary
exercise soreness. A rhabdo cocktail of waste metabolites and by-products of tissue damage is
probably why we feel cruddy after any intense biological stress or trauma — but they can’t be
“flushed” away by massage (or by drinking water).
The rhabdo problem is on pretty firm scientific ground, and the case study I referred to is
particularly persuasive — an 88-year old man who got an unusually extreme massage, and ended
up with a dangerous case of rhabdo. 245 If extreme massage can do that, it’s a sure bet that all
strong massage is wreaking at least a little of the same kind of havoc. See Poisoned by Massage for
much more detail on this topic.
More speculatively — but reasonably — the rhabdo might be worse when you’ve got a lot of
trigger points.
Trigger points, rhabdo and healing crisis
The tissue of trigger points may be in a poor state, with waste metabolites already present in force
before anyone starts massaging, and probably more vulnerable. There’s even some evidence that
the tissue of a trigger point is physically fragile, and treatment may really traumatize cells — which
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
would certainly liberate a nastier “rhabdo cocktail” of molecules into the bloodstream when
squeezed, like a popped zit squirting pus. Even if the trigger point is neutralized at this point —
even if it stops “revving” metabolically and producing more waste product — it will take some
time to clear out the sewage from the area.
(The number and severity of trigger points might even be one of the key variables that makes some
people more vulnerable to PMSM than others. More trigger points, more PMSM? There’s a good
question for a researcher to work on.)
It also means that the tissue might have more actual post-massage healing to do. Hopefully, when
the tissue repairs itself, the trigger point does not return, or does not return quickly. But if cells are
actually broken, obviously the spot will feel irritable as it heals. So this is certainly a “healing crisis”
— treatment may actually work by “nuking” the trigger point with trauma that temporarily makes
it feel worse, temporarily disguising the fact that the situation has improved.
A lot of ifs and maybes in there. But that’s the best we can do.
Advertising the idea of a normal “healing crisis” as part of trigger point therapy worries me, even
though it is defensible. It’s an abused cliché in alternative medicine, and often a harmful one 246
— most healing processes do not involve feeling worse before you feel better. However, trigger
point massage may actually be one of the exceptions that proves the rule. Many patients do indeed
seem to feel improvement after a day or two of significant discomfort.
How bad a negative reaction should you tolerate?
There are certainly limits to how painful a trigger point should be in the hours and days following
treatment. If you have a negative reaction involving a lot of pain, say, anything more than 50% of
your pre-treatment symptoms, what you’re experiencing is probably actual aggravation of the
trigger point — and an aggravated (intensified) trigger point can hurt a lot. By contrast, a puddle of
caustic trigger point remains is simply not going to hurt as much as an active, pissed-off trigger
point!
Here are three ways that you might be able to tell the difference between a “true” negative
reaction, and healing crisis:
1. The quality and intensity of the negative reaction contain valuable clues. The pain of a truly
activated/irritated trigger point will be very similar to your normal symptoms, just worse! By
contrast the pain of a trigger point that has actually been deactivated, but the tissue in the area is
still irritated, will tend to feel more like inflammation and/or bruising.
2. Another distinguishing feature is the duration. A proper healing crisis should resolve quickly and
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
steadily, showing clear improvement within two days. A negative reaction that tends to persist
beyond two days, or which only fades back to the intensity of your original symptoms — no net
improvement — almost certainly indicates that it is actually a negative reaction to a failed treatment.
3. The appearance of similar symptoms, but in new locations, is a particularly interesting case of a
negative reaction that probably isn’t really a negative reaction. As long as they aren’t too severe
and/or persistent, new symptoms may be the best possible reaction to treatment short of simply
being cured. Why? Because it usually means that your highest priority trigger points are
responding positively to therapy, and your brain has decided to move on to other concerns: i.e. the
next worst muscle pains you have. This is sensory triage, and your nervous system is very good at
it. It’s usually a strong sign of progress! However, it can be confusing, especially if the new pain is
particularly close to the old pain. 247
Other kinds of bad reactions
So far I’ve just discussed excessively painful reactions. But other kinds of negative reactions can be
bad news, too. More serious versions of the normal negative reactions top the list: dizziness,
headaches, and nausea are particularly of concern.
These symptoms, if they are mild and resolve quickly, are probably just particularly bad PMSM —
more rhabdomyolysis than usual, but mostly just a sign that treatment intensity should probably
be dialed back a notch or two. However, if dizziness, headaches, and/or nausea happen at all, they
should be mild or temporary. If they are severe or do not steadily fade over 1-2 days, you should be
concerned.
If you vomit or feel extremely disoriented or dizzy after an
appointment, you should consider it a potential medical
emergency. Please note, I have never had a vomiting client
myself. But it does happen, and rarely in a good way. Sometimes
people are just prone to more dramatically woozy reactions to an
intense treatment (vasovagal syncope), 248 but even then it’s
usually a milder reaction, more like a nasty swoon. But if you
feel really terrible and it doesn’t steadily ease up, then you should
get to a doctor immediately.
If your symptoms are significantly aggravated for more than a
Severe or persistent dizziness, headaches,
or nausea are important warning signs! Do
not brush off these symptoms as “normal”
reactions to trigger point therapy. There are
absolutely no circumstances in which these
symptoms can be considered a normal,
healthy reaction. It’s acceptable to have a
little of them — woozy, groggy, queasy —
but if you are actually impaired to any
significant degree by such symptoms
following trigger point therapy, please
few hours, if you feel extremely tender, or if you have major
immediately consult your physician. For an
bruising, that’s not a good sign either.
interesting example of this kind of negative
Most genuinely negative, no-benefit-involved reactions to
reaction following a massage, see What
Happened To My Barber?
treatment can usually be resolved simply by refining your
treatment methods. 249 I have had many successful experiences with clients who initially claimed
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
that it was “impossible” to massage a certain area of their body without a negative reaction. In
virtually every case, it’s simply a matter of experimenting gently and building trust. Before they
know it, trigger points that seemed to “freak out” are suddenly easing for the first time.
In self-treatment, you’re usually less anxious — after all, you’re
in charge. You know you’re only going to be so rough with
yourself. However, if you’ve experienced nothing but negative
reactions, and you don’t know how to prevent it, you can pretty
quickly get into a head space where results seem impossible …
which, interestingly enough, tends to make it quite hard to get
results.
Avoiding basic treatment mistakes and having generally good
technique is critical, of course, to preventing negative reactions.
There’s every possibility that negative reactions can be
Why “build trust”? Other than the fact that
it’s just nice to trust your therapist …
emotional context is surprisingly relevant to
trigger point therapy! If you feel confident
and safe, trigger points are a lot less likely
to react negatively to treatment. And for
people who have learned the hard way to
fear therapy, for people who’ve been
treated roughly and impatiently by
previous therapists and suffered for days
afterwards, there is virtually no hope of
eliminated not with specific reaction-eliminating strategies, but
successful treatment until the traumatized
simply by getting more skilled with self-massage. So, to avoid
patient discovers through experience that
negative reactions, study this tutorial carefully and learn
massage sessions are safe and pleasant.
everything there is to know about effective self-treatment!
However, the promise of this tutorial is also to help you troubleshoot every possible problem. So,
here are three specific tips for avoiding negative reactions:
Above all, less treatment. Less pressure, shorter sessions, fewer sessions … whatever it takes.
Trust me, there is some level of treatment that will not cause a negative reaction. Whatever you can do
that doesn’t provoke a negative reaction, then that’s what you do. If you have to back off so much
that it seems like you aren’t even doing anything: everything about your biology is designed to
adapt to stimulation and stresses. If you gradually add intensity to treatment, your trigger points
will adapt. It may start slowly, but it’ll happen!
Or even don’t “treat” at all — not with self-massage. In the sections below you will find many
non-massage treatment methods, such as hot baths and mobilizations. A great way to avoid negative
reactions is to stay away from “poky,” self-massaging treatment entirely, for a while. A few days of
other, gentler approaches, and you will probably find that you are much more tolerant of pressure.
Greater diligence with combo treatments. People with cranky, reactive trigger points need to
place greater emphasis on treatment that isn’t just 5 minutes of digging in, but is a well-designed
session combining a number of positive elements: i.e. 2 minutes of meditation and deep breathing
and heating, followed by 2 minutes of mobilizing, followed by 2 minutes of gentle massage,
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
followed by a hot shower, and then another 2 minutes of treatment. This kind of approach is
covered pretty thoroughly in the combination treatments section.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
Part 6
PERPETUATING FACTORS
What makes trigger points stubborn?
Many stubborn trigger points are not so tough once you understand and eliminate the perpetuating
factors — the (evil!) forces in your life that cause trigger points to form in the first place, and then
keep them going. Typical perpetuators are nutritional and hormone deficiencies, other sources of
pain (such as a slow healing injury), muscle fatigue or stagnation or alternating between them
(weekend warriorism), awkward working postures and positions, sleep deprivation, and so on.
Unfortunately, there is a bottomless pit of possibilities in trying to understand, identify and purge
such factors from your life. Most advanced trigger point troubleshooting is all about trying to
identify and eliminate these perpetuating factors. They are divided into two broad categories — the
medical and non-medical. The medical factors are usually the most important but also most
difficult to diagnose, and they are covered in chapters below by Dr. Tim Taylor. Don’t be fooled
into thinking they are less important just because they aren’t described first — they are actually the
most important factors for people with serious cases of chronic pain. But I will kick things off with
the next several chapters about the more obvious perpetuators of pain — the most important factors
for the average person with average muscle pain. To begin this journey, please chant with me:
Trigger points come back for the same reasons that they formed in the first place!
Trigger points come back for the same reasons that they formed in the first place!
Trigger points come back for the same reasons that they formed in the first place!
Usually. Sooner or later.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Roughly 20% of people who come to see me with a straightforward case of trigger point pain are
the “lucky ones” who get quick and lasting relief of more than 6 months. Of those, perhaps one
third will never feel that pain again, or they will self-treat it so effectively that it is never much more
than an annoyance. The remainder will get the pain again, probably within a year or two …
because of perpetuating factors.
Perpetuating factors are numerous and often require special knowledge to recognize their
importance to trigger points. They are commonly overlooked and neglected. In patients
with chronic myofascial pain syndrome, attention to perpetuating factors often spells the
difference between successful and failed therapy.
Travell & Simons, Myofascial Pain and Dysfunction, p178
Here are three typical examples to help illustrate how this works:
Renee is a receptionist with headaches caused by trigger points in her neck muscles. One hour of
therapy once per week for a month “resolves” her headaches in the short term, but there’s nothing
she can do about her bad chair at work. 250 So, three months later she’s right back where she
started. This is the most typical scenario — trigger point therapy “works,” but not for long. For
Renee, a maintenance treatment every six to eight weeks would probably be enough to keep her free
of headaches for years. Is this “effective” therapy?
George is a workaholic executive with headaches just like Renee’s, except that severe emotional
stress, terrible working posture (he’s got a computer monitor that forces him to look up), and
weekend warrior-ism make treatment relatively futile. For a while he comes for therapy weekly,
and feels terrific for two or three days after every appointment … but then he hits the slopes after a
week of slouching in front of a computer, and every trigger point comes screaming back. He
actually loses ground, but he keeps making appointments for “damage control.” Is this effective
therapy?
Claire is another executive, but she does a good job of balancing work and play. A low-velocity car
accident gives her a bit of whiplash, however, and she heals too slowly. Treatment resolves the
problem completely in three appointments, because she isn’t doing anything that aggravates her
neck.
The next few sections will troubleshoot the most common and
obvious perpetuating factors. But first, an overview of all
perpetuating factors. Check off the ones that you have. Any more
than 2 or 3 is significant!
Where have I seen this list before? You
saw a similar list earlier in the tutorial: the
list of things that cause trigger points
(trigger for trigger points). However, now
we’re discussing the causes of trigger points
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Once again, medical factors, especially nutritional and
hormonal deficiencies. Of course, most medical factors are
unknowable without proper testing, so you can’t check this
one off — I’m including it here just to keep reminding you
that there are such factors. Once again, they will be covered
in Dr. Tim Taylor’s section of this book.
more in the context of their common
manifestations in life. For instance,
“sustained muscle shortening” is a direct
trigger for trigger points — but what are the
common circumstances in life where your
muscles are shortened too much? What’s
the general practical implication?
Pain from any other cause, and other chronic health problems.
Anything that stresses the system seems to increase trigger
point pain, but there are conditions that seem to more directly aggravate trigger points. A classic
example is fibromyalgia, which is usually complicated by many severe and stubborn trigger points.
Some of the worst perpetuating factors are in this class.
Muscle fatigue, over-exertion, over-stretch. Anything that pushes your muscle tissue to its limits may
aggravate your trigger points. Serious athletics and intense manual labour may perpetuate trigger
points. Rather than being unusually healthy, people who constantly over-exert themselves often
struggle constantly with muscle pain. “Fitness” does not necessarily mean “painless”!
Weekend warrior-ism. Yo-yoing between a sedentary life and
intense muscular activity seems to be even worse than the
extremes themselves. If your muscle tissues are stagnant in an
office chair all week, and then pushed to their limits for three
hours on Saturday, trigger point trouble is even more likely than
if you’d only been a couch potato or if you worked out
excessively every day.
Insomnia and shift work are the most common cause of serious
sleep deprivation/disturbance, which are major trigger point
generators. Since this is such a common problem, it tops the list
of serious yet manageable troubleshooting goals.
Psychological stress, especially anxiety about pain itself, has
numerous consequences that lead in complex ways to trigger
point aggravation. The more upset you are psychologically, the
more likely that you’ll have noisy trigger points. There are many
ways to learn to chill out — and a lot of books all about it — but
it’s reassuring for many people to know that they do not
necessarily require an interest in meditation and yoga. A variety
of other options are explored below, in the context of eliminating
stress as a perpetuating factor.
Poor posture and anatomical asymmetries (being crooked) may be
important in some cases, but are extremely difficult to
troubleshoot. A firm diagnosis of the exact nature of your
postural problems is usually almost impossible to obtain —
professionals will almost invariably disagree — and fixing the
alleged problem is rarely straightforward and often just
physically or neurologically impossible.
Poor ergonomics, or inherently awkward working postures cause
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
PRO A disagreement about the
importance of crookedness. While this
entire document is significantly inspired
by the work of Drs. Travell and Simons,
the Big Red Books are old and have many
problems. One of the most glaring
differences between my opinion and
theirs concerns the clinical importance of
“crookedness” — that is, anatomical
asymmetries and/or chronically poor
posture.
I do not believe that these things matter
much, while Travell and Simons believe
that they can be “potent perpetuators of
trigger points.” While they go on for
pages about it, I have a long article
devoted to pretty much the opposite.
Crookedness is not always unimportant,
of course. It surely is a factor in at least
some pain problems, and a major factor in
a few — I just don’t agree that they are
major factors in most cases, and I think
that there are serious practical problems
The Complete Guide to Trigger Points & Myofascial Pain (2019)
problems for the same reasons as poor posture and being
crooked, but they are much easier to troubleshoot.
with treating myofascial pain syndrome
as a crookedness problem. Therefore, you
won’t find it discussed in detail in this
tutorial.
6.1
Troubleshooting “stuck” trigger points — adhesions and contracture
Recently I was speaking with a client, in his early thirties, who
wanted my opinion of his massage therapist’s diagnosis.
“Apparently my muscles are contractured,” he said. “He says
my back muscles are really hard and ropy and the only thing we
can do is try to break it up. What do you think?”
I think back muscles are routinely hard and ropy without
contracture. I think it’s almost impossible for a fairly young man
to have anything we would call “contracture.” I think that
practically everyone over the age of 16 has “hard and ropy” back
muscles. Back muscles are naturally pretty hard and ropy,
Quick Review of Adhesions &
Contracture Adhesions are sticky
molecular bonds between the hydrogen
atoms that carpet the surface of connective
tissues. The longer tissue is stagnant, the
more hydrogen bonds form, and a Velcrolike stickiness begins to make it harder and
harder for the tissues to separate. Over a
period of years, adhesions in and near
trigger points can progress to a point where
the trigger point is physically bound into a
especially in certain body types. And if you’ve got trigger
shortened position (“contracture”), even if it
points? They are guaranteed to feel “hard and ropy,” because
is deactivated. See the adhesions section for
trigger points always cinch up the muscle cells on either side of
complete details.
them, creating the taut strap of muscle that is diagnostic of trigger
points.
So a therapist should never feel a tight strap and say, “You’re contractured.” Trigger points do not
generally involve a true whole-muscle contracture, let alone scar tissue (as often claimed by
therapists). There has to be other evidence of adhesions or contracture. Here’s a checklist for
identifying “sticky” trigger points.
Adhered trigger points tend to be old trigger points. For adhesion to be a factor, a severe trigger
point would probably have to exist in the tissues more or less continuously for at least a few years,
and a milder trigger point would have to be fairly constant for at least a decade. 251
Adhered trigger points tend to occur in older people. Age is definitely a factor as well. Clinically
significant adhesions become much more likely with advancing age. A senior will develop
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
adhesions much more quickly than a middle-aged patient. People in their teens and twenties are
unlikely to develop any significant adhesions at all, even with nasty trigger points.
Adhered trigger points don’t release well. Of course, there’s a lot of other reasons why trigger
points might not release: to the extent that you feel you’ve eliminated other concerns, a trigger
point that still won’t release may be adhered.
Adhered trigger points usually feel harder and more fibrous. This is a loose guideline. Nonadhered trigger points can still be plenty hard. And not every adhered trigger point feels like a
rock. But generally speaking there is a greater hardness in the adhered trigger point.
Crunchy, crinkly texture. When adhesions break, you can feel a kind of “giving way,” a crunchy,
crinkly, crackly sensation as fibres pull apart, as skin tears away from the tissue below it. It can be
subtle or dramatic. Full-blown adhesions are harder to break, so you’re actually less likely to notice
this phenomenon in the worst cases, and more likely to notice it as it’s developing. Also, it may
occur in the area around the trigger point.
None of these is a “dead giveaway.” It is almost impossible to confidently diagnose adhered trigger
points. You can only be sort of sure. So, if you’re sort of sure, what do you do about it? The
technique is simple, but difficult to apply yourself in many locations.
1. Strum with focused, poky, fingertip or thumb pressure back and forth across the fibres of the
muscle knot, and in the taut band of muscle tissue that it causes. It’s got to be hard pressure,
because nothing less will actually break the adhesions. Do at least five minutes of pressure that is
almost too strong to tolerate.
2. Massage it with an ice cube briefly, perhaps a minute. Yes, ice! Ice it in spite of the warnings not to
ice in other places in this tutorial — this is an exception. You have to risk irritating the trigger point
with ice in this case: the pros usually outweigh the cons.
3. Do not re-treat for at least 48 hours. When breaking adhesions and using such strong pressures, it’s
essential to give the tissue a chance to recover.
At least 3–6 such sessions will probably be necessary to break up adhesions, depending on their
severity.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
6.2
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Troubleshooting stress (without meditation or yoga, unless you like that sort of thing)
Trigger points are a genuine physical problem, but — like an
ulcer — they are sensitive to your emotional state. In other words,
stress is a trigger point trigger. I have countless examples of
clients who invariably feel better when they are on holiday, so
you really should take the beach vacation option seriously.
Stress-reduction is an obvious goal in advanced trigger point
management — with many other benefits as well, of course.
But there is rarely a one-to-one relationship between stressful
incidents and flare-ups of trigger point pain. As discussed in the
“out of nowhere” section, there are many other factors affecting
trigger point pain — so simply having a bad day at the office is
rarely going to be the direct, obvious, primary cause of a trigger
What can you do about stress other
than going here? Or, then again, what’s
wrong with going here?
point incident. That doesn’t stop people from trying to make that
connection, mind you! The temptation is immense. But do not succumb: it’s just not that simple an
equation.
What stressful incidents do is create a
physiological context of generally increased
vulnerability to trigger point aggravation. A
bad day at the office won’t usually lead
directly to pain, but it will lead to a .5%
increase in muscle tone (tension), adrenalin
fatigue, a sleepless night, et cetera … and those
There is rarely a one-to-one relationship
between stressful incidents & flare-ups of
trigger point pain.
things, in turn, will ramp up the odds of
having a trigger point problem over the next
few days, weeks, months …
So stress reduction is a great idea. ��
But how to do it? The stress reduction thing is a bit of a stumper.
When it comes to cures for stress that don’t involve a beach, the
imagination seems to stop at “meditation or yoga.” Even people
who don’t need to be convinced that they “need to relax more”
or “reduce stress” don’t know how to do it. They don’t know
what stress reduction looks like, what actual practical steps or
actions they have to take to achieve it.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
If stress doesn’t directly cause trigger
points … why do vacations work? If there
isn’t a one to one relationship between
stress and trigger point pain, why did I say
that there are countless examples of clients
who invariably feel better when they are on
The Complete Guide to Trigger Points & Myofascial Pain (2019)
holiday? Actually, it makes perfect sense:
Meditation and yoga are appealing for some people, and
certainly effective for nearly anyone who chooses to pursue them
diligently. For those who have had previous experience with
good vacations relieve many aggravating
factors simultaneously. Trying to reduce
stress and other aggravating factors during
the normal daily grind is like trying to fix
yoga and meditating, extending that practice may be an excellent
an engine while it’s still running. It’s never
and practical self-treatment strategy for trigger points.
perfect. There’s always a bunch of factors
Yet the reputation of yoga and meditation is immense, almost
you can’t control. But when you go on a
vacation, and you don’t lose your luggage
oppressive, eclipsing other options. People feel that they
or have a problem in Mexican customs, you
“should” try them, and often feel guilty for not trying them or
eliminate about 300 stresses all at once. A
for not liking them.
bunch of problems that you couldn’t avoid
As popular
radar. The effect of such a significant
as yoga and
reduction of stresses all at once can be quite
meditation
are in North
America,
they are still
not
before are suddenly completely off your
The reputation of yoga & meditation is
dramatic.
immense, almost oppressive, eclipsing other
options.
mainstream. 252 Most of my clients have only dabbled in them at best, and have never
experienced any success more significant than “taking the edge off” their stress. Many of my clients
are also productive, energetic people who find it difficult — almost alien — to invest in subtle or
indirect self-improvement, and find meditation particularly exasperating. They have a kind of
personality conflict with it. It’s not that they can’t or shouldn’t try to learn these skills, but it’s really
not for everyone, it’s a steep learning curve, and trying to climb that curve quickly while also
coping with pain may just not be a practical solution.
Relaxing? Or scary?
Yoga classes are allegedly
relaxing — in reality, they
can be emotional pressure
cookers, inflicting intense
performance anxiety & selfconsciousness about fat &
fitness on the participants.
And, worse still, stretching
can aggravate trigger points,
especially in those
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
conditions.
There’s another large group of people who might like to reduce their stress, but just aren’t suited to
yoga and meditation: the ones who never liked the idea to begin with! You know who you are, and
you’re not alone. Plenty of you think that all “that flaky stuff” is a cure that’s worse than the
disease, and you are more likely to want to reduce stress by “blowing off steam” with exercise …
which would be a great idea, if only your pain allowed it. It often doesn’t, and so you may despair
at the loss of the only stress-management strategy you take seriously.
Many of my clients have identified this
exasperating Catch-22: they know stress
aggravates trigger point pain, yet they have to
reduce the pain before they can reduce the
stress! Frustrating. Stressful, even!
For some, meditation & yoga are a cure that’s
worse than the disease.
Please consider the option of studying yoga
and/or meditation. They really are worthwhile pursuits, and they definitely have the potential to
reduce stress and trigger point pain — especially in regions that are “emotionally charged,” like the
low back — and offer you a host of other benefits. But rest assured that they are not the only
options, nor even necessarily the best options.
Better, more practical, more understandable stress-reduction options for most people are as
follows:
Reducing fatigue by resolving sleep problems — not just blatant insomnia, but chronic mild sleep
deprivation as well. See the next section for more about this.
Reducing a feeling of a loss of control by solving problems in your life. Wouldn’t that be nice? Most
of you will object that you can only wish you could solve your most stressful problems, but most
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
people can actually start solving problems more effectively when they are viewed as critical to your
health as well as your peace of mind.
Relationships heal. Most people can benefit enormously when stressed by emphasizing and
deepening their friendships and romances wherever possible. Stated even more simply, spend time
with people. (And animals, if you can.) Do not isolate yourself. Once again, this is a more practical
goal than meditation for most people, and extremely effective. A corollary of this strategy is to limit,
avoid, or even eliminate toxic relationships wherever possible.
Knowledge and confidence is critical to stress reduction. A lack of knowledge is at the root of many
stressful problems. Learning is a tangible goal that most people can grapple with. Many problems
become less stressful when you understand them better, whether you can fix them or not.
Exercise, “blowing off steam,” if your pain will allow it, remains one of the best of all possible
stress-reduction options. Exploit it in any way that you can.
Although it’s a little on the flaky side for many people, bioenergetic breathing is another form of
exercise, sort of, that is very effective at “blowing off steam.” It’s a weird breathing exercise. If you
like the idea of a weird breathing exercise for the sake of stress relief, then get yourself over to this
article: The Art of Bioenergetic Breathing. It’s also discussed elsewhere in the tutorial here for it’s
possibly excellent blood-acidity-reducing effect.
Counselling or coaching services are a no-brainer: if you are overwhelmed by troubles, get help. This
constitutes trigger point therapy!
My favorite way to blow off steam is to sing obnoxiously loud in the
shower.
Chris Pratt, actor
Troubleshooting insomnia
Based on personal experience and clinical observation, I have long believed
that myofascial trigger points are probably aggravated by insomnia or even by
mild but chronic sleep deprivation. There is no direct scientific evidence to
support this idea, but there is plenty of indirect evidence.
At the very least, insomnia results in increased pain perception by “messing
with your head” (changes to your central nervous system) and/or increased
sensitization of nerve endings. But that is the tip of the iceberg.
Kundermann et al write, “Although it is well documented that subjects with
different pain syndromes suffer from sleep disturbances, the direction of cause and effect in this
relationship is still a matter of debate.” In fact, insomnia almost certainly causes painful changes in
your tissues. 253
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Many studies over the years have shown how sleep disturbances of different types result in all
kinds of pain. Sleep-deprived people with fibromyalgia hurt more, 254 people with insomnia get a
lot more migraines, 255 and low back pain increases, 256 along with virtually any other
musculoskeletal complaint. 257
And what insomnia taketh away, sleep giveth back … and then some. One fascinating study
showed that letting sleep-deprived people with pain catch up on their sleep had a strong painrelieving effect … greater than the pain-causing effect of the sleep disturbance … and even greater
than standard pain medications. Catching up on your sleep will help more than losing sleep will
hurt, and it will also help more than Tylenol. Cool! 258
Another important point is that Dr. Stanley Coren’s excellent book about sleep science 259
generally comes to the conclusion that everyone needs to take sleep deprivation much more
seriously than we generally do: essentially, that there is no such thing as “mild” sleep deprivation.
If you’d like to know more about this subject, read my article which specifically looks at more of
the scientific evidence that insomnia aggravates trigger points — pretty much required reading for
insomniacs with body pain! See Insomnia Until it Hurts
Okay, so insomnia and even just chronic low-grade sleep deprivation are probably factors in
stubborn myofascial pain syndrome. Now what?
Talk about “easier said than done”!
Of course it’s a no-brainer that stress is a cause of insomnia of any severity. In fact, so pervasive
and strong is the idea that stress is the cause of insomnia that many people feel quite helpless to fix
insomnia. If you can’t fix the stress, how can you fix the insomnia?
But both stress (see previous section) and insomnia itself are easier to treat than you probably
realized.
Insomnia is much more of a behavioural condition — a bad habit — than most of us realize (or
want to admit). I can say this with great authority, because I am personally one of the all-time worst
offenders in this category: I have suffered from extremely severe insomnia in my life, refused to
believe for years that it was a “bad habit,” and then eventually got smart with the help of a good
doctor at a sleep disorders clinic. So this is one of those cases in health care where a professional
can say, “Listen up — I know about this, personally.”
There are good, logical ways to tackle most insomnia, including insomnia that you think is
“invincible,” including cases in which you think you’ve “tried everything” — no offense, but you
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
almost certainly haven’t tried everything. I believed that for a long time, only to discover that I still
had a great deal yet to try, and it was the stuff I hadn’t learned about yet that finally did the trick
for me.
That said, I’m going to refer you to other articles now, because this is too big a subject to cover
properly even in this large tutorial. For more detailed information about the relationship between
insomnia and pain, and specifically how insomnia might affect trigger points, see Insomnia Until it
Hurts. For good information on treating insomnia, see: The Insomnia Guide
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
6.3
Troubleshooting posture, ergonomics, and muscle imbalance
This is a major category of confusing but important perpetuating factors.
It stands to reason — or seems to — that poor posture, an awkward computer keyboard position, or
being obviously crooked (as in scoliosis) is going to predispose people towards trigger point
formation. However, it very much depends. Yes and no. Sort of. It’s complex.
Posture is a difficult subject. It’s one of those things that seems straightforward, and yet becomes
slippery and complicated when you try to get a firm grip on it. The basic problem with posture is
that it’s actually surprisingly hard to define, no one is quite sure whether or not “bad posture” is
even harmful, and it’s very difficult to change it in any case. If the postural question interests you,
you can find much more detailed information in this article: Does Posture Correction Matter?.
Everyone is just a little too keen on the appealingly simple idea that crookedness is bad for you (and
I’ve already brought this idea up a couple of times above — overemphasizing “structure”). In fact,
scientific evidence constantly shows that “mechanical” problems are routinely not the cause of
pain, and many “common sense” ideas about crookedness and pain have been disproved over the
years.
For instance, way back in 1984, a paper in the British medical journal Lancet showed that leg length
differences — a very common diagnosis — are unrelated to back pain, period. 260 Not that minor
differences can even be reliably diagnosed in the first place. 261 And just last year, Grob et al
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
published findings in the European Spine Journal that abnormal neck curvatures do not have any
connection with neck pain. 262 There are many other examples.
On the other hand, it seems clear that some
kinds of “crookedness” absolutely do cause
problems.
The British medical journal Lancet published
For instance, I just spoke to a gentleman who
good evidence in 1984 that leg length
lost his leg at the age of four — talk about a
leg length difference! — and he regaled me
differences do not correlate with back pain.
with detailed stories of his extremely painful
and stiff shoulders, and of the way minor
changes to the length of his crutches had major effects on the trigger points in his upper body.
Over the years, I have seen numerous cases in which poor computer workstation ergonomics
seemed to be the cause of trigger point pain. And people with certain kinds of congenital
deformities like torticollis (wry neck) or scoliosis clearly suffer from severe, chronic trigger point
pain — such trigger points are often nearly invincible, and it seems clear that they are directly
related to the crookedness of the body.
I myself have a very minor deformity called “fixed forefoot varus” — a slight twisting of the foot
that causes me to walk with my right leg turned fairly far out, because it’s easier to get my big toe
down on the ground to push off with that way. My parents first realized I had a problem when I
was about four years old, and couldn’t keep my right ski in its track while cross country skiing!
That deformity, slight as it is, has resulted in a more or less permanent collection of trigger points
in my right foot and hip that I cannot ever get rid of, despite all my knowledge and experience
with treating trigger points. The problem is mild, and yet apparently invincible. (I tell the story of
my funky foot in more detail in my plantar fasciitis tutorial.)
Where is the line between an unambiguous muscle imbalance that is causing problems, or at least
contributing, and a subtle postural defect that may not have any real importance? The short answer
is: no one knows.
Ergonomic improvements are an important option to pursue because ergonomic problems are
simply more fixable than other kinds of postural problems or muscle imbalances. A scoliotic spine
cannot be straightened — if it can, I have never seen it happen yet in my career — but computer
keyboards can be moved. It is easy to make ergonomic changes that might make a difference, and
simply find out if they are important. For troubleshooting ergonomics and a life spent in chairs, see
The Trouble with Chairs.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
6.4
Troubleshooting mysterious perpetuating factors
Harold Smage of Elkhorn, Wisconsin, wrote to me:
As I search for therapists and peruse reading material I often come on the statement that
just erasing trigger points will result in a return of the problem — that the underlying
cause and/or perpetuating factors must be addressed.
Okay. But, to date, I have not been able to find what these might be.
Often, significant perpetuating factors are missed due to lack of knowledge, experience and selfawareness. But, sometimes, they are missed because they are mysterious and difficult to identify.
Just like some trigger points are not actually physically accessible to any kind of therapy, some
perpetuating factors can never be definitively diagnosed. They may be hard to identify because
they are subtle, trivial, odd, or they may be strange and also terrible: an ominous biological
vulnerability that you will probably never be able to identify, or do anything about even if you
could. More about the terrible possibilities in the next section.
The defense against the problem of mysterious perpetuating
factors is to start by understanding your body and known
perpetuating factors as well as possible. If you do this diligently
and never can identify any significant perpetuating factors, then
eventually you can more or less safely conclude that your
perpetuating factors are likely to remain mysterious. Just don’t
try to tell me that your perpetuating factors are a mystery before
that! First you have to put in the time.
Another long-term strategy for troubleshooting mysterious
perpetuating factors is to “tinker” with the major forces in your
Er, not so mysterious, really. It’s a pretty
common experience for me to identify
major perpetuating factors within all of
about 60 seconds of being told, “I just can’t
figure out what keeps aggravating my
trigger points!” No offense, clients and
readers, but you’re usually overlooking the
painfully obvious while simultaneously
complaining about it within moments of
starting to talk about your problems! It’s
usually not so much that you don’t know
life: where you live, what you do for a living, your hobbies, your
what the big perpetuating factors are, it’s
hang-ups. Here’s a couple of examples:
that you don’t think it’s an option to fix
them. Bit of a blind spot there. Can’t see the
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
A bad marriage might be the “mysterious” perpetuating factor
factors for the TPs (groan)!
in your pain. While it might seem like sitting all day at work is
the main aggravating factor, you might find that no amount of microbreaking or mobilizing or even
a career change makes any difference, because you are still suffering from constant low-grade
unhappiness and countless minor and major irritations at home. Until you actually get the divorce
over with, no amount of squirming around with other perpetuating factors is ever going to do any
good.
Or, suppose you live on the coast, and you’ve
never lived anywhere else, and you don’t want
to live anywhere else — but, unbeknownst to
you, humid air is actually a problem for you.
You’ve noticed on vacations that you really
prefer dry air, but you haven’t yet made the
opposite observation, which is that you
actually feel a bit lousy when you breathe
coastal air. You have more colds, more
Until you actually get the divorce over with, no
amount of squirming around with other
perpetuating factors is ever going to do any
good.
allergies, a general logeyness, you don’t sleep
as well, and so on, all of which adds up to a “mysterious” and major aggravating factor — a
physiological context of vulnerability. Until you decide to up and move inland, you will probably
fail to identify your aggravating factors.
So, shaking up the big picture can shake loose some pretty big revelations! This is related to the
idea of treating difficult health problems by personal growth.
On the other hand, if you “change everything” in your life and still have unrelenting trigger point
pain, then trigger points may be your “biological destiny” — perpetuated by forces that will never
be clear and may not ever change. The next section addresses the idea that some people are “just
triggery.”
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
6.5
The relationship between trigger points and other physiological disorders and diseases,
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
especially fibromyalgia
What if your perpetuating factor is just your biological destiny?
Some diseases are obviously likely to cause and aggravate trigger points. Some straightforward
examples include any of the inflammatory arthritides, such as rheumatoid arthritis or ankylosing
spondylitis, or diseases that directly affect muscle tissue, such as Parkinson’s disease or
amyotrophic lateral sclerosis (Lou Gehrig’s disease).
Put yourself in the shoes of someone with Parkinson’s.
If you have Parkinson’s, the disease may well predispose you
strongly to trigger point formation. You are more likely than
someone without Parkinson’s to get more trigger points and
worse trigger points. Indeed, trigger points are probably one of
the main ways that Parkinson’s becomes painful. Parkinson’s
may also cause similar kinds of pain by other means, and there is
no way be sure how much of a Parkinson’s patient’s muscle pain
Parkinson’s is a central nervous system
disease that causes muscle rigidity, tremors,
and a slowing of physical movement.
Famous Parkinson’s sufferers include
Michael J Fox, Pope John Paul II, and
Muhammed Ali.
is “pure Parkinson’s” versus “Parkinson’s causing trigger
points.” However, it is a reasonable theory that trigger points could be a major mechanism by
which Parkinson’s causes pain.
As with other diseases that aggravate trigger points, treating trigger points in a Parkinson’s patient
is both (a) a valuable method of controlling muscle pain symptoms, and (b) probably doomed to be
not especially effective. In other words, when a disease process is driving myofascial pain
syndrome, trigger point therapy is both vital and somewhat futile.
This might seem a bit discouraging, but there is a legitimate glass-is-half-full perspective here —
despite the ineffectiveness of therapy in terms of actually vanquishing trigger points, trigger point
therapy for a patient in this situation can be a godsend. Even if it can’t get rid of trigger points, it
may still help a lot, and that ain’t nothing — patients with invincible, disease-powered trigger points
may actually get more subjective value from therapy than someone with more defeatable trigger
points!
Some people seem to be awfully triggery in
the absence of any other obvious problems that
cause trigger points. Something about their
personal chemistry seems to predispose them
to trigger points: more of them, more painful,
When a disease process is driving myofascial
pain syndrome, trigger point therapy is both
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
more stubborn. This often seems to occur in
people who have other syndromes with no
vital & somewhat futile.
obvious effect on muscle tissue, such as a
pain-system dysfunction like fibromyalgia,
poorly understood autoimmune disorders like lupus or irritable bowel syndrome, or not-reallyunderstood-at-all conditions like chronic fatigue syndrome.
Something about the neurology and biochemistry of these patients “obviously” — obvious to me,
anyway, from clinical experience — makes trigger points worse. But I cannot overstate how
mysterious this all is. As much as trigger point science has advanced, we are still nowhere close to
understanding exactly why some people get trigger points and some people don’t, or why one
person has relatively little difficulty getting rid of them while another person seems to be stuck
with them forever.
Fibromyalgia is a particularly important topic for this section, because it is so common, and
because the relationship between fibromyalgia and trigger points causes so much confusion. The
major diagnostic difference between having trigger points and having fibromyalgia is widespread
sensitivity to pressure. Fibromyalgics are “sensitive” — as though the volume on all their nerves is
turned way up. Things that shouldn’t hurt at all hurt quite a bit. Things that used to just hurt a
little hurt a lot. This includes all kinds of stimuli that would not cause any problem for someone
who only has trigger points — i.e. a toe stub. Due to their system-wide sensitivity, a fibromyalgia
patient will just about go through the roof with a minor toe stub that would cause no particular
problem whatsoever to the “pure” trigger point sufferer.
Fibromyalgia patients will suffer greater
sensitivity than anyone else in several key
locations around the body — these are the
“tender points” of fibromyalgia, often
confused with trigger points.
Fibromyalgics are “sensitive” — as though the
volume on all their nerves is turned way up.
Tender points vs. trigger points
Trigger points describe localized pain that can occur in almost any location, but typically occurs in
muscles, and which can come and go like the weather, and are routinely not associated with any
other symptoms.
The tender points of fibromyalgia are a carefully chosen set of spots that tend to be sensitive on
anyone, but are excessively sore with FM. It’s not that FM makes those spots sore — it’s that FM
makes everything sore, which is most obvious at those spots. 263
Tender points are not trigger points, and do not seem to respond like trigger points. Trigger points
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
routinely change in response to stimulation. Tender points remain stubbornly tender. Massage
therapy does not seem to be of much help to fibromyalgia patients, not even temporarily (see
Li et al ). The data are inconclusive, but the absence of any good news is bad news: it may well be
helpful for some FM patients (probably the ones who also have trigger points), but not many and
not much. To be fair, this may be the case for trigger point massage as well, strictly speaking — as
far as we can tell from the limited evidence. But the anecdotal difference between seems huge.
Distinguishing between a case of fibromyalgia and a case of serious widespread trigger points may
be almost impossible, because fibromyalgia patients almost always have the symptoms of both
conditions, and because serious myofascial pain syndrome is so painful and it causes such a wide
variety of symptoms.
What makes fibromyalgia an important thing to discuss in this tutorial is that differences between
the conditions can be so hazy that serious questions must be raised about their relationship.
Are they opposite sides of the same coin?
Is fibromyalgia an extreme form or a different “flavour” of myofascial pain syndrome? Quite
possibly.
I have seen numerous cases in my career of “tender points” that acted suspiciously like trigger
points, and vice versa. Some patients defy diagnosis: they are like hybrids, not entirely
fibromyalgic and yet obviously not “just” suffering from trigger points.
More or less exactly the same relationship exists between myofascial pain syndrome and an
extremely painful and all-too-common neurological disease called either “reflex sympathetic
dystrophy” (old name) or “complex regional pain syndrome” (the new name, CRPS).
CRPS is a really nasty condition that causes literally the worst imaginable pain — it is a disease in
which virtually all sensory signals are mistakenly interpreted by the brain as the worst possible
pain, and for which there is not yet a single proven treatment and the research is “something of a
mess.” 264 Suicide rates among people with this disease are high, as you might imagine. They
often develop open sores and have to have amputations and are treated with drastic methods like
induced comas. They do strange things like walk around with their hands wrapped in wet towels
for years because “the air hurts,” a terrible phenomenon known as allodynia — a painful response
to a harmless stimulus. So this is a truly serious disease — and what could it possibly have to do
with trigger points?
Maybe nothing.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
But I once had a patient I got to know very well who had “mild” CRPS (meaning that it is not as
severe as other cases of CRPS, but still incredibly nasty). We discussed this ad infinitum, and we
developed a pet theory, completely unsubstantiated by science but rational. Our hypothesis is that
there is overlap between the physiology of trigger points and the kind of neurological
Armageddon that occurs in extreme diseases like CRPS. Diseases of pain system dysfunction are
simply be one end of a spectrum. Whatever goes wrong in CRPS may be going wrong — obviously
to a much lesser degree — in people with nasty trigger points, and to an even lesser degree in
people with mild trigger points.
CRPS only gets diagnosed when the process degenerates beyond trigger points and into severe
neurological problems. If this is true, if this is how it actually works, it would account for a major
category of “triggery” people who have shockingly serious myofascial pain syndrome, yet fall
short of a diagnosis of fibromyalgia, CRPS, or one of the painful autoimmune diseases (i.e.
polymyalgia rheumatica would be a good example, a disease my father had).
For now, though, this is an area of real scientific mystery, and nothing can yet be done about the
uncertainties.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
6.6
Way beyond stubborn: troubleshooting extreme cases
There are tragic cases of trigger point pain that seem to exceed all reasonable limits. See the earlier
section, What’s the worst case scenario for trigger points? for more information about just how
truly bad it can get. Although rare, the worst cases really are awful. Generally speaking, they can
transcend mere myofascial pain syndrome and become something else: probably a general
breakdown of the neurological systems that regulate pain perception. In such cases, trigger points
are probably no longer the main cause of pain, but simply the original trigger, or only one trigger,
for generally broken pain perception.
What do you do when the problem seems extreme? What do you
do when “stubborn” doesn’t even come close to describing the
persistence of your trigger points? What if they seem to respond
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
An invitation to the afflicted: So, you’re a
freak of nature … now what? How about
telling your story for PainScience.com? An
The Complete Guide to Trigger Points & Myofascial Pain (2019)
to nothing? Either no response at all, or relief so temporary it
might as well not have even happened.
Of course, there are not going to be any easy answers for you.
But I do have considerable experience working with people in
the same boat. While I was editing this section a few minutes
ago, I received a call from a 50-year-old woman with severe low
back pain who said, “I’m too young to have this much pain.” No
one should have that kind of pain, at any age! Yet I have often
extreme case of myofascial pain syndrome,
like any other anomaly in nature, helps us
to understand how the world works. Over
time, I would like to collect many stories
from people who have faced severe trigger
points. If you think your experience is
unusually extreme, please contact me.
Maybe telling your story will even help a
little …
worked with 25-year-olds who were in equally bad shape. You
are not alone, even if it seems that way.
Here are some strategies to consider:
First of all, make sure you’ve actually tried everything yourself. Most people haven’t — even
desperate folks who’ve been working at it for years have typically spent 75% of that time chasing
red herrings and exploring dead ends. It’s not uncommon for me to hear from people with severe
cases who have literally never experimented with a single massage tool other than a tennis ball.
That sounds strange, but it’s true — it takes a long time, and a certain outlook, before most people
get truly creative with their self-treatment. So go through all the ideas in this tutorial one by one,
and then start experimenting with combining them. Chances are good that you haven’t already
been that thorough. And it’s possible that, before you’re done, you will have found something that
helps more than anything else you’ve ever tried.
Shop around. Never give up looking for the right therapist or doctor. Expect to eliminate many
practitioners. Never continue to pay anyone for therapy that isn’t showing promise relatively soon.
And never buy into anyone’s sales pitch. The very same woman I just referred to also told me that
her last attempt at therapy was with a chiropractor who insisted that she had to try at least 45
appointments before giving up. Forty-five is excessive. Although it may be possible for therapeutic
benefits to take that long to develop, it’s unlikely, and irresponsible for a therapist to claim to have
reasonable confidence in such a long term outcome.
Take it slow. The nicest thing about self-treatment is that it’s cheap, so you have the luxury to give
it more time to work than if you were paying by the hour. Take the self-treatments that seem to
work a little, or that seem like they could work — just something you have a good feeling about, if
that’s what it takes — and apply it slowly and gently and carefully and consistently for a long time —
weeks. Tedious? Maybe. But desperate times call for desperate measures.
Work on personal growth. As science advances and mind-body perspectives on health and healing
become more sophisticated and practical, we understand that pain problems are powerfully
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
mediated by stress, self-limiting behaviours, and “emotional constipation.” Professionally, I am in
an ideal position to see how people’s quirks and habits cause, slow or prevent all kinds of healing.
Particularly for clients struggling with a difficult and slow healing process, I recommend that they
“get personal” with their problem. Sometimes it’s a matter of just learning new coping skills for a
problem that is never going to go away. And sometimes people need to come to terms with the fact
that years of self-sacrificial workaholism, for example, are actually the root cause of severe chronic
pain. Usually the truth is in the middle: healing requires a complex mix of coping skills and
personal responsibility. Through this kind of learning, people often find long term relief.
Of course, there are nearly infinite ways of approaching this challenge, and I’ve written about it in
several ways. I discuss the theory in detail Why Do We Get Sick?, and I get more thoroughly
practical in Pain Relief from Personal Growth. You might also want to read Dr. Gabor Maté’s
excellent book When the Body Says No. However, the best thing you can do is just go straight to
Haven.
Hit the breathing particularly hard. If you don’t get into the personal growth approach, at least try
to get into the breathing exercises. Even in the advanced troubleshooting sections above, I don’t
really go overboard recommending bioenergetic breathing to my readers. But for really nasty cases
of trigger points, deep and fast breathing is my favourite secret weapon. Do I know if it works? Is it
evidence-based? No and no. But I have a lot of reasons to believe it’s well worth trying. It certainly
won’t do any harm, it will be an interesting experiment no matter what, and it has the potential to
make a big difference. So, if you haven’t already gone looking at it, read The Art of Bioenergetic
Breathing.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
6.7
Reality checks: some self-treatments that don’t work at all (or not nearly as well as you
would hope)
Stretching. It’s already been mentioned several times, but it can’t be mentioned enough: stretching
is a less effective method of treating trigger points than most people think it is or “should” be. It’s
not completely ineffective, but it is certainly much less effective than we would all like. A massive
stretching section is coming up right after this one.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Epsom salts. Many people look to Epsom salt baths to relieve muscular aches
and pains in general, and assume that it’s probably good for trigger points in
particular. While a hot bath is certainly a good idea for other reasons, as we’ve
already discussed, I’m afraid that it’s unlikely that salting your bath will help
much with trigger points. Recent scientific evidence has shown that Epsom
salts do indeed soak through the skin when you bathe in them 265 — which is
a bit surprising, and had never been proven before!
Unfortunately, there is just no scientific evidence about what happens after Epsom salts soak
through the skin. Do they have any therapeutic effect? On anything? On trigger points in
particular?! No one knows. It’s possible, but not particularly likely. One thing is certain: Epsom
salts definitely don’t work miracles. Even stretching, which is obviously ineffective for many
patients, has more obvious benefits. For a very detailed discussion of the whole Epsom salt issue,
see Does Epsom Salt Work? The science of Epsom salt bathing for recovery from muscle pain,
soreness, or injury.
Drinking water. It’s common for massage therapists to tell patients to drink some extra water
following massage therapy. The only rationale ever given for this is “detoxification,” which makes
no sense. 266 While it certainly won’t hurt you to drink a little extra — nothing could be cheaper
or safer — I have never seen any good reason to believe that it’s a factor in recovery from trigger
point therapy, let alone treatment or prevention of muscle pain. Meanwhile, there are good reasons
to be skeptical. For instance, we now know that dehydration does not cause cramping in athletes —
no, seriously! 267 And paranoia about dehydration clearly comes mainly from one disreputable
source, Dr. Batmanghelidj, whose books and writings on the subject are simply awful … and yet
they sell well, because Joe Public loves a simple solution to all his problems! For the sordid history,
see Water Fever and the Fear of Chronic Dehydration: Do we really need eight glasses of water per
day?
Traumeel. Homeopathic (diluted) herbal ointments featuring Arnica are
claimed to be good medicine for muscle pain, joint pain, sports injuries
and bruises, but their effectiveness is questionable. Known to most
customers as an “herbal” arnica cream, most actually contain only trace
amounts — too little to be a chemically active ingredient. Homeopathy
involves extreme dilution of ingredients, to the point of completely
removing them. Some other herbal ingredients may be less diluted and
more useful. However, neither homeopathic or pure herbal creams of
this type have produced results better than placebo in good quality
modern tests.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
It is questionable whether
Traumeel is even relevant to
myofascial pain syndrome.
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Despite the broad manufacturer claim of effectiveness for “muscular pain,” it’s important to
explain that Traumeel is marketed primarily as an anti-inflammatory cream for acute superficial
injuries like bruises and sprains, and trigger points are not an inflammatory problem, and often much
too deep in the tissue to be easily affected by any topical ointment. And so it is questionable
whether Traumeel is relevant to most myofascial pain syndrome, regardless of whatever else you
might think of homeopathy. However, homeopathic remedies are over-priced and ineffective in
general, and homeopathy as a profession is rotten with dangerously irresponsible ideas, as shown
in the BBC’s 2006 exposé of homeopaths in London recommending completely ineffective remedies
to travellers in place of genuine anti-malarial medication. 268 Wikipedia has quite a good complete
review of homeopathy. 269 For more detailed information about Traumeel, see my article, Does
Arnica Gel Work for Pain?.
Popular muscle relaxant drugs based on methocarbamol. The trade names of these drugs are
Robaxin, Robaxacet, Robax Platinum, Robaxisal. Methocarbamol may be combined with other
drugs, such as Aspirin or codeine, which actually do more good. Here’s some good information I
can’t give a reference for, just a credible source you’ll have to take my word for: a pharmacologist I
know explained to me in detail that methocarbamol is simply ineffective at recommended dosages.
Higher dosages will indeed reduce muscle tone, but with unpleasant side effects. Somehow the
drug got approved even though the low recommended dosages are virtually useless. Any benefit
you seem to get from these drugs at normal dosages is a placebo and/or the result of other active
ingredients, especially codeine, which is much more effective at relaxing anyone.
Acupuncture for muscle pain in general, and for low back pain in particular. Acupuncture’s
failure to treat low back pain in well-designed scientific trials earns its inclusion here in this list of
particularly underwhelming treatments. The evidence is discussed more below.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
Part 7
MEDICAL FACTORS THAT PERPETUATE PAIN
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
The effect of statin drugs, nutritional and hormonal deficiencies, infections, and inflammatory diseases
by Tim Taylor, MD
This book has already introduced the concept of “perpetuating factors,” such as insomnia or
postural stresses. Although those things are important, the worst of all perpetuating factors are
medical: drug side effects, a shortage of vitamin D, or a lingering infection with some virus you’ve
never even heard of. If such forces are at work on your muscles, the most heroic efforts to treat
your trigger points are probably doomed, like pissing on a bonfire. Fortunately, the most common
medical factors that make pain stubborn are relatively easy to diagnose and treat, and you can do it
by yourself, using this chapter as a guide — although, of course, it is always preferable to have
expert guidance. One way or another, every patient with a tough, chronic case of myofascial pain
syndrome must investigate these factors.
I purchased this ebook myself in the spring of 2010 out of professional curiosity — I am always
interested in a new resource about trigger points. I liked what I found, but I did see a problem: it
was missing information on the medical factors that make pain stubborn. This was a serious
omission! I contacted Paul Ingraham and offered to contribute this chapter. To his credit, Paul
cheerfully acknowledged the weakness in his book. This chapter became a reality soon after.
Although the writing is mine, Paul has contributed as well — look for the occasional “note from
Paul” — and we will continue to update it together in the future.
Note from Paul: hey, there.
Why should you trust me? The short answer: because I want to help other people find pain relief.
The long answer: I developed myofascial pain with trigger points years ago. I went to dozens of
doctors, physical therapists and massage therapists. Most of what they did made me worse, until
the pain had spread through most of my muscles. I was nearly disabled by pain and anxiety.
Eventually, I found Dr. Robert Gerwin who wrote the chapter on medical perpetuating factors of
pain in Travell and Simons’s Myofascial Pain and Dysfunction: The Trigger Point Manual. Treatment at
Dr. Gerwin’s and Doctor of Physical Therapy Jan Dommerholt’s clinic led to my recovery.
My wife, Anna Bittner, MD, who has fibromyalgia and myofascial pain, also enjoyed tremendous
improvement after treatment with Drs. Gerwin and Dommerholt. We started our own clinic, Pain
Relief Home, a medical micro practice, where we enjoy helping our patients feel better. We
continually learn from our patients, from reading medical studies, from our colleagues and from
Myopain Seminars students.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
7.1
Some usual, unusual, and unique medical disclaimers
The Usual Disclaimer: This material is for information
purposes only and is not a substitute for professional
medical care.
The Unusual Disclaimer: This information is based on
the accumulated patient-care experience and research of
Doctors of Medicine Robert Gerwin, Janet Travell, David
This is Dr. Taylor’s disclaimer, but of
course, PainScience.com has a
disclaimer too, because Dammit, Jim,
I’m Not a Doctor!
Simons, Anna Bittner, and me, Tim Taylor, as well as my
and Dr. Bittner’s experience as pain patients. Any medical
treatment could make you sick or kill you, but I do not
know of any deaths or other serious problems among my patients resulting from my methods.
The Unique Disclaimer: The more I learn, the greater grows my awareness of my ignorance. The
most dangerously ignorant practitioner thinks he or she knows everything about your problems.
As a medical student and resident, I was taught to “play it safe”: Avoid liability issues by never
promising good results. I abandoned this teaching when my pain patients taught me that they will
only get better if I give them hope. I have reverted to the bedside manner I learned as a boy going
with my father to visit sick friends and relatives. As a parachute infantry officer facing casualties in
many terrible battles, he learned what people in pain need to hear. On the battlefield or in the
hospital, he would take each patient by the hand, hold their attention with his commanding
manner and convincingly tell them, “Hang on. Help is on the way. You will get better.”
Here are some of the most common medical reasons that myofascial pain syndrome may be
stubborn. They may complicate muscle pain in particular, chronic pain in general, or both. Click
one to jump to more information about it below.
statin (cholesterol reducing) drugs
vitamin D deficiency
vitamin C deficiency
vitamin B12 deficiency
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
vitamin B1, B2, folate & magnesium deficiencies
thyroid hormone deficiency
iron deficiency
testosterone deficiency
estrogen deficiency
inflammation
infections
smoking
The awful truth is that very, very few doctors know about these perpetuating factors.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
7.2
Getting tested and treated: the hard way, the easy way, and the right way
You can start like I did: the hard way. Go to your community’s best-known family-practice doctors,
neurologists, physical medicine and rehabilitation specialists, pain management anesthesiologists
and osteopaths. You may find one who helps you greatly. Or they may nearly cripple you like they
did me.
My local doctors and physical therapists told me to stretch and strengthen my muscles, which
caused my myofascial pain to spread from a one-muscle (piriformis) problem to multiple muscles
from my head to my knees and out both arms to my hands. They also gave me ineffectual trigger
point injections. They never got a twitch response with the needle to indicate that they had hit the
trigger point.
Eventually, I diagnosed my own problem, studied myofascial pain and started searching for the
nearest contributor to a book on the subject. I found Dr. Robert Gerwin, author of chapters in
Travell and Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual. He and his associates
Steven Shannon, MD, and Jan Dommerholt DPT treated me effectively.
Or you could do it the easy way.
The easy way: manage your own diagnosis using this chapter as a guide. Find a doctor and office
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
nurse who will comply with your requests. Download this PDF file: Laboratory Tests for Medical
Perpetuating Factors of Pain [PDF]. Print it out, and take it to your doctor’s office nurse. Ask the
nurse to fill out a lab order form for these tests, and get the doctor’s signature on the form.
Fortunately, the big drug and insurance companies have blazed the trail for you: As a result of
massive direct-to-consumer drug advertising, doctors are accustomed to patients asking for
specific medicines and tests. Insurance companies pay doctors per number of patient visits, not
time per visit. The insurance-paid doctor needs to finish your visit quickly to get the most visits in
per day. Many doctors sign any lab form the nurse presents. Many doctors will prescribe whatever
medicine you ask for rather than take time for discussion of the subject.
After your doctor gets the lab results, get a copy. Compare your results for each item to the desired
range for pain relief, spelled out in the sections below. Make a list of any deficiencies indicated by
the testing.
Make an appointment with your doctor to ask for the prescriptions you need. You may encounter
some resistance: your doctor may not want to encourage/enable indulgence in the hype around a
supplementation option that he doesn’t believe is necessary. That’s a reasonable concern. Never
push — just discuss. (Any doctor you have to “push” isn't worth working with anyhow.) If
reasonable discussion can't get the job done, find another doctor, or let it go.
Any direct treatment of trigger points will not give lasting benefit until you have taken the
medications for a month to correct your metabolic problems. During that month, learn self
treatment of your own trigger points. Study this tutorial. Also use that time to get a source of
muscle diagrams and trigger point pain referral patterns (The Trigger Point Symptom Checker is a
convenient place to start). You will also need to find a source of stretches for each of your involved
muscles. 270 I found all these together in The Concise Book of Trigger Points, 2nd edition.
After one month on the medications, start self-treating.
All of that is easy enough. But there’s still the right way to do this …
The right way: Instead of having to make yourself an expert, find an expert. One way is to use the
online lists of people who may know a doctor in your area to help you. You can start by checking
websites of The International Myopain Society (IMS), National Association of Myofascial Trigger
Point Therapists (NAMTPT) and Myopain Seminars graduates for a member in your area who is a
doctor or who can recommend a doctor who knows myofascial pain.
Alternatively, consider travelling to the clinic of doctors who I know have spent years studying
and treating myofascial pain. These include:
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Dr. Robert Gerwin, at Pain and Rehabilitation Medicine (Bethesda, Maryland, USA).
Dr. Steven Shannon at Advanced Pain Management (primarily at the clinic in Annapolis, Maryland,
USA)
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
7.3
Pain-causing drug side effects: statins (cholesterol-reducing drugs) and bisphosphonates
(for osteoporosis)
Statin drugs to lower blood cholesterol may also cause pain. Statins are important
and widely used drugs, and their deleterious effect on muscle is seemingly common
that is widely considered a diagnosable condition: statin myalgia, or statin-associated
muscle symptoms (SAMS). 271 A few patients, about 1 in 10,000, get a more obvious,
The Statins
Lipitor (atorvastatin)
Crestor (rouvastatin)
serious case of muscle poisoning, rhabdomyolysis, 272 and an even rarer and more
Mevacor (lovastatin)
serious condition afflicts 1 in 100,000: statin-associated autoimmune myopathy. 273 274
Zocor (simvistatin)
And yet there is also confusion and controversy about the prevalence of statin
Lescol (fluvastatin)
myalgia. 275 There’s even clear evidence that it could be some kind of illusion or
misunderstanding: in one head-scratcher of a study, taking statins only increased pain when
patients knew they were taking statins. 276 So that’s weird! The truth is probably “all of the above”
and “it’s complicated” — it seems likely that some patients are genuinely intolerant of statins,
while others are suffering from fear of statins and/or some other cause of musculoskeletal pain (of
which there many). There might also be some tricky X-factors, like vitamin D deficiency, which
seems to be linked to statin myalgia. 277
There is good news, though! Ridding yourself of these side effects, even the worst, is usually as
easy as lowering the dose or switching to another statin. Important: The risks of stopping statins
include stroke, heart attack and peripheral vascular disease, unless your doctor prescribes another
treatment for your hypercholesterolemia.
Example: My family member developed a sudden case of frozen shoulder a few days after his
statin dose was increased. I found active, painful, motion-limiting trigger points in every muscle of
his right shoulder region. On my advice, he stopped his statin. He improved within a few days. I
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
then treated his trigger points with dry needling once. He was cured! Then he followed my
instruction to go to his doctor to get another type of medicine for his high cholesterol. She then
prescribed him a different statin and we went through the whole process again. Finally, he went
back to her with a letter from me describing statin myopathy and how statins affected him, and
requesting a non-statin drug.
And bisphosphonates too
The statin (cholesterol-reducing) drugs are probably the biggest
culprit for drugs that cause pain, but another popular class of
drugs that may do so are the bisphosphonate (Wikipedia), for
osteoporosis and Paget’s disease. On January 7, 2008, the U.S. Food
and Drug Administration alerted health professionals and
consumers to their unusually severe side effects. 278 They can
cause “severe and sometimes incapacitating bone, joint, and/or
muscle pain” which “may occur within days, months, or years”
after first taking the medication. This probably explains a lot
otherwise undiagnosable pain in a lot of people.
Actonel (risedronate) is one of the
more popular bisphosphonate drugs,
any of which may cause severe
musculoskeletal pain years after
first exposure.
Alendronate and risedronate are the two most popular
bisphosphonates, and they are usually prescribed for osteoporosis
or for a bone-deforming condition called Paget’s disease. If you are 40+ and grappling with a
mysterious pain problem, check your medicine cabinet for bisphosphonates in particular, but of
course any other medication that could cause pain as a side effect.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
7.4
Nutritional and hormone deficiencies
Proper blood tests can reveal the problems listed below. The healthiest blood amount of each of
these chemicals is usually different from the laboratory report “normal” or “reference range.”
Why? Because the laboratory companies have not updated their long-standing “normal” or
“reference ranges” to reflect current medical knowledge. Also, the “healthy” people sampled to
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
determine the “normal” range are often college students, army recruits or other groups who may
not be thoroughly examined to determine their health. Their blood laboratory results may not
reflect what we need to keep our muscles healthy in middle age and beyond.
You may have a hard time finding a doctor in your region who will prescribe medication to help
you achieve the healthiest blood amount if the laboratory report says “normal” or “within
reference range.”
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
7.5
Vitamin D deficiency
Vitamin D deficiency is surprisingly common in general, 279 and causes many problems 280
probably including muscle pain 281 282 283 284 and dysfunction 285 286 Nearly all my pain
patients have low blood serum vitamin D. My vitamin D levels, and my wife’s, were low when our
pain problems began. Our pain improved after we increased our vitamin D intake. Good quality
experiments are now backing up our experiences. 287
Note from Paul: there are many possible ways that Vitamin D may be helpful. For instance, chronic
pain is well-known to have strong psychological and social elements. Vitamin D may have effects
on these factors by helping with conditions like seasonal affective disorder (SAD), depression, and
anxiety. That would be a curvy road to take to get to improved regulation of pain, but it might just
work that way. Hat tip to New Zealand pain science writer Bronnie Thompson for this observation.
Our goal is a patient serum 25 (OH) vitamin D level between 50 nanograms per milliliter
(abbreviated as 50ng/ml) and 100ng/ml. That’s more than what was considered adequate
historically. According to outdated sources, 15ng/ml is enough — but this is almost certainly
wrong. According to Holick et al , 30ng/ml is the lower level of what his research indicates is
healthy, and you may need even more to eliminate chronic pain.
A huge range of vitamin D dosages have been used in various studies. For patients below 50ng/ml,
I prescribe a fairly high dosage of vitamin D. My current protocol is based on the recent new
development of many drugstores stocking over-the-counter vitamin D3 in 5000 IU capsules. I
recommend one 5000-IU tablet with each meal for one month, then one per day as a maintenance
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
dose for another month, and then it’s time to check the serum vitamin D again.
Obviously there could be safety concerns with high dosages. However, there is firm scientific
evidence that high dosages are safe, 288 289 290 291 According to Heaney, “There is, in fact, a
comfortable margin of safety between the intakes required for optimization of vitamin D status and
those associated with toxicity,” 292 and I have yet to have anyone in a toxic range, and that
includes patients on even higher dosages that I’ve recommended in the past.
Still, it’s very important to know that taking more vitamin D than you need can kill you, starting
with the destruction of your kidneys. 293 Please do not assume that “more is better”! If you are not
deficient, anything more than minor supplementation could be dangerous. If you are deficient, too
much supplementation could be dangerous. Despite the wide margin of safety, please stick to the
dosages recommended here!
Note from Paul: in late 2010, the Institute of Medicine published new guidelines for dosages of
Vitamin D, prompting a thorough review of this topic. Keen readers can get a full dose of
information about it here: Vitamin D for Pain: Is it safe and reasonable for chronic pain patients to
take higher doses of Vitamin D? And just how high is safe?
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
7.6
Thyroid hormone deficiency
Hypothyroidism is the medical term for thyroid hormone deficiency. It perpetuated my own pain
until an open-minded endocrinologist gave me thyroid hormone despite my “normal” lab report. I
improved within two days of starting taking thyroid hormone pills. This is the second most
common deficiency I find in my pain patients. 294 295 The simplest lab blood test for this is serum
thyroid stimulating hormone (TSH).
TSH inversely relates to thyroid hormone like this: Your brain measures how much thyroid
hormone is in your blood. If you do not have enough thyroid hormone, your brain releases more
TSH. So the higher your TSH, the less thyroid hormone is in your blood. My goal is to keep my
patient’s TSH between 0.3 and 2.25 uIU/ml. (The laboratory report “normal” or “reference range” is
0.5 to 5.5 uIU/ml.) Thyroid hormone dosage must be carefully monitored to avoid making you
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
hyperthyroid. I start my hypothyroid patients on Levoxyl brand levothyroxine thyroid hormone 50
microgram tablet, one upon awakening each morning with at least 8 ounces of water, at least 30
minutes before eating or drinking anything else except other medicine and water. I retest the serum
TSH after 3 months. 296
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
7.7
Iron deficiency (and excess)
Low muscle iron supply is the third most common deficiency that I find in my pain
patients. 297 298 Most doctors only look at your red blood cell iron. Your red blood cells may have
plenty of iron, and the red blood cell lab tests may be fine, while your hurting muscles are starving
for iron. Muscle gets iron from serum ferritin. My target for serum ferritin is 50 to 100 nanograms
per milliliter (50-100 ng/ml), higher than the bottom of the laboratory report “normal range” or
“reference range.”
This chart (click the zoom button in the upper left hand corner for a better view) from the
eMedicine article on iron deficiency shows the relationship between several measures of iron in the
body. There are two points of interest here. First, note that several of the measurements (inside the
large blue circle) do not change even as when the serum ferritin (top row) is showing significant
deficiency. Put another way, it shows that iron deficiency (including inadequate ferritin to
transport iron to muscle), happens before the usual red blood cell tests show a problem.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
The second point of interest is that the chart also shows a normal serum ferritin to be 60
micrograms/liter of blood serum. Most laboratory report forms that I have seen are based on
outdated information which states ferritin as low as 20 is “normal.”
As you can see, science is not always exact.
So if you’re deficient, what can you do about it? Unfortunately, our bodies keep only a fraction of
the iron we eat in food and little of what we take in pill supplements. You might never get enough
iron from food or oral supplements. The best food sources are chicken liver and very lean red meat
such as venison. If you can get a source of good, clean blood to drink or cook with, go for it.
Not only are iron pills a relatively ineffective way of
supplementing, they also commonly cause ulcers. Indeed, “oral
iron supplements are highly corrosive to the entire
gastrointestinal tract.” 299 I give iron shots instead: Infed brand
iron dextran liquid suspension, 50 milligrams elemental iron per
milliliter, one injection of 2 milliliters deep gluteal intramuscular
per day for ten days.
Beware that you may have a hard time finding a doctor who
Blood as food?! Eating
blood sounds bizarre, and it
is unusual and even taboo
in some places. The most
common and familiar form
of blood as food in the West is blood
sausage, although many North Americans
are repelled by the idea.
knows enough about iron metabolism to recognize that you need
Dr. Bittner’s mother remembers that her
iron shots. You will probably have to limp along with red meat
mother regularly took her and her cousins
and iron pills.
to drink fresh blood at the slaughterhouse
Too much iron, either absorbed from pills or injected, can kill
bought his meat for his shop in Evansville
you by building up in your body and poisoning your heart, brain
Indiana in the 1930’s.
where Dr. Bittner’s grandfather, a butcher,
and liver. Iron pills can give you stomach or bowel ulcers.
Ironically, excessive iron can also cause pain, especially joint pain. High iron is a much less common
problem than low iron, but it is another medical factor that you should be aware of. There is a
genetic disease, hemochromatosis, which causes the body to retain too much iron. (Which is treated
by, no joke, bloodletting.) So if you see too high an iron measurement on your blood test, it’s
definitely a concern. This is a great example of how more is definitely not always better — indeed,
the symptoms of too much iron can easily be confused with the symptoms of too little.
Treatment for excessive iron is wonderfully simple, though: you can treat it quite effectively just by
donating blood frequently!
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
7.8
Vitamin C deficiency
Vitamin C is not a proven villain in myofascial pain syndrome. The recommendation to take it, if
you are deficient, is based on the clinical experience of Drs. Gerwin 300 and Travell. In any case,
Vitamin C supplementation is cheap and safe.
The laboratory test for your blood vitamin C is unreliable because the blood specimen must be
handled in a particular, unusual way for the test to work. If the blood is mishandled, your report
comes back “0.” If that happens, or if the result is below the laboratory reference range, I tell the
patient to take one nonprescription extended-release vitamin C 500 milligram tablet per day.
Regular vitamin C can burn a hole through your stomach, so be sure to get the extended release, or
take a regular tablet with food.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
7.9
Vitamin B12 deficiency
You can be B12 deficient without knowing it: even significant deficiency may be mostly
asymptomatic, and symptoms are vague when they do occur. Common early symptoms are
tiredness, poor concentration and memory, irritability and depression — all of which can be caused
by other problems as well. However, if your serum vitamin B12 is below 350 pg/ml (350 picograms
per milliliter), then this could keep you in pain. 301 This level is higher than the bottom of the
usual laboratory report “normal” or reference range.
Many people have a stomach problem, called intrinsic factor deficiency, which prevents them from
absorbing B12 from food or supplements. Vegans have few sources of B12 in their diet.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
The best way to treat B12 deficiency is with an injection once per month.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
7.10
Vitamin B1, B2, folate, and magnesium deficiencies
Amounts of any of these substances in your blood below the lab “normal” or “reference range”
might perpetuate pain. Eating a healthier diet and taking non-prescription oral supplements at
standard dosages, as directed by the manufacturer, may correct these deficiencies.
Magnesium may be the least important of these. In cases of acute magnesium deficiency, aka
hypomagnesemia, the primary symptoms are weakness, muscle cramping, or rapid heartbeats —
not pain. It has been anecdotally reported as a perpetuating factor for myofascial pain, so I test all
my patients for it. So far, I have not found a case.
Note from Paul: Interestingly, it might be possible to absorb magnesium through the skin in an
Epsom salts bath. Topical delivery remains controversial, and it’s probably not an adequate or
predictable source of supplementation — it’s basically impossible to know how much you’re
getting. People with magnesium deficiency should probably stick to oral supplementation. But this
might might explain why people believe that Epsom salts baths help with aches and pains. See
Does Epsom Salt Work? for a very detailed discussion of Epsom salt bathing.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
7.11
Testosterone deficiency
A downward spiral: Chronic pain and pain medicines can cause low blood serum testosterone, and
low testosterone can in turn aggravate pain. 302 Men or women in pain with serum testosterone
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
below “normal” should get testosterone injections. You cannot get more testosterone into your
blood by taking testosterone or supplements by mouth, despite what supplement sellers say.
Testosterone deficiency must be treated by testosterone injections. The injections may be once per
week, once every two weeks, or once per month, depending on the patient’s situation.
Androgel and testosterone patches are good alternatives, if the patient’s health insurance will pay
for the topical medication. Androgel and testosterone patches are more expensive than injections. I
have prescribed the topical gel or patch for many of my patients, only to have their health
insurance company refuse to pay for it. The insurance has always paid for the injectable. Topical
testosterone must be applied daily, versus a weekly or every-other-week injection. Also, some
people (including me) are allergic to the adhesive of the testosterone patches.
Testosterone is often prescribed simply as a tonic to men who may or may not actually be deficient,
and have no real problem to treat — this should be avoided! Too much testosterone can kill you in
a lot of different ways. It can make you a public nuisance like many of our steroid-crazed athletes
in the news.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
7.12
Estrogen deficiency
Estrogen deficiency can occur at any age in women and is a part of menopause. Below-normal
serum estrogen contributes to pain. 303 Prescription estrogen pills or birth control pills easily
correct the deficiency. Please note that estrogen supplementation to attempt to treat a medical
problem is much more justifiable and less controversial than hormone replacement therapy “just
‘cuz.”
Note from Paul: Estrogen supplementation is a complex and controversial subject. For instance, the
aggressive marketing of bioidentical hormone therapy is hype, not medicine, and you should ignore
Suzanne Somers. And it is not clear that menopausal levels of estrogen are actually a “problem” that
needs to be “fixed,” and attempting to do so may well be risky. By far the most sensible medical
writer on this subject is right here in my backyard in Vancouver, at the University of British
Columbia. Dr. Jerilynn Prior, MD, publishes a great website for The Centre for Menstrual Cycle
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
and Ovulation Research. However, if you are suffering from chronic pain, that gives you an
additional reason to consider estrogen supplementation in spite of the risks.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
7.13
Infections
Many viral infections such as the common cold, flu and others can cause muscle aches, but all you
can do is wait for them to go away.
Hepatitis C virus, on the other hand, is often mostly asymptomatic — you can have it without
knowing it — but it can be found by a blood test, and it can be treated.
Lyme disease may cause pain long after the initial infection. Some people do not know they had
Lyme disease. Blood serum Lyme antibody tests show if you had the disease. 304 Treatment can be
difficult, and it’s controversial.
Note from Paul: controversy alert! Dr. Mark Crislip writes, “I do not think that the data supports
the concept of chronic Lyme disease, and being a Tool of the Medical Industrial Complex (TMIC®),
that is just what you would expect me to say.” For more, see the footnote. 305
Vaginal candida infections may contribute to pain. If they persist or recur after the usual topical
medication, then investigate for causes.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
7.14
Inflammation
Inflammatory diseases such as rheumatoid arthritis, systemic lupus erythematosis and others can
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
perpetuate pain. Their diagnosis includes blood serum antibody tests. Treatment can be
challenging.
Other pain-associated infections and inflammation can be detected by blood serum laboratory tests
for C-reactive protein, antinuclear antibodies (ANA) and others.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
7.15
Smoking
I write you from Virginia, the unofficial capitol of the United States
cigarette industry, where the relatively cheap, machine-made cigarette
was invented, and major producers still manufacture and headquarter.
Laboratories here are actively working on new nicotine addiction
systems for a potential future no-smoking culture. The strength of the
tobacco industry here is such that I fear to speak too loudly, or mention
the names of specific companies.
Smoking was established long ago as a strong predictor of failure of
pain treatment. 306 307 It probably also increases the risk that pain will become chronic in the first
place. 308
Smokers are so difficult to treat for chronic pain that I originally did not include this information in
this chapter of the trigger points tutorial because I will not accept smokers as patients. Back
surgeons of my acquaintance — who glibly hack at peoples’ spines despite the lack of proven
efficacy of back surgery 309 — refuse to operate on smokers for the same reason. What’s the point
in a risky procedure with a patient who is virtually doomed to on-going pain regardless?
In my opinion, quitting is a vital pre-requisite for treatment of any chronic pain problem.
Unfortunately, “hard” doesn’t even begin to describe the challenge of breaking this addiction: the
reported long-term (greater than one year) smoking cessation rate for most quitting products and
programs is from 10 to 20%, with many findings of worse success rates probably “buried” by the
medical industry sponsors.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
See Smoking and Chronic Pain.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
7.16
Overall treatment strategy
Attack on all fronts!
I treat all pain-perpetuating factors at the same time, and not just the medical factors covered in
this chapter. I also evaluate and treat posture, inactivity, activities, sleep hygiene, nicotine abuse,
alcohol use, anxiety, depression, insomnia, life stressors and other problems. I send patients to
other practitioners when needed.
My patients take their nutrient or hormone replacements for one month before I attempt to
deactivate their trigger points. Some patients’ pain goes away during replacement therapy without
any additional treatment.
Some patients may be tempted to take the path of least resistance and just take a multivitamin — a
generic “insurance policy” approach to nutritional deficiency. Travell and Simons endorsed this
approach as better than nothing. However, they also made it clear that they wished for better
scientific understanding and better medical assessment, and some of that superior understanding
now exists. Patients can get better medical assessment by using this guide and with the assistance
of clinics like mine.
I have seen no definitive proof of benefit or harm of taking a daily multivitamin/multimineral.
Unfortunately, in the race to the bottom for production cost, many supplements and drugs do not
contain what their label states, have active ingredients with poor bioavailability, and/or have
dangerous contaminants or adulterants, so taking them has unknown risks as well as unknown
benefits. That is not an approach that I can endorse. Instead, find out what your deficiencies
actually are, and address them specifically.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Part 8
STRETCHING
Stretching is generally over-rated … but it might be good for trigger points
Stretching is the number one thing that people want to try — or just do
reflexively, instinctively — to help their own muscle pain, and the number
one thing that I get asked about. Surprisingly, given the popularity, it’s
not a very effective treatment for treating trigger points (or much of
anything else). However, because it is so popular, and because it does
seem to help some people a little, it deserves detailed discussion in this
tutorial.
The next several sections address the topic extremely thoroughly. (I have
read entire books about both stretching and trigger points that barely
mention the relationship between them, let alone examine it this
carefully!) If you don’t want all the gory details, you can definitely just
Stretching feels good. But is
does it fix anything?
stick with the executive summary in the advanced treatment sections. And
it can all be boiled down even further, to just this:
It might help, a little, but probably much less than you might think, and please don’t overdo it
(because it can backfire).
Stretching has been a popular form of exercise in North America for a few decades now, but no one
can figure out why.
Scientific research has yet to produce any
convincing evidence that one method of
stretching is better than any other for
anything, and in the last decade or so one
medical journal after another has published
papers showing that stretching is basically not
good for much, particularly popular goals like
One medical journal after another has
published papers showing that stretching is
basically not good for much.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
“warming up” and “preventing injury.” Some
have even concluded that stretching is actually
risky, that people tend to injure themselves: bad technique, too much intensity, vague goals and
poor judgement often combine to make stretching a little bit dangerous.
The simple truth is most people (and even professionals) simply don’t know why they are
stretching, and the explanations they come up with when quizzed about it don’t hold up under
close scrutiny. Inevitably, when confronted with the facts and the evidence, people retreat to safe
territory, to a reason that not one can shoot down, or needs to: they tell me that they stretch
because it feels good.
And you know what? Stretching does feel good! Really, really good.
And that is probably why people keep stretching … even though it doesn’t necessarily mean that
there is anything therapeutic about it. Is food therapeutic because it tastes good? Is music
therapeutic because it sounds good? Pleasant sensations and experiences may have therapeutic
qualities, but that doesn’t make them effective therapy.
Why does stretching feel good? And does that good feeling
correspond to any medical benefit? Can stretching-as-atreatment be vindicated? Can it be justified by anything other
than feeling scrumptious?
There could be reasons why stretching is good for pain that we
don’t understand, or are only just barely starting to understand.
So far I’m just summarizing the usefulness
and science of stretching in general, which
is all covered in detail (with references) in
my main stretching article. This tutorial
focusses on the relationship between
stretching and trigger points.
A 2016 study dug up some evidence that stretching reduces
inflammation in connective tissues, 310 and there is also
evidence that inflamed connective tissue is involved in back
pain. 311 The evidence is too scanty to trust yet, but it’s
suggestive. If stretching relieves pain this way, it could explain
why so many people think it works for trigger points.
Quite a Stretch Stretching science has
shown that this extremely popular
form of exercise has almost no
~ 15,000 words
measurable benefits
Or maybe it just works for trigger points. Stretching may
“scratch” trigger points like an “itch,” and it may even truly
banish them sometimes. But there’s even less evidence for that than there is the inflammation
theory. I will now explain why stretching is at best a pretty hit and miss self-treatment method for
trigger points, with many problems in both theory and practice.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
8.1
The anecdotal evidence for stretching (is just huge)
The anecdotal evidence that stretching “works” for trigger points is substantial. Massive really. An
avalanche of faith. People with aches and pains believe that it works. They tell me that it works.
They insist that it works. It’s practically religion. It’s one of the most common of all self-treating
behaviours.
This alone should not impress you, of course. Large numbers of people have been completely
wrong about many things. There are countless examples of this in medical history alone, let alone
history in general. Millions of people can be wrong, and millions of people almost certainly are
wrong about all kinds of benefits of stretching which do not actually happen.
And yet there is a persistent observation that cannot be ignored: many people in pain stretch, and
then they claim to feel better, for a little while at least. I’ve experienced it myself many times.
Stretching doesn’t usually seem to “cure” anything, but darned if it doesn’t seem to “take the edge
off” certain kinds of muscular pain and stiffness, and enough to make it worth doing.
These sensations demand some kind of
explanation. (And this is the purpose that
anecdotal evidence serves: it cannot answer
questions, but it can tell us what questions to
ask.)
People in pain stretch & then they often feel
better. But why? And why doesn’t it last?
For 19 years now, it has been my job — one
way or another — to try to help people whose bodies are hurting. When I hear that stretching
helps, it’s almost always in association with the idea of muscle pain. People don’t tell me that it
feels good to stretch their arthritic knees or their dislocated shoulders. They don’t talk about how
much they like to stretch their lesioned cervical nerve plexuses or their torn hamstrings. Hell no!
Those things don’t feel good! Stretch obviously isn’t a treatment for traumatized tissue.
But they do talk about good-feeling stretches when they have pain that seems to fill their muscles.
Of course, it is equally obvious that these people have not found any lasting relief from stretching.
When I ask them, “What helps your problem?” they will often tell me about stretching … but they
still have the problem. This is important. In my experience, only the mildest cases, and perhaps a small
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
minority of moderately serious cases, actually get any lasting relief from stretching. The anecdotal
evidence may be enthusiastic, but it also seems to clearly show that stretching helps only a little
and only for a little while — roughly as worthwhile as a hot bath.
So we must not only try to understand why stretching seems to be good for trigger points, we must
also try to understand why it isn’t better.
Speaking of anecdotes, there’s another kind of story that people tell: stories of stretching gone
wrong. In fact, I have my own …
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
8.2
Case study: A cautionary tale of stretching: that time I almost ripped my own head off
I am my own laboratory. And sometimes things in labs blow up. I’d like
to tell you about the time I almost ripped my own head off. This is
certainly my worst self-treatment disaster.
And this section is the short version of a story that I tell at greater length
in another article. If you’re particularly interested in how stretching can
go terribly wrong when treating neck pain, I recommend reading the
long version.
Stretching Injury How I almost ripped my own head off! A cautionary tale about the risks of
~ 1,100 words
injury while stretching
I’d had a crick in the neck for about a day, and it was getting worse. I was on Bowen Island, just
offshore from Vancouver, staying in a suite with a great clawfoot tub. I’d just finished a nice hot
soak that hadn’t really put a dent in the neck discomfort, so I decided to do some intense stretching
as well. I had three reasons:
1. It had worked before. Back in 2007, I’d had a particularly good result from a hard stretch of a very
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
similar neck crick. That was a success story, and a good one. This crick felt the same. Perhaps the
same treatment would work again! Hope springs eternal. (So does stupidity.)
2. I was really relaxed and toasty warm from the bath.
3. I like to experiment.
So I started stretching! Not only did it feel good, but the sensitivity eased steadily as I held the
stretch at a moderate intensity, so I upped the ante and started to stretch really hard. This was a
truly strong stretch.
It was that “scratching the itch” feeling that kept me going. It felt like good massage. It felt
satisfying. Something bad was happening but it felt good. I stretched hard and long, and then sank
back into the bath to recover, sighing deeply.
Victory seemed certain. I felt great in the minutes after the stretch. My range of motion was full and
free and painless. I could no longer detect that distinctive cricky sensation in my spine.
But within another half hour, the crick was back. I shrugged it off as a mere failure to treat —
disappointing — but it kept getting worse. And worse. And worse …
Over the next three hours, my annoying little neck crick turned into a full-blown three-alarm fire. It
grew to be so much more intense that it defied quantification. Six times worse? Nine? Does it
matter?
It was baaad.
I had either injured myself, aggravated the problem, or both. For the next three days — long days
of computer time — I suffered the equivalent of a pounding headache in my neck, a hot grinding
ache that had me squirming and grabbing at it constantly. Fat lot of good it did me. Even with all
the tricks I know, I was not able to put a dent in the pain.
The first signs of relief finally came on day four, after a good sleep in my own bed. It slowly calmed
down over the next five days until I had one of those “hey, I haven’t noticed that pain in a while”
moments.
I feel lucky that it calmed down as quickly as it did.
Was it worth the risk? No. I will never take a chance with a hard stretch like that again. I would far
prefer to sacrifice the chance of a quick cure rather than risk ever giving myself another week like
that.
Bear this story in mind as you read on. Don’t assume that stretching must be good for you just
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
because it feels good. In fact, you can’t even assume that it’s safe.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
8.3
Winning a tug-of-war: how stretching might help trigger points in principle
In the weighty text Muscle Pain (2000), expert authors and researchers Dr. David Simons and Dr.
Siegfried Mense are enthusiastic about stretching as a treatment for trigger points. They propose
that “essentially any technique that elongates the muscle out to its full stretch length” constitutes
effective treatment for trigger points therein. 312 “A newly activated, single-muscle myofascial
trigger point is usually remarkably responsive to simple stretch therapy,” they write. Stretching
“by almost any means is beneficial … At least five ways can be used to augment simple muscle
stretch.” 313
They make stretching for trigger points sound good.
Probably too good to be all true. A few pages later, they also write that it has “not been firmly
established” that stretching trigger points is helpful, emphasizing that they are making educated
guesses. No kidding. 314
If stretching ever actually works, it probably works about the same way that stretching out a calf
cramp works: you win the tug-of-war with spasming muscle. It just happens on a smaller scale.
This is superficially plausible. Certainly stretching is the only defense against big cramps.
To understand the how of it, you should bring back to mind some key features of the “exhausted
contraction knot” theory about what a trigger point is: a sick, poisoned patch of spasming muscle
experiencing a metabolic bad day. It is consuming lots of fuel and excreting lots of junk molecules
at exactly the same time that it is choking off its own blood supply. Waste accumulates and irritates
nerve endings (causes nociception), and everything goes downhill. The main idea is that it’s a
vicious cycle (“energy crisis”). Therefore …
If the muscle fibres in a trigger point could be fully elongated by stretching the muscle, they cannot
burn fuel. Muscle fibres can burn fuel only when the working molecules inside the muscle fibre are
mostly overlapping. When stretched out and disengaged, they cannot work, like a hamster without
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
a wheel to run in. According to Simons and Mense, the stretch-state disengages muscle fibres,
interrupts contraction, and presumably allows the energy crisis to abate, the vicious cycle derailed
a little more with each passing moment of stretch.
The proteins in a muscle overlap like the tines of two
forks as the muscle contracts. If they are pulled apart,
they can’t burn fuel.
This is state-of-the-art of trigger point science, such as it is. It is one of the most educated guesses
available, from credible authors on the topic. This is about as close as we’re going to get to a good
rationale for why stretching might help trigger points.
Alas, there are major concerns.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
8.4
The bad news about stretching for trigger points
Even if all of the above is correct — which is granting quite a bit — there are still many problems.
There are so many problems that I’ll be exploring them for the next four sections.
We are in an evidence-free zone, by the way. The efficacy of stretching for this kind of pain has
never been studied well enough to guide us to a conclusion.
There are practical circumstances in which you cannot realistically hope to win a tug-of-war with
your trigger points, even if it works in principle. But there are also reasons to doubt that it even
works in principle, even in ideal circumstances. If it does, stretching probably mostly only works
on the milder cases that don’t matter very much in the first place.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Simons and Mense importantly concede that stretching works primarily for “newly activated,
single-muscle” trigger points, presumably because they think that you can more easily win a tugof-war with a milder contraction knot than a meaner one. Newer trigger points are probably
milder, on average, and milder trigger points probably aren’t contracting as powerfully. The less
extreme physiological circumstances (less painful!) mean that a “defensive contraction” is
relatively unlikely, and that the trigger point is not so tough that it can’t be pulled apart. That is, it
will “fight back” less.
But what about the fiercer trigger points? Exactly how are you supposed to pull apart a powerful
contraction knot — muscle fibres in full spasm — with anything less than a pliers and a vice and a
glass of bourbon? We probably don’t have the leverage or pain tolerance required to actually
elongate the bigger, stronger contraction knots. If Simons and Mense are correct about how this
works, a wee pull is not going to do the job — you have to elongate them enough to substantially
disengage the overlapping proteins that are burning fuel. Simons and Mense emphasize that a
trigger point must be “fully” elongated in order — theoretically — to have any effect on a severe
energy crisis.
Many factors make “fully” elongating a trigger point unlikely.
The first is pain. After emphasizing that you must “fully elongate” trigger points to treat them,
Simons and Mense also wisely caution that the stretch must be applied “slowly and only to the
onset of discomfort.” I agree. Unfortunately, there is no hope of doing this to any seriously hurting
muscle by applying stretch “only to the onset of discomfort.” By their own theory, discomfort will
start when you’ve only begun to tug on a contracted trigger point! If you stop there, you’ve done
nothing — either in theory or in practice. Such a gentle stretch could probably only be useful in the
case of the most minor trigger points. Stretching for such minor symptoms might feel good to
some, but it has no therapeutic importance to anyone troubleshooting serious pain.
People often have such acute muscle pain that they can’t bend over to tie up their shoes. They can’t
fully elongate a Slinky without an onset of discomfort, let alone their trigger-point-riddled muscles.
The second big problem is the biomechanics. In many muscles, a strong stretch is biomechanically
awkward at best, or just impossible.
Some muscles literally cannot be meaningfully stretched at all, no matter how you pretzel yourself.
Most of the quadriceps, for instance, simply cannot be elongated significantly before the
hamstrings meet the calf. 315 Similar biomechanical limitations occur in several places in the body.
The paraspinal muscles in the upper back and lower back are another great example, because they
often harbour some of the worst stiffness and pain in the body, and they are also difficult to stretch
— not impossible, but difficult — simply because the spine does not bend enough or in the right
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
way to apply a firm stretch. There are many other examples of muscles we’d all really like to
stretch, but it isn’t ever going to happen outside of a circus, or without dislocations and fractures.
For more information about this important concept, see:
The Unstretchables Eleven muscles you can’t actually stretch hard (but wish you could)
~ 4,000 words
That’s a macroscopic biomechnical problem with arranging limbs and pulling on entire muscles.
There’s also a microscopic biomechanical problem in principle: trying to stretch out a trigger point is
like trying to stretch out a knot in a bungie cord.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
8.5
Like a knot in a bungie cord
Terms like “tight” and “stiff” describe only a sensation, not a tissue state or functional limitation. It
might be tempting to assume that “stiffness” refers to poor flexibility, at least in part … but people
can and frequently do feel stiff without any apparent limitation in their range of motion. Since
trigger points are so closely associated with the sensations of stiffness and tightness, there are some
strong common assumptions and guesses about how they create that sensation.
For instance, if we accept the contraction knot theory, it
has an obvious implication: all other things being equal,
muscles containing trigger points probably can’t elongate
as much as muscles without trigger points. A trigger
point theoretically reduces the extensibility of a muscle,
Déjà vu? Yes, you’ve seen this before:
there is an abridged version of this
section above.
because a patch of shortened sarcomeres in a muscle is
like a knot in a bungie cord.
Killer analogy, right? If I stopped there, I’d have quite a
compelling story/image that artfully connects the dominant idea of how trigger points work with
an incredibly familiar human symptom. It “explains” how trigger points restrict range of motion …
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
which in turn strongly implies the need to stretch them out. Such stories are the bread and butter of
many professionals who want to put a little science sauce on their work. But if it sounds too good
to be true, it probably is. It is a lovely analogy in several ways, but it only goes so far, because …
A knotted bungie cord actually still works well. (And they are a lot simpler than muscles.)
I’ve tried a blindfolded test of pulling on two medium-length bungie cords, one knotted and the
other not, and I cannot tell the difference by feel alone. Try it. You can’t feel it because a bungie
knot affects only a small segment of the full length of the cord. Only at the extremes of stretch are
you going to see any difference in the maximum length, and that much is probably true of knots in
both muscles and bungie cords.
And good luck stretching the knot itself! The stretchiest parts yield first, and a lot. In fact, you will
probably take up all of the slack in the elastic components of a muscle and its tendons before even
starting to apply tension to any trigger point it contains. It will just sit there, a rigid section of an
otherwise elastic structure. You’ll have a few contracted sarcomeres surrounded by stretched (or
even over-stretched) sarcomeres.
Another difference between bungie and muscle is significant: while a knot in a bungie cord affects
the entire cross-section of the cord, a trigger point afflicts only a small part of the total crosssectional area of a muscle. So a trigger point in a muscle is more like a knot in one bungie cord that
is part of a whole bundle of bungie cords, most of which are not knotted. One knot in a single cord
in the bundle is not going to have a significant effect on extensibility of the whole bundle, and
stretching the bundle will not have a significant effect — none really — on a knot in one of the
cords.
This matches what we see in the real world: although trigger points are very common, significant
restriction of range of motion with no other clear cause is not common. In general, muscles seem to
elongate as well with trigger points as they do without. What seems like an obvious problem in
principle when playing with cool analogies is probably completely trivial in biological practice.
But it is nevertheless possible that many severe trigger points could limit flexibility enough to be
obvious. The effect could also completely depend on what kind of muscle we’re talking about. It
might be much more of a problem in shorter muscles, for instance. And it’s possible that there is an
effect on muscle extensibility that has nothing to do with the mechanics of contraction and
everything to do with the discomfort — neurology, not mechanics. We feel the knot, even if we
can’t actually detect any limitation in ROM.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
8.6
The spray-and-stretch method, if it works, implies that stretch alone may not work
I’ve reviewed several practical and theoretical challenges for stretching trigger points so far. Here’s
a logical problem with stretching trigger points that’s a bit glaring.
Travell and Simons — considered the world’s original experts on myofascial trigger points — were
very keen on an augmented stretching method called “spray and stretch,” which must be applied
by a skilled therapist. This method features prominently in The Big Red Books, with high quality
illustrations demonstrating how the method should be applied for most muscle groups in the
body. Basically, the stretch is supposedly enhanced with a spray that cools the skin. Many
therapists believe that Travell and Simons’ method means that stretching must be unequivocally
good for trigger points … forgetting the reason for the spray.
The spray is important, according to Travell and Simons! They actually caution against stretching
without it — supposedly the coolant provides an important sensory “distraction” from the pain of
stretching a dysfunctional muscle (jargon: the spray acts as a diffuse noxious inhibitory control).
Without the distraction, the nervous system might otherwise react “defensively.”
This rationale for the spray and stretch technique is obviously based on the assumption that
muscles may resist painful stretch without the help of the cooling spray. And I think they do: that
matches my clinical experience, and extensive personal experience with my own muscle pain. And
so apparently, according to Travell and Simons, sprayless stretch is actually a poor treatment method,
especially for the worst trigger points. But if stretch-without-spray is fine and effective, then
Travell and Simons were just wrong on an critical point.
We can’t have it both ways, and either way is a bit discouraging.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
8.7
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Other practical limitations of stretching for trigger points
After all the complex theoretical, practical, and logical problems with stretching, here’s a
refreshingly simple one: self-stretching is just imprecise and inefficient! Even if it “works,” it’s just
too blunt an instrument. Trigger points are small and finicky, and stretches are “big.”
Trying to get at ... relatively small trigger points by stretching whole groups of
recalcitrant muscles seemed unnecessarily indirected and inefficient.
The Trigger Point Therapy Workbook, by Clair Davies, p. 8
Most people have only a little anatomy knowledge. It’s obvious how to stretch many muscles, but
there are a number of important ones that aren’t so obvious. No patient has the faintest idea how to
stretch the infraspinatus muscle until they’ve been trained. The infrawhatus? It’s anatomically
obscure, and yet clinically important.
Even if stretching worked perfectly on every trigger point, trigger points are usually quite
numerous … and stretches are slow. It could take literally hours to thoroughly stretch every muscle
containing trigger points relevant to a particular pain problem … assuming that you even know
which muscles to stretch, and how to stretch them.
And referred pain, of course, probably fools people into stretching the wrong muscles.
These are all practical problems with stretching even if it actually works. They are a factor
regardless of the biology. They go a long way to explaining why stretching doesn’t seem to be
saving many people from trigger point pain.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
8.8
What about neurology? Stretch tolerance
Just to emphasize the depth of the theoretical uncertainty about stretching, now I’m going to give
an example of a completely different theory of how stretching might be helpful!
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
The grumpy elephant in the corner here — for this whole book, really — is that the exhausted-tinycramp idea could just be wrong, in which case good luck “interrupting” it with stretch. It may be
the best-educated guess available today, but it could still be wrong, in which case stretch simply
can’t help trigger points.
What if trigger points are merely a symptom or an illusion of a neurological cause of pain? Stretch
might still help, but it would have to do so by a completely different mechanism, with its own pros
and cons. Stretching might still help even “pure pain” in muscle — even if there isn’t a contraction
knot. This could actually be more a more plausible explanation for why stretching sorta kinda
helps.
We know (pretty well) that a diligent stretching habit
increases flexibility, but probably not by actually changing
muscle and connective tissue (or not with any ordinary
stretching effort, anyway). Fascinatingly, it is probably just
our tolerance for stretch that increases with practice. 316
Muscle elongation is normally strictly limited by the brain
and spinal cord, and only with repeated exposure to strong
stretch can we “get used to” the discomfort and gradually
push the limit back.
Trigger points might be a symptom or side effect of the
nervous system imposing excessive limits on muscle
extensibility. If so, they might — sometimes, when the
Muscle & connective tissues are very difficult
to physically change with stretch. It is
probably just sensory tolerance for stretch
that increases with practice.
planets align — fade away as we train ourselves with
stretching to tolerate greater muscle extensibility.
It might also explain why stretch seems to backfire fairly often: because stretch is challenging a
neurological edict. The wisdom of the body does not impose limits without some reason … and it
may fight back. It is usually neither easy nor safe to “argue” with your spinal cord’s opinion of
how flexible you should be.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
8.9
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
What about stretching the antagonist muscle?
An “antagonist” muscle is a muscle that pulls a joint in the opposite direction. The triceps and
biceps are antagonists to each other: the biceps flex the elbow, the triceps extend it. Agonist,
antagonist. Could it be helpful to focus stretching on the antagonist to the muscle with a suspected
trigger point? This is an idea that crops up now and then.
That’s just unknown, and not likely to be all that effective, but it is a little bit plausible and worth
experimenting with. If it works, the effect would likely be entirely neurological. Certainly the
nervous system treats a joint as a system, and sensory input received from any part of the system
may change how the system is behaving. Stretching the antagonist might be a good way of
stimulating the system without directly challenging the trigger point. Work on both sides of the
functional equation of the joint, as opposed to just yarding on one side of it.
The main down side is that there’s no particular reason to think that this particular stimulation will
have much effect. It’s indirectness is a both a highly speculative advantage and it’s obvious
disadvantage: it may just not be relevant.
Another discouraging consideration is that there are many common locations for trigger points
where the antagonist is either unclear, or seems — I can only cite my intuition here — especially
relevant. For instance, trigger points in the low back and buttocks are common, but stretching the
hip flexors and abdominals seems rather futile. The sensation of stretching the trunk and hip
flexors doesn’t feel like it has anything to do with stiff and aching butt and back.
Other antagonists do feel more relevant. The best example I can think of is the forearm: whenever
the forearm extensors are rotten with trigger points (as they often seem to be), the forearm flexors
seem to be quite pleasing to stretch as well (pulling the hand and fingers backwards).
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
8.10
Stretching “conclusions”
Stretching for trigger points is an inefficient and imprecise crapshoot, afflicted with countless
theoretical and practical problems — and yet that does not mean it’s useless. Almost everything
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
therapeutic is “inefficient and imprecise.” Life is messy, and lots of solutions are imperfect: that
doesn’t mean they should be ignored.
Although people may routinely be misled by referred pain to try to stretch the wrong muscles, I
also trust that many people have sufficient body awareness that, sooner or later, they will find
more relevant stretches by trial and error — especially with the aid of the systematic stretching and
wide variety of postures and movements experienced in yoga or Pilates classes.
Stretching probably does have at least a small therapeutic effect on milder trigger points some of
the time. This probably explains why it often feels so good, and partially, temporarily relieves pain
and stiffness.
But please bear in mind that conventional stretching, as we know it — sustained, static elongation
of muscle tissue — is almost certainly not the best method. For instance, there are some excellent
reasons to believe that rhythmic, repetitive movements — dynamic stretches or mobilizations —
might have a better chance, probably because they are more neurologically and metabolically
“interesting” than stretch.
Yet there is no research validation for using
any method of self-stretching to release trigger
points. As long as this remains true, feel free
to do your own research. Just be cautious with
strong stretches of more severe trigger points
in the shorter muscles, because it can backfire.
Conventional stretching is almost certainly not
the best method of stretching to release
trigger points.
And beware of wasting your time, not so
much because the benefits of stretching trigger
points are unknown and controversial at best — which they assuredly are! — but because there are
other treatment methods that are almost certainly more useful. This is the worst problem with
stretching for this or virtually any other reason: just that it’s too inefficient and too uncertain, life is
full, and there are probably better things you could be doing with your time. You should only try
to stretch your trigger points if you seem to get results. If it isn’t working for you, experimenting
thoroughly is a long shot: better to just move on.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Part 9
GETTING HELP
How do you find good therapy for your trigger points?
Getting good professional help for your trigger points can be difficult. Remember, the evidence is
clear that most professionals can’t reliably confirm the location of trigger points. Although there is
a lively community of health care professionals who understand trigger points well, it is a small
community — they are spread thin and are often difficult for patients to find. How is a patient to
know the difference between a therapist who really has substantial expertise in trigger point
therapy and one who only knows the basics yet claims to do trigger point therapy? In the sections
ahead, we’ll try to help you solve this puzzle.
Generally speaking, massage in its many forms is the best flavour of therapy for trigger points. It
offers the best bang for your buck. It is the type of physical therapy most likely to provide relief.
Massage therapists work directly with muscle tissue, by feel, all day, every day. Therefore, even the
most poorly trained massage therapists often have at least some concept of what a trigger point is,
and some idea of how to help.
I often tell people to choose the therapist, not the therapy, because the competence and dedication
of an individual health care professional is almost always the most important factor in the quality
of care they provide — not the particular profession they got into. In other words, a competent
professional of any kind is almost always better than an incompetent professional in any other
profession. However, trigger point therapy may be an exception to this rule of thumb.
Whereas massage therapists are inevitably, directly exposed to
trigger points, most other kinds of therapists and doctors really
have to “go out of their way” to learn about trigger points —
they are extremely unlikely to learn much about them
“naturally” as a part of their work. Although a few do make a
point of studying trigger point therapy, most do not. Those who
do could be valuable resources for you. Those who do not are
usually worse than useless, extremely likely to misdiagnose — to
“see a nail” because “all they have is a hammer.”
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
Of historical interest, my old conflict of
interest : I retired from clinical practice in
2010, but I think this disclaimer is rather
interesting, so I’m going to keep it around
for a few years. Here’s what I wrote about
my conflict of interest back in the mid 00’s,
when I was first creating this book and also
working full-time as a massage therapist …
I have to acknowledge a blatant conflict of
The Complete Guide to Trigger Points & Myofascial Pain (2019)
The challenge for the patient is to know enough about trigger
points themselves to quickly detect the difference between health
care professionals who do and do not know much about trigger
points. It may be simpler just to err on the side of massage
therapy, because the odds of finding a massage therapist who
understands trigger points well are generally so much higher.
Nevertheless, here’s a bird’s eye view of your options for
professional therapy. All of the types of therapies mentioned
here will be discussed in detail further below …
interest in this section: this is a rare case on
my website where I recommend massage
therapy as the “best” therapy for a problem.
It’s a conflict of interest to make that
recommendation, of course, because I am a
massage therapist, and I make my living
selling massage therapy. However,
acknowledging the bias is the best I can do:
I still have it! I do believe that massage
therapy is the most likely source of effective
treatment for trigger points for most people,
most of the time. However, I will also
explain in detail that massage therapy as a
profession often fails to help people with
their trigger points.
9.1
Types of therapists and doctors and their relationship to trigger point therapy
Physiatry, or physical medicine and rehabilitation (PM&R), is the medical speciality devoted to
rehabilitation and many musculoskeletal problems not addressed by other doctors. Think of them
as “super physiotherapists.” Their job is to restore optimal function to people with injuries to the
muscles, bones, tissues, and nervous system (such as stroke patients). This field has a broad scope,
and many physiatrists may only be interested in and knowledgeable about more serious injuries
and diseases (i.e. not muscle pain, even severe and chronic muscle pain). For instance, when my
wife suffered a serious spinal fracture in a car accident, a physiatrist managed her rehabilitation in
collaboration with surgeons and other specialists. Despite the importance of their expertise to
seriously injured patients, however, of all medical doctors, they are the most likely to be welleducated about muscle pain (yay!) and may be able to accurately diagnose, locate and treat trigger
points. The right physiatrist might be hard to find, but is also the professional most likely to be the
best for a difficult muscle pain job.
Rheumatologists deal mainly with clinical problems involving joints, soft tissues and the allied
conditions of connective tissues. This might seem to be an ideal fit for myofascial pain syndrome,
but it’s not. Few rheumatologists are interested in “garden variety” muscle pain — their expertise
is almost entirely devoted to autoimmune disease and some other serious medical problems. In my
career, I can only remember a couple of cases of a rheumatologists who showed the least bit of
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
interest in a muscle pain case. The vast majority simply screen for autoimmune disease, and that’s
the end of it. And yet many muscle pain patients are sent to rheumatologists by family doctors
because muscle pain is not suspected.
Massage therapists are generally the most likely source of trigger point therapy, but the quality
varies widely. Massage therapists will almost exclusively use massage therapy, but a few might use
stretch and spray, which is a good option.
Physiotherapists work hands-on quite a lot, and are probably the next most likely kind of
professional to have any kind of trigger point expertise. However, they are probably a somewhat
distant second in North America, because the profession on this continent is dominated by a
business model that depends heavily on short appointments and numerous technological
treatments of dubious value. Physiotherapists who do study trigger point therapy usually treat it
with massage, high-intensity ultrasound, or dry-needling (IMS). Physiotherapists abroad are more
likely to spend longer with their patients per session, and generally have a more physical approach
to their work. Maybe I’ve just gotten lucky, but the Aussie and New Zealish (sic) physiotherapists
I’ve met have been unusually good.
Chiropractors also rapidly accumulate hands-on experience, and the best of them may do massage
as well as joint adjustment, and they are capable of being excellent trigger point therapists when
they study the subject. However, only a tiny fraction of chiropractors do so. Joint adjustment alone
is probably of limited value to trigger point therapy, and the few chiropractors who do any kind of
muscle manipulation tend to do so without much knowledge of trigger points, practicing primarily
ART® or Graston Technique instead, both of which are also probably of limited value for trigger
point treatment. And, like North American physiotherapists, the chiropractic business model is
dominated by short appointments, which are never adequate for trigger point therapy.
Medical doctors are an unlikely source of trigger point therapy, and the extreme minority of those
who have knowledge of trigger points usually use injection therapies almost exclusively (which is
not necessarily a bad thing, but it is often premature — conservative therapies should be tried
first). Once in a while you’ll find one who works with dry-needling (IMS), high-intensity
ultrasound or TENS, and perhaps stretch and spray.
Any kind of medical specialist working in a pain clinic — there are usually a couple pain clinics in
every major city — are by far the most likely to know anything about trigger points. The specialists
most likely to know something about trigger points are sports medicine doctors, orthopaedic
surgeons, rheumatologists and neurologists. However, in all cases, their knowledge is usually
limited to simply knowing that trigger points exist, and it’s only a rare one that actually knows
what to do about them. However, a doctor who will diagnose myofascial pain syndrome can at
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
least be useful for insurance purposes, even if they can’t treat it!
Naturopathic physicians are perhaps slightly more likely than mainstream physicians to offer
trigger point therapy, but practitioners of that profession hold such a wide range of beliefs about
health care that I don’t generally recommend “going there” — there’s a high risk of being charged
for expensive diagnostic procedures like Vega testing, or therapies like homeopathy, both of which
have failed every scientific test they’ve ever been given.
Acupuncturists are unlikely to help your trigger points. Their only method of treatment is
acupuncture, of course, and it is mostly debunked as a trigger point therapy below.
So, once again, you can see how massage therapy is probably your best bet for trigger point
therapy. So, our next challenge is to address the quality control problem in massage therapy …
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
9.2
Massage quality control issues (“But I’ve already tried massage therapy … ”)
Massage therapy may be the therapy most likely to succeed, but a great many patients have
already tried massage therapy … and given up.
Unfortunately, there are many significant challenges in trying to find effective trigger point
therapy. I routinely hear from people around the world who live in small towns and remote areas
and cannot find a massage therapist who seems particularly qualified to treat trigger points,
assuming they can find any kind of massage therapist at all. Even people who live in or near cities
often struggle to find the right therapist. Consider this typical report from a reader (and also a
professional himself, a chiropractor, with a clear sense of what he’s trying to find):
I’ve been to just about every massage therapist around — I love massage — and no one
does trigger point therapy, even when I direct them exactly how I would like it done.
Why is it so hard to find effective trigger point therapy? There are a lot of reasons. First, there’s
several problems with quality control in massage therapy generally:
Training and certification standards vary dramatically around the world, and are literally zilch in
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
many states and provinces in North America. 317 There are no large directories of well-trained,
certified therapists.
The profession attracts people with beliefs that are not consistent with medical science. Some such
beliefs are quite outlandish. 318 Bluntly put, a lot of massage therapists are flakes. For instance, a
huge percentage of therapists practice “energy” massage — massaging your aura.
Many more therapists are preoccupied with “advanced” or “subtle” techniques of dubious value.
Industry turnover is high. Many therapists burn out early with arm and hand injuries, long before
they have the chance to get more seasoned, confident, and skilful.
Both public and private insurance for massage is sketchy, which is a catch-22: the profession has
difficulty standardizing and upgrading without insurance industry support, but insurers won’t
offer funds for massage therapy until it’s more medically credible.
And then there’s several more problems with trigger point therapy specifically:
More training and certification issues: there are few widely known certification programs for
methods of trigger point therapy. Travell & Simons never got into the business of certifying
therapists … which is actually a good thing. I have serious concerns about the certification systems
that do exist. 319
Many know almost nothing about trigger points at all. They simply don’t have the education. 320
Most of those that do know a little about them know too little and are overconfident: they “believe” in
trigger points, rather than understanding the history, science, and controversies. 321
Difficult cases involve many factors that massage therapists are largely unaware of, and unqualified
and legally unable to advise patients on. 322 Meanwhile, the importance of some factors (like
posture and ergonomics) gets way too much air time.
And so, myths and bogus treatment concepts have always been rampant in the world of trigger
point therapy. It’s a mess.
Trigger point therapy does not come standard in massage therapy offices — it is a specialization
without standards or regulation. It is not reasonable to expect all massage therapists to understand
how to treat serious trigger points properly. Most massage therapists are unprepared to treat
anything worse than mild-to-moderate cases of isolated trigger point pain.
And this is why readers from around the world so often tell me that they have “already tried
massage therapy,” but got no relief. It’s pretty clear that they didn’t get good good massage
therapy. Specifically, the probably didn’t get good trigger point therapy.
If you’ve already tried something branded as trigger point therapy, and failed to get good results,
do not give up yet!
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
9.3
Two case studies: highly-trained therapists failing miserably
This section presents two stories of well-trained massage therapists failing to understanding basic
things about trigger points. Both problems were also success stories in the end, easily and
completely treated without difficulty: a persistent headache, and a chronic shoulder pain, both
relieved indefinitely in a single appointment.
Case study #1
“No one has ever pressed on that spot before”? Really?!
A young woman with a long history of completely unreasonable chronic headaches sought
treatment from three of my colleagues — three unusually well-trained Registered Massage
Therapists. 323 These people were my colleagues: what would usually be called “medical”
massage therapists most other places, and, in theory, the créme de la créme of massage therapy. Any
BC-RMT could walk into virtually any jurisdiction in America and be — by far — the best-trained
massage therapist available to that population.
My client had seen three of these elite therapists before coming to visit me, but had not gotten any
relief whatsoever. She enjoyed the massages, but unfortunately did not find them therapeutically
useful.
I soon found out why.
Not long after I started her first treatment, I checked for unusual sensitivity in her suboccipital
muscle group (a “trigger point,” a common sore spot linked to tension headaches). This is an
assessement procedure I consider to be as automatic as breathing for a client with her symptoms —
I can’t imagine not doing it. And I immediately found what I was looking for: a highly relevant
trigger point, which is exactly what you’d expect to find in about 60% of cases.
What happened next is what makes it a good story. My client said in amazement (emphasis
definitely hers):
That’s it! That’s where my headache is coming from! You’ve got it! And no one has ever
pressed on that spot before.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Really? Could this possibly be? I asked her to confirm this in detail, because I found it so strange.
Looking for and treating suboccipital trigger points is one the most elementary things I can
imagine a massage therapist doing for a client with chronic tension headaches. Not only is it a
classic spot for massage therapy for headaches specifically, it’s one of the most most useful and
pleasant targets for good massage anywhere in the body — “Perfect Spot #1”! And yet three other
fancy RMTs had not only missed it, but apparently had not even looked for it — an inexplicable
oversight.
Actually, failing to massage suboccipitally in a
headache patient is worse than an
“inexplicable oversight”: it seems almost
impossible to believe that well-trained
massage therapists could make this mistake.
“No one has ever pressed on that spot
before.”
But, unfortunately, such failures may be
typical of the state of trigger point therapy in
the world today — even from “elite” therapists.
A little massage of her trigger points relieved her symptoms for several months at least.
Case study #2
Missing the point: failed trigger point therapy for a simple shoulder case
In another common and disappointing scenario, massage therapy is focused … but focused on the
wrong tissue. This story is about a determined and experienced patient, a middle-aged woman
with severe, chronic shoulder pain on the “end” of her shoulder — where an officer’s epaulets
would be — and radiating downwards on the side of her arm and through her biceps almost to the
elbow. It was a nagging, sickening pain, like a toothache in her deltoid muscle.
She had been diagnosed with a whole bunch of common shoulder conditions, basically all of them
— which is typical when someone has a nasty trigger point. Such people tend to get diagnosed
with every possible thing except the trigger point.
What made her case a bit unusual was that she
really had given physical therapy and massage
therapy a good chance to work. She had seen a
massage therapist and a physiotherapist
concurrently and frequently for 12 weeks. But
It was a nagging, sickening pain, like a
toothache in her deltoid muscle.
she had gotten exactly no relief. And, if two
therapists working with a cooperative,
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
diligent client continuously for many weeks hadn’t helped her … what chance did I stand of
making a difference?
I cautiously quizzed her about exactly what kind of therapy she had received. “Oh, trigger point
therapy,” she said. “She did detailed trigger point therapy on my shoulder muscles.” That sounded
good. She almost certainly had shoulder trigger points! But why hadn’t she gotten relief?
“Did your massage therapist ever work here, on the back of your shoulder blade, several
centimetres away from the location of your symptoms?”
“Oh, no,” she replied. “No, she only worked here,” she said, pointing clearly at her deltoid and
biceps — the exact location of the symptoms.
Uh oh. Well, there’s your problem, I thought.
“Twelve weeks of that?” I asked. “Only there?”
She nodded. “Why? Is that bad?”
Yes, that is bad.
Her therapists had never checked a likely cause of this particular pattern of symptoms — which
happens to be the infraspinatus muscle on the back of the shoulder blade, several centimetres away
from the symptoms. Infraspinatus trigger points have a highly predictable pattern of referred pain
— knots in that muscle cause pain on the end of the shoulder, and the side and front of the upper
arm, exactly like this patient’s symptoms.
Every massage therapist should know this. A massage therapist who doesn’t know it is flying
blind, doing massage that is about as therapeutic as a manicure.
So what happened? Her shoulder problem, after almost a year of misery and misdiagnosis, was
100% relieved by a single dose of infraspinatus treatment. Just one properly directed massage. She
sure was happy!
It doesn’t always go quite that smoothly, of course. A therapist may have to spend a fair bit of time
looking for sensory relationships like this, and it can be tricky even if when single trigger point
really is the only problem. But the point is that any good therapist will be trying to do that. Without
knowledgeable exploration, it can’t be good trigger point therapy. And there should be pleasant,
satisfying massage along the way — that’s the valuable consolation prize, if hunting for and
prodding trigger points should fail to produce therapeutic results, which is of course all too
possible.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
9.4
Worst practices in massage therapy
Massage therapy is like pizza: even when it’s bad, it’s pretty good. But when you’re in pain and
you really need competent help, your standards go up, and you start to notice that a lot of so-called
therapeutic massage is a bit sketchy.
From 2001 to 2010, I systematically asked patients why they left previous massage therapists. The
experiment continues in correspondence with readers today. I have heard it all. Excessive pressure
is the most common problem, and massage that is only “skin deep” and unsatisfying is a close
second. (See The Pressure Question for more about that.)
But I have also heard a litany of basic
problems with customer service. You’ve heard
of “best practices” — a bit of a buzzword for
the last few years. Well, these are some worst
practices in massage therapy. For example:
The most common reason patients leave
massage therapists is “too much pressure.”
The second most common? “Not
“He spent the entire time talking, mostly
telling stories with lots of hand gestures. I’ll
pressure.”
bet, in the entire hour, he spent less than
50% of the time with his hands actually on
my body. Furthermore, he was a middleaged man, and his topic-of-the-day was
how he was feeling frustrated because he was still attracted to young women. Good grief!”
enough
“I had been three times already, and every time she ignored what I asked her to work on. The
fourth time I went, I told her that I was feeling frustrated by this, and that I really did not want to
work on my lower back, but wanted to work on my shoulders instead. I was that clear. Shoulders.
Not back. No lower back, please. Then she started the massage with 15 minutes of work on my
lower back. I was so flabbergasted I didn’t even say anything. What do you say to someone like
that?”
“The pain was ridiculous. I told her I was sensitive. I told her I didn’t want a no-pain-no-gain
treatment. I stopped her at least a half dozen times and asked her to back off, and she would at first,
and then it would creep right back up to agonizing again. I was a wreck for days!”
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
This is a random sampling from about one third of such recent conversations that I’ve had recently
… in the last month or so! And these are Registered Massage Therapists in Vancouver, Canada,
with our much-vaunted standards.
What’s a patient to do in a sleepy midwestern town in the US, in a state where “medical” massage
is simply an unheard of specialization? Where the only massage to be had comes from an old hippy
bodyworker who speaks passionately about reflexology and wants know what colour the pressure
makes you think of?
Oh, dear.
One day I got a somewhat cranky email from a representative of an association of trigger point
therapists, criticizing me for giving the impression to the public that patients can’t find good help
for their trigger points. And yet her own organization’s so-called “directory” of therapists offers
barely more than a few dozen therapists listed for the entire United States … and 90% of them were
in the big cities. As much as I agree that there are many dedicated and talented trigger point
therapists out there trying to help, there simply aren’t enough of them.
My own worst massage ever
I knew I was in trouble the moment I walked into her office: the place reeked of essential oils,
enough to give me a headache, her shelves were festooned with crystals, and her walls were
covered with Scientology posters. If I’d been just a bit older and wiser at the time, I would have
walked out immediately. Unfortunately, I stayed — perhaps out of morbid curiosity.
Cheesy, loud new age music, of course. Violently strong pressures, and total disregard for my
requests to ease up. Rapid, erratic changes in
technique, intensity and location — one
moment she was wrenching my neck, the next
slapping my back, and a few seconds later she
was driving her elbow into my kidneys. And
so on and on. It felt more like an assault than a
massage. She actually shoved the heel of her
She actually shoved the heel of her hand into
my eye socket, apparently by accident — I
wonder what she actually intended to do?
hand into my eye socket, apparently by
accident — I wonder what she actually
intended to do? For what purpose, exactly, would you shove so hard and suddenly on any part of a
person’s face that you might accidentally miss?!
At the very end, she drenched her hands in some floral scent that made me want to throw up,
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
covered my nose and mouth, and commanded, “Breathe! Deeper! Deeper!”
At the end, great insult was added to injury: not only was it the worst massage I’d ever received, it
was also the most expensive at $110/hour.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
9.5
How to find good trigger point therapy
I constantly hear from readers who have been dissatisfied with therapeutic massage, and the most
common question I get (by far) is:
Can you recommend a therapist in [insert any place on Earth]?
I have been asked a thousand times if I can recommend a therapist in Europe, Asia, India, Africa,
Australia … whole continents where I know only a few people, and only thanks to email and
Facebook and Twitter. And so, unfortunately, the question is mostly impossible to answer. I really
need to know a therapist well before I’m prepared to recommend his or her services … and I don’t
know them if haven’t been on their table a few times. Even right here in Vancouver I barely know
any therapists that well. And even if I did, they’d soon be too busy to take new patients (or they
move, or they retire).
Here are some tips for locating a therapist who will be able to help you with trigger points.
The high-maintenance test
When you start with a new therapist, ask for what you want, and watch what happens. Be politely
demanding. In particular, be picky about pressure. Ask for more or less as needed throughout the
treatment. Be nice about it, but say things like, “That’s a bit too strong for me right there, could I
get a little less?” If you get a no-pain-no-gain response, counter with this: “Sure, okay, but I’d still
like a little break from the intensity for a couple minutes — I need to catch my breath and relax a
bit.” Or, if it’s too fluffy a treatment for your tastes, ask for more pressure.
If your therapist doesn’t respond well to your clearly expressed preferences, never go back. This is
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
the most efficient (and likely) way of eliminating therapists who aren’t worth paying.
If your therapist doesn’t seem to hear you, or is dismissive, never go back. This is the single most
efficient (and likely) way of eliminating therapists who aren’t worth paying.
The letters-behind-the-name test.
Find out what the certification standards are in your state or province. Do some Googling. Does
your government regulate massage therapy? How much? What does it take for the massage
therapists in your region to become massage therapists? Now that you know what the standards
are, use them, and favour the therapists who are well-trained and certified.
Credentials really do not guarantee anything, but they are better than nothing. Look for someone
with letters behind their name, preferably a “BSc” (although that’s a long shot in most places), but
at least “LMT” or “RMT” (licensed or registered massage therapist). I am not saying that
unlicensed bodyworkers can’t be good therapists — some of them are truly excellent — but just
that your odds are better with someone credentialed.
“Medical massage” on the sign is usually a good sign
Favour therapists who advertise “medical” massage therapy, especially in jurisdictions with low
certification standards. It may be a false front, but it usually indicates a therapist who has
promising aspirations to professionalism. For instance, it strongly suggests that they are more
interested in working with physicians than against them. The odds of finding good trigger point
therapy are definitely higher in such offices.
“Sports massage” is much less of a gaurantee, but it’s better than nothing: therapists interested in
sports massage are a little more likely to be focused on sensible goals and techniques.
The big-red-books test
You can check on this before you even book an appointment: call therapists and just ask them if
they know the work of Drs. Janet Travell and David Simons. Tell them you are looking for a
therapist with specific skills. Be an assertive consumer, and just politely ask, as easy as asking for
their rate: “Do you know the big red textbooks by Travell and Simons?” If they don’t immediately
say, “Of course,” then thank them for their time and hang up the phone.
On the other hand, it’s another kind of good sign if they express any kind of skepticism or concern
about trigger point therapy … because knowing that there is a controversy is probably more
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
important than which side of it they are on. A therapist who doesn’t think the big red books are any
kind of bible is likely a well-read and a creative and independent thinker — and more valuable to
you than a therapist who has no clear opinion about it one way or the other.
Let the results speak for themselves
Try it out! If you haven’t seen some sign of progress after your first 3-6 hours of therapy, stop going:
you need compelling reason to wait any longer than that for results. There is some “wiggle room”
for things getting worse before they get better, but not that much, and definitely beware of
excessively poor results, like feeling too sore and sick after a strong massage (as discussed above in
Troubleshooting negative reactions to treatment.)
If you’re having trouble deciding whether or not continuing with a massage therapist is worth it,
see the section on measuring progress.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
9.6
The Pressure Question: how much is too much?
For the whole decade I was a massage therapist, the most frequently discussed questions in my
office was “the pressure question.” How much is enough? How deep is too deep? Should deep
tissue massage be painful?
(There’s some duplication in this section with the troubleshooting negative-reactions section.
Figuring out if a reaction is negative or not has some things in common with figuring out how
much pressure is the right pressure. I’ll try not to repeat myself much. Just bear in mind that both
sections are relevant to each other.)
There’s rarely any justification for extremely painful massage, unless it clearly produces a better
result than gentler treatment — and that is rarely clear. It is possible that a few “brutal” massages
could do the trick where gentler treatment would fail — but there is no way to know this in
advance, and massage is expensive stuff. If you’re going to gamble on a treatment strategy, gamble
on cheaper and less painful ones.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
The reason the Pressure Question exists is that it’s hard for patients to tell the difference between
nasty pain that might be a necessary part of therapy, and ugly pain that is just abusive. Not
everything that hurts is therapeutic, but not every therapeutic procedure painless! How can we tell
if an intense massage technique is therapeutic or not?
Survey says: a super scientific poll of massage therapy clients
On my client intake form, I asked clients why they left their last massage therapist. The results,
after several years of doing that …
Why people
55%
20%
20%
5%
“fired” their massage therapists
too intense 324
not intense enough
unfocused or wrong focus
other
People vote with their feet, and it seems clear from the results of this informal poll I’ve been taking
that many people have been dissatisfied with the pressure they’ve received during massage. They
do not like their massage to be too painful … or too fluffy, regardless of whether or not they think it
works. 325
People also clearly don’t like their preferences
to be ignored. Many of these clients, whether
they wanted less pressure or more, have told
me that massage therapists should ask about
the pressure, to find out what each person
wants. So there is one point, above all, that I
would like to make about pressure …
People vote with their feet & they do not like
their massage to be too painful … or too
fluffy.
Everyone’s different: massage pressure tolerance is incredibly varied
It fascinates me just how different people can be in this regard. Pressure that would be quite
comfortable for one person would certainly cause severe pain and emotional distress in another,
and probably even injury. 326
These differences can also occur between body parts. Pressures that worked well on the back can
prove to be disastrously intense in the lower legs. And pressure tolerance changes with time:
pressures that seemed fine on Tuesday can be brutal on Friday.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
All of this highlights the necessity of trigger point therapy that is:
communicative
respectful
attentive
That is, regardless of all other considerations, a massage therapist must talk to you about pressure,
respect your preferences (they are more important than any treatment ideology), and be careful
about stumbling into areas that need much less pressure (for comfort) or much more pressure (for
satisfaction). Far too many therapists make the mistake of setting a “default” pressure for a client
early on, and then using roughly that much pressure everywhere.
And if therapy isn’t communicative, respectful, and cautious? If the pressure feels wrong to you
again and again?
Be assertive! Politely demand the pressure you want
A reader told me this alarming story by email, a typical example of unpleasantly intense massage
therapy:
My massage therapist has been doing massages for 30 years. He is really aggressive. I
thought that I was going to die. The pain was so intense that I honestly feel that it was
worse than having children. When the massage was complete, I felt relaxed. When I got
home I felt exhausted, like I had been in a major accident. Truthfully I feel like crap. I ache
from head to toe, what the heck is this? I feel absolutely horrible. I had a bath before bed
and it did help somewhat. But this morning I still feel like hell …
an anonymous reader
It’s tough to be assertive with a therapist like that! How much luck do you think most new clients
would have telling an “aggressive” 30-year veteran of massage therapy to “ease up, please”? The
trouble with most therapists like this is that they are set in their ways and are not communicative,
respectful, or cautious.
You’d hope this sort of thing would be rare,
but it’s not. Readers regularly tell me about
massage therapists who do not ask them what
they want, who dismiss their patients’ concerns
about pressure, and who ignore signs that their
The pain was so intense that I honestly feel
that it was worse than having children.
clients are in pain. They display a “doctor
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
knows best” arrogance — ironic for an
alternative health care professional — imposing their own idea of the “right” intensity.
If you have the misfortune of hiring with such a therapist, and you are not a natural masochist —
hey, everyone’s different! — then by all means find another therapist. Be a consumer and shop around.
Painfully intense massage therapy may be regrettably common, but it is by no means the only kind
available.
And trigger point therapy needs to get this right. Although no one actually knows the
characteristics of successful trigger point therapy, I could make a good case that it involves careful
regulation of pressure to achieve a “just right” intensity — that both too much and too little will fail
or even aggravate the problem, rather than helping it.
The Answer to the Pressure question begins with three flavours of pain …
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
9.7
Pain in three flavours: the good, the bad, and the ugly
May — Editing: Some clarifications about the mechanism of “flushing” and whether uncomfortable massage intensity can be justified for
that reason.
Painful experiences on the massage table can be divided into three familiar categories: the good,
the bad, and the ugly.
Good pain is intense but somehow welcome, a paradoxical feeling, and probably what you mostly
want out of therapy. (We’ve already discussed good pain in detail earlier in the tutorial, so we
won’t go over it again any more here.)
Bad pain has no component of pleasantness in it, but is not necessarily incompatible with therapy —
it might have positive effects. And it might have harmful effects. It’s hard to tell.
Ugly pain is particularly extreme and a bad idea in every way. It is nothing but bad news as far as
trigger points are concerned — they will probably be aggravated by it.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
There is definitely such a thing as too much
pressure. (Drawing by Claude Serre.)
Ugly pain in massage therapy
Ugly pain in massage therapy is, by my definition, never okay. Ugly pain is often caused by things
that are not going to offer even minimal, delayed benefits, and may even be dangerous. It’s
important to be able to spot ugly pain for what it is and completely eliminate it from any therapy you’re
receiving. What kinds of handling may cause “ugly” pain?
truly excessive pressure or overstretch that is simply way over your personal pain threshold for
that day, location, or situation (it might be therapeutic or even good pain if the pressure was
reduced, but it’s just too much)
fingernail digging or skin tearing sensations, very common in “fascial release” therapy —
unmistakable and quite different from therapeutic pressure on trigger points
nerve pinching (electric zapping) or gland compression (strong sensitivity without a trace of
goodness) in one of the body’s “endangerment zones,” vulnerable spots where sensitive tissue is
exposed
disturbing infected or inflamed tissue, which is usually hypersensitive to light pressures (pressures
that are just not strong enough to irritate a trigger point)
“Ugly” pain is inflicted only by careless, incompetent therapists. Ugly pain should simply never
happen. Yet it does happen, and a shocking number of therapists will actually attempt to justify it
or minimize the concern.
For instance, many poorly trained therapists do not know the endangerment sites, and will
carelessly dig their thumbs into that hollow between your jaw and your ear, where there are
exposed nerve bundles and salivary glands that can really smart when poked. 327
Another alarmingly common example is the sensation of skin tearing. This has been inflicted on me
personally on at least three occasions, and not by poorly trained therapists — quite the opposite,
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
the perpetrators were all well-trained massage therapists doing a kind of “fascial release” therapy
that they clearly thought of as an “advanced” technique. (This philosophy of treatment is discussed
in another section.)
This may come as a surprise, but in fact there is no therapeutic benefit to stretching skin so hard
that it feels like it is going to tear! And it is a completely different and uglier sensation than how
fascial stretching can feel and should feel (more like a good massage) 328 When I complained
about this (politely), the therapists made no distinction between skin-tearing and fascial stretching,
and more or less tried to tell me that I was objecting to perfectly good therapy. Needless to say, I
never returned to those therapists.
There are massage therapists who seem to believe that any painful sensation is simply part of the
process, and if they poked you in the eye they would call it “ocular release therapy.”
Ugly pain can be a sign of real dangers, one more obvious than the other:
1. Direct injury. Tissues may actually tear, break, bruise. Significant damage is unlikely, of course, but
it’s not impossible. For instance, I even know of a patient whose femur (the big leg bone!) was
fractured by a massage — it was a weak and injured femur already … but wow!
2. Sensory injury. A painful, alarming experience can actually dial up pain sensitivity — even long
term. 329 Vulnerability to this awful phenomenon is much more common and significant in
desperate patients who already have chronic pain — so they seek and tolerate intense therapy.
Consequently, ugly pain in massage therapy is all too common and tragic. I cringe to think how
many people have been abused this way. If you have a therapist you suspect of carelessly or
deliberately inflicting ugly pain, just say no!
For more information about the potential hazards of intense manual therapy, see the section
Troubleshooting negative reactions to treatment, or the article Massage Therapy Side Effects: What
could possibly go wrong with massage? The risks and side effects of massage therapy are usually
mild, but “deep tissue” massage can cause trouble.
Now, let’s move on to “bad” pain.
Bad pain in massage
Bad pain in massage comes with no obvious benefits. If there is anything good about it, there is no
way to tell from the sensation alone. Bad pains are usually sharp, burning, or hot. Such pain is
usually caused by excessive but more or less harmless pressure on your muscles, or by pressure on
nasty active trigger points. As bad as it feels, it probably won’t hurt you — maybe a little bruising
— but there’s also a good chance that it won’t be therapeutic either.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Once again, the Pressure Question is basically about whether or not bad pain is ever justified. If
unpleasant pain is therapeutic, then I would call it “bad pain” — unpleasant, but worthwhile. If it’s
not therapeutic, and you are paying to experience pain with no benefit, then it should be
considered ugly pain — both unpleasant and pointless!
But how do you know?
For starters, you bear in mind the things described above that tend to cause ugly pain, and you
avoid that kind of therapy like the plague. Then you look for some clues that painful pressure is
okay. Here are at least three reasons (below) why unpleasantly intense pressure might be
therapeutic — “bad pain,” but not ugly. In each of these situations, it might be acceptable to
tolerate sensations so intense and painful that the only thing about them that is pleasant is the part
where it stops.
Bad pain can be therapeutic, but it’s possible that it may not be therapeutic much. The main
problem with pain in trigger point therapy is that pain causes activation of “fight-or-flight”
neurology, which might make trigger point release more difficult or impossible. But there are also
some ways in which unpleasantly intense pressure might also be therapeutic. For instance, motor
end plate destruction …
Motor end plate destruction. As previously discussed, we know that muscle knots may be caused
by something that goes wrong with the “motor end plate” — where a nerve ending attaches to a
muscle cell — and research has suggested that it may actually be possible to physically destroy the
motor end plate with strong massage, thereby “deactivating” the trigger point. When it regrows —
these are microscopic structures, so it doesn’t take them long to heal — the trigger point may be
gone for good, or at least for a while. It’s just a theory: no one knows if this is actually effective.
However, it may explain why so many massage patients report a “gets a bit worse before it gets
much better” response to quite painful treatments: motor end plates are (painfully) destroyed by
strong pressures, and then that tissue is quite sensitive and a bit weak as it heals over a day or two
… and then you finally feel much better after that!
We also don’t know how this process might balance out against the neurological aggravation that
may be caused by intense pain. The most we can know is that there is some reason to believe that
painful pressures on muscles might be therapeutic for some people, some of the time. Pretty decisive,
eh? 330
Somatoemotional release. Mental and emotional context is a major factor in how we experience
pain. Painful sensations are unusually good at stimulating catharsis — the expression of strong or
repressed emotion. — because physical pain often strongly “resonates” with emotional pain. 331
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
For instance, the pain of an injury may blur together with the emotional frustrations of functional
limits and rehab. That’s a basic example, and much more complex interactions between emotional
and physical pain are obviously possible. Whether it is the clear goal of therapy, or simply a
natural side benefit, experiencing very strong sensations can certainly be a meaningful part of a
personal growth process “just” by changing your sense of yourself, how it feels to be in your skin,
and perhaps bumping you out of some other sensory rut. 332
Flushing. If massage can “improve” any tissue — unknown! — one way it might do it is through
simple hydraulics. It’s probably a myth that massage increases circulation. Either it doesn’t do it at
all, or so little compared to exercise that it’s unimportant. I review the evidence in Does Massage
Increase Circulation? But let’s keep an open mind: what if massage really does increase circulation
in some specific situations that just haven’t been studied yet? It’s possible. While the existing
evidence suggests otherwise, it’s obviously incomplete evidence. Or what if increasing circulation
just matters more in some circumstances, in the same sense that an aspirin matters more to someone
with a headache?
Trigger points could be one of those biological situations where an effect on circulation might be
more meaningful. We know from Shah et al that TrPs are probably “polluted” with stagnant tissue
fluids, which implies a greater need for and sensitivity to flushing, and it’s also possible that mere
exercise won’t do the trick. 333 So it could make sense to vigorously massage an entire muscle,
casting a wide net, hoping to flush whatever trigger points might be present, and that doing it
more firmly could also be more effective — potentially worth doing even if it’s uncomfortable.
Connective tissue stimulation. A lot of therapists are keen on
stretching connective tissues — tendons, ligaments, and layers of
Saran wrap-like tissue called “fascia.” I’m not a huge fan of this
style, not so much because I don’t think it works, but just
because I think trigger point therapy works much better — much
more bang for my patients’ buck. (I explain this in detail in the
fascial release chapter.) However, I can imagine reasons why
strong manipulations of connective tissue might be therapeutic
Trust and pain. Bear in mind that feeling
safe is critical to the experience of good
pain. Tiny differences in trust and comfort
can make the difference between an intense
pain being good or bad. Much of the
“goodness” of good pain comes from
mental context, from knowing that a pain is
not dangerous or pointless, that it will not
(independently of treating trigger points). Certainly it’s a way of
increase suddenly, or anything else yucky
generating many potent and novel sensations, which may be
or shocking.
inherently valuable to us — another form of touch. Although
“improving” the fascia itself is implausible and unproven,
perhaps fascial manipulations affect bodies indirectly, just as a
sailboat is affected by pulling on its rigging. People have written
In fact, when therapists tell patients “no
pain, no gain,” this is often just a clumsy
and mostly ineffective way of trying to
make the pain seem safe and reasonable
whole books full of speculation along these lines. So, as long as
and less bad — but there are much (much)
the sensations are not like skin tearing (that’s an ugly pain for
better ways to do that, and the “no pain, no
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
gain” rationalization is usually a cover-up
sure), you might choose to tolerate this kind of massage if it
for sloppy technique.
seems to be helping you.
This is why it is so important, especially for
chronic pain sufferers, to find a massage
The choice is yours
therapist who is curious and concerned
In massage therapy, so much can be achieved while inflicting
about your sensory experience and
only good pain on patients that bad pain must be justified by
responsive when you ask for pressure
changes.
vivid, quick, and somewhat lasting benefits — which is a high
bar to clear. All health care practices must be justified by benefits.
As risk and pain and expense increase, the benefits must also. There is simply no point in tolerating
— and paying for — painful treatment without an obvious return on the investment.
I’ll refer you again to the troubleshooting negative-reactions section for help judging exactly how
long you should tolerate a lack of results. But obviously a persistent lack of results should make
you question any kind of therapy, especially a very painful therapy.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
9.8
Training your therapist
Believe it or not, if you can’t find a therapist who already understands trigger point therapy,
another realistic option is to train your massage therapist yourself.
A confident and assertive client can often direct therapy. After reading this tutorial, you will know
significantly more about trigger point therapy than roughly 90% of the massage therapists in the
world, most of whom are unlicensed or earned their license with no more than a few hundred
hours of training. Yet they have hands and hearts and talents. Many if not most of them are
humble, good people who have no illusions about their own lack of training.
So, simply go ask for massage of the trigger points you suspect you need help with.
Any therapist who is respectful, attentive and provides good customer service will respond by
giving you what you want. As long as they are cooperative and massage some of your trigger
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
points, it hardly matters what else they might believe, or what they do or do not know about trigger
points. In most cases, if you are polite and friendly about it, therapists will appreciate working with
a client who knows what he or she wants!
A few therapist training tips:
1. Ask them if it’s okay if you’re bossy. Why not? Be up front about it! Ask permission. “I have a clear
idea what I want. Will you mind if I clearly ask for what I want and set good boundaries?” Who’s
going to mind when you ask like that?
2. Don’t just lie there. Give clear and immediate feedback. Say, “That spot feels really relevant to the
problem. I think that spot is important!”
3. Report results. Give clear feedback when you return for your next appointment. Tell your therapist
exactly what you think worked best for you the last time. And what didn’t.
4. Use a pain scale. Tell your therapist that you are familiar with using a pain scale, and tell them
what range is acceptable to you, and then actually use the scale a few times during the
appointment. Just say, “That pressure there on that spot is a 6 out of 10.”
5. Recommend this tutorial. ��
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
9.9
Other kinds of therapies
So far in the “getting help” sections above I’ve introduced you to the different kinds of
professionals, and to the ins and outs of massage: the overall best option for trigger point therapy.
However, there are dozens more specific therapies or “modalities” — modes of treatment — that
patients will encounter in the wild. Some of these are excellent and interesting options to consider.
Others are literally dangerous and/or utterly bogus. I’ve chosen about a dozen to focus on: not the
best dozen, but the most popular or familiar out of ten times as many possibilities.
Incredibly, even after immersing myself in this subject matter for more than a decade, it is still
actually common for me to get email from readers asking about treatment modalities I have literally
never even heard of. “What do you think of ______ treatment method? Does it work?” There are a
gazillion of ‘em! Treatment systems and widgets of every description!
The answer is always basically the same: nobody really knows, and there’s not really any way to
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
know.
In most cases these treatments are close cousins to one of the more popular ones, perhaps even
barely distinguishable. And most of the more obscure treatments are obscure for a reason: poorly
conceived and promoted, they are usually the work of a lone therapist trying to create a new
income stream from a branded technique, their own “modality empire” (a concept that will come
up several times). Such therapies usually reek of amateurism and snake oil salesmanship. Their
websites are cluttered with red flags: big promises, heavy reliance on testimonials, sloppy logic,
and so on.
My point is that anything that isn’t discussed below probably isn’t worth discussing!
Bear in mind that all trigger point treatment methods and systems are essentially experimental. The
scientific situation is that we have a pretty good idea what trigger points are, and a reasonably good
idea of what tends to aggravate them, but only a very foggy idea of what makes them go away.
I have seen trigger points respond to a truly wacky variety of inputs ... or fail to respond.
So here are three dazzlingly insightful rules of thumb to bear in mind regarding essentially any
trigger point therapy system or product:
1. It might work.
2. It might not.
3. So beware of anyone who claims to “know.”
What you mostly need to know about treatment methods is that anyone who claims to know how
to release trigger points in most people, most of the time, is seriously overconfident! Please, do not
trust any treatment claim that seems “too good to be true.” Watch out for marketing language that
claims that a particular approach is highly effective. You might prefer not to give your money to a
person or company that acts like God’s gift to trigger point release.
That said, let’s look more closely at the options …
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
9.10
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
How about spray and stretch therapy?
Spray and stretch therapy is a stretching and movement therapy enhanced by a chill on the skin,
usually delivered by a cooling spray. This appears to have some effects on several kinds of pain,
including trigger points. Its mechanism of action is probably mainly neurological.
The effectiveness of spray and stretch has yet to be confirmed by any well-designed scientific tests,
and it has been a long time now. It might pass those tests if they are finally done: the technique is
based on some sound, evidence-based reasoning, and it is well established that there is a pain-relief
phenomenon at work here. Many professionals use the technique regularly, and it has the
additional benefits of being quite safe, relatively inexpensive — it does not require a long series of
appointments — and in many cases (depending on the tissues involved) patients can learn to spray
and stretch themselves.
Basically, the therapist stretches you while spraying the skin with a coolant in a specific pattern.
The muscle is elongated to take up the slack, and then the spray is applied before and during
stretch.
An illustration of stretch & spray technique.
One of the advantages of stretch and spray therapy technique is that it does not require precise
localization of the trigger point, only identification of where in the muscle the taut bands are
located, to insure that those fibers are stretched. However, considerable skill is required to
coordinate the course of the spray so that it covers those fibers that are being placed on maximum
tension by passive stretch. Thus the technique should be applied by a skilled therapist for
maximum benefit, although obviously there is some potential for patients to treat themselves this
way.
How do you find a “spray and stretch” therapist? It’s not nearly as widespread as it probably
should be. Even though the technique is widely regarded as the “workhorse” of trigger point
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
therapy, and is constantly referred to in Travell & Simons texts — which every good trigger point
therapist has — I have never actually met a spray and stretch practitioner in the wild, though of course
the very act of publishing these words has produced a few emails from therapist-readers who do
practice it (including my co-author Dr. Tim Taylor). It doesn’t seem to have caught on on to any
great degree. It is a small subculture within the subculture of trigger point therapy.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
9.11
How about the Paul St. John Method of Neuromuscular Therapy?
Neurosomatic Educators Inc. is the current official source of training and certification related to the
work and teachings of Paul St. John, a massage therapist who made a name for himself as a trainer
in trigger point therapy and related ideas. However, the current manifestation of his certification
program offers training in a bunch of stuff that Travell and Simons probably would not approve of,
including “Posturology” and “Neuro-Certification” and “Somatic Certification” — a grab bag of
miscellaneous ideas about physical therapy, many of which are not evidence-based in my opinion,
and stray far from straightforward trigger point therapy as defined by Travell and Simons.
Therapists with one of the various St. John-inspired certifications are fairly common, and they are
probably a better choice for trigger point therapy than the average bodyworker. There are several
certifications, so identifying them isn’t straightforward — a reference to the name “St. John” is
probably the thing to look for. See their website for more information, but unfortunately it’s not
helpful for finding therapists. If you’re in Florida (Clearwater), or willing to travel, you could go
see Mr. St. John himself at his clinic, the St. John-Clark Pain Treatment Centre.
However, I consider St. John-inspired therapists to be a distant second choice to any therapist who
simply knows “the big red books” well. I’ve simply met too many Paul St. John trainees who had
never heard of Travell & Simons, which is just terrible. I’ve been unimpressed by the St. John
videos I’ve seen. I was unimpressed by the instructor at my college who was a St. John therapist.
Also, I know that the method is highly preoccupied with posture and alignment, a treatment
philosophy that I criticize thoroughly for its lack of scientific basis in many of my articles, as
previously mentioned.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Not exactly a ringing endorsement. Still, it’s prevalent and probably better than nothing. A
therapist with one of the St. John certifications may be the best bet you have available to you in
your area.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
9.12
How about transcutaneous electrical nerve stimulation therapy? (TENS or ENS)
TENS is routinely offered in physiotherapy and chronic pain clinics. There are even consumer
TENS units on the market. TENS has a wide following of people who believe it works, without
much evidence, 334 while others maintain that it is ineffective. The truth is surely in the middle:
the jury is simply “out.” There are many kinds of pain. TENS is probably somewhat effective for
some types of pain some of the time, and not at all for other types of pain at other times, and it
depends on a bunch of variables that simply haven’t been sorted out yet. A major problem, for
instance, is simply that no one knows which of the many types of TENS might or might not have
the desired effect under certain circumstances. I don’t think anyone really doubts that there are
therapeutic effects buried amongst all the variables — but no one knows how to get those benefits
reliably! Bear that in mind when your therapist recommends TENS with unqualified enthusiasm.
A 2007 analysis of scientific studies going back many years showed that TENS is an effective
treatment for chronic musculoskeletal pain. 335 However, the conclusions of that paper are flatly
contradicted by a much more credible source, The Cochrane Collaboration, the gold-standard source
for evidence-based care, which has slammed the quality of TENS research. 336
Interestingly, one study of ENS specifically for treating trigger points found positive results. It was a
tiny study, but promising. 337 Unfortunately, the available evidence makes it perfectly clear that
TENS/ENS is a bit of a crapshoot therapy — it might work, and that’s all we really know.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
9.13
How about ultrasound therapy? (ESWT and “Sonic Relief™”)
Therapeutic ultrasound is an interesting technology: its effects on
tissue are complex, and there are many different ways that it might
aid in healing. There is a great deal of general evidence that ultrasound
has effects on tissues … but a great deal less evidence that it is helpful
for any particular kind of problem. Your mileage will vary. It will vary
widely.
Extracorporeal Shock Wave Therapy (ESWT), or high-intensity
ultrasound, is a technology that uses strong sound waves to
“stimulate healing” in tissues. It can be painfully intense. Think of it as
a high-falutin’ version of “regular” ultrasound. It comes in many
flavours and intensities.
There is also a prominent ultrasound product for consumers available
on the internet called Sonic Relief™. It’s not the same as ESWT, but
we’ll discuss it as well.
ESWT has recently become quite popular in the treatment of
Super-duper ultrasound
ESWT is high tech. The main
implication of this for most
patients is that it ain’t cheap.
Yes, it’s increasingly evidencebased — but there are nice
cheap options that are
more reliable.
musculoskeletal conditions. That popularity is probably premature in
the sense that it is sold to patients with much greater confidence than it has yet earned
scientifically. And yet ESWT is in the process of being proved effective. In fact its efficacy is
increasingly evidence-based. 338 Two recent, decent quality scientific experiments have shown
that ESWT was good for trigger points specifically. 339 340 Yay! I discuss one of those a little more
below.
However, even with these encouraging
results, I will still not be recommending ESWT
therapy to most patients, simply because there
are other highly effective, cheaper, and more
comfortable alternatives. This is only an
option for people who are running out of
options — but it is a good option for those
patients.
ESWT’s popularity is probably premature in
the sense that it is sold to patients with much
greater confidence than it has yet earned
scientifically.
What about Sonic Relief™ and “regular”
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
ultrasound? This is an ultrasound machine
intended for home use, manufactured and marketed by a
Canadian company called Home Therapeutics and retailing
for $250 (update: now $130 as of summer 2010, which is
quite the price drop … economic hard times?). Home
Therapeutics publishes a Sonic Relief™ advertisement web
page for virtually every musculoskeletal condition known
to humankind — and generally speaking they do it more
responsibly, with less hard selling and better quality
information, than most companies selling health care
products online. That’s a good sign, although there are also
a few bad signs, 341 and typical selling silliness like calling
it “medical grade” ultrasound, which means nothing at all.
Sonic Relief™ is a prominent ultrasound
product available on the internet & intended
for home use.
But … is a Sonic Relief™ machine a good idea for selftreating trigger points? Well, who knows? Nobody. Although ultrasound is generally well-studied,
its effect on trigger points specifically is not. There haven’t even been enough experiments for a
scientific review. What little evidence we have to work with is contradictory and weak, but leans a
bit towards the positive. The sour notes are:
Evidence about the value of ultrasound for a wide variety of conditions is just generally pretty blah
for such a popular therapy. 342
A 1998 study found that ultrasound made no difference 343 — a clear case of failure-to-impress.
Majlesi et al published an interesting mix of good news and bad news in 2004, comparing two types
of ultrasound for trigger points: garden variety and high-intensity (which can only be applied by a
trained professional). On the one hand, they found that regular ultrasound — the kind you’d get
from Sonic Relief, or in most physiotherapy offices — had very little effect on pain, less than a 10%
reduction. We’ll return to this study for the better news in the next section. But this was a clear
thumbs down for regular ultrasound. 344
Three other science experiments since then have seemed a little more optimistic, while still falling
short of impressing anyone:
Esenyel et al compared ultrasound to stretching and injection and found that they all had similar
results, implying that ultrasound is at least as effective as the other, but that also assumes that the
others are effective — hardly a safe assumption. 345
Aguilera et al found a “satisfactory” decrease in electrical activity and trigger point sensitivity with
ultrasound: just a single dose, with quite a small effect. 346
Turkish researchers Dündar et al also damned ultrasound with faint praise, reporting results that
were positive but not, apparently, quite positive enough to spell out. 347
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
And then there’s that good-news-bad-news paper I promised to bring up again. On the one hand,
they reported bad news for regular ultrasound. But on the other …
Majlesi et al claim quite good pain relief from high-intensity ultrasound, reporting that it reduced
the sensitivity of trigger points more than 50%. Not bad! If it’s real. Unfortunately, the study was
also small, uncontrolled, and conducted in a clinic that sold high-intensity ultrasound treatments …
so we have to take their results with a grain of salt the size of a football.
I can’t emphasize enough that all of these experiments are small and have weaknesses, despite their
cheerful conclusions. What’s a consumer to do with such findings? Such a mix of results is
probably trying to tell you something: that ultrasound is either not particularly powerful, and/or
“it depends” on too many things for it to be reliable. Although Majlesi et al give me some hope for
ESWT ultrasound, that treatment is not yet widely available, and much more expensive in any case.
Sonic Relief is a bit pricey for a shot in the dark (though less so at the new $130 price point). Thanks
to reader Michael B. for pointing out that there are now some even cheaper devices on the market,
like these, in the $50–60 zone. As he put it, “like many other people, I am not too eager to
experiment with a $250 device, but for around $60 I’m suddenly a whole lot more interested.” All
other things being equally uncertain, price certainly does matter.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
9.14
How about chiropractic joint adjustment and popping?
The idea of “adjusting” the spine refers to many different manual therapies that wiggle, pop and
otherwise manipulate spinal joints. Other joints may be adjusted as well. Such adjustments
probably have some effect on trigger points.
The correct umbrella term for these treatments is “spinal manipulative therapy” or SMT. Expert
opinions on SMT range widely, with some prominent medical scientists expressing strong concern
and skepticism. Its provenance in chiropractic subluxation theory is dubious, its benefits are not
major, and there are serious risks, even including paralysis and death in the case of SMT for the
joints of the neck.
The topic of SMT, including its effects on trigger points, is covered exhaustively in the special
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
supplement, Does Spinal Manipulation Work? A few more highlights are summarized here.
Despite all the controversy, there has been little high quality scientific research to determine
whether or not SMT is safe and really works. Major reviews of that literature published in recent
years came to “underwhelming” and generally inconclusive conclusions. 348 Thus, SMT fails the
“impress me” test — it can’t possibly be working any miracles. And if SMT doesn’t work all that
well for neck and back pain in general, then it can’t possibly be doing much for trigger points in
particular.
And yet spinal joint popping is something that people crave, and most clinicians — including me
— believe that some forms of SMT can be helpful to some of their patients, some of the time.
There is no definitive evidence that spinal manipulative therapy is more effective than
other forms of treatment for patients with acute or chronic low-back pain. However,
manual therapists know from experience that spinal manipulation is often more effective
for providing immediate short-term relief for some types of back pain.
chiropractor Sam Hom in “Can Chiropractors and Evidence-Based
Manual Therapists Work Together?” 349
There seems to be almost no doubt that there is something of therapeutic interest going on in SMT.
Most likely joint popping, just like several other forms of manual therapy, provides a blast of novel
sensory input to tissue that is feeling stuck and stagnant, both the joint and/or the muscle tissue
around it. It’s like a little massage, deep in the joint, that scratches an itch that is otherwise very
difficult to reach. Joint and muscle dysfunction probably reinforce each other, and SMT sometimes
provides some helpful stimulation that may help to break the vicious cycle.
Sounds good, doesn’t it? However, there’s a list of reasons to curb your enthusiasm. As with
stretching, it’s just as clear that these benefits — while probably real — are also dependent on
many other factors and thus highly variable, generally modest, rarely lasting, have much less effect
on more severe and chronic pain, and are associated with some of the significant risks of SMT, 350
and are mostly limited to spinal pain in any case. Granted, spinal pain is certainly a major part of
most cases of myofascial pain syndrome, but trigger points can affect any region of the body, and
joint adjustment has much less potential to help trigger point pain in the extremities.
For more information about how to find a chiropractor, see my article The Chiropractic
Controversies, the special supplement Does Spinal Manipulation Work?, or pick up a copy of Dr.
Samuel Homola’s book, Inside Chiropractic: A patient’s guide.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
9.15
How about myofascial release and fascial stretching?
Many forms of myofascial release (MFR) are often touted as a particularly effective approach to
treating myofascial trigger points. There are numerous flavours of this kind of therapy. What they
all have in common is a fashionable focus on “fascia” — the Saran Wrap-like sheets of connective
tissue that contain and permeate us. Absolutely everything in our anatomy is fractally “wrapped”
in fascia, fractacally enclosing every anatomical structure, from whole muscles and large
subdivisions, down to individual cells. A great many massage therapists and other manual
therapists attribute great importance to the idea of “tight” fascia.
There is considerable public and even professional confusion about the terms “myofascial” and
“fascial” in combination with the words “therapy” and “release.” “Myofascial release” can mean
practically anything. Patients often ask me, “What do you think of myofascial release?” But
“myofascial release” is such a vague and abused term that it could refer to virtually anything I’m
doing to my patient at the moment they happen to ask. I usually reply, “You tell me! We’re doing it
right now!” I’m a real wit.
The words “myofascial release” have been particularly co-opted to refer to a branded treatment
modality. MFR is one of the classic “modality empires,” characterized by big promises and
expensive therapy and workshops. The short story is that I have almost little good to say about it,
and there is absolutely no evidence that it works: in the only half-decent effectiveness test it’s ever
been subjected to, it wasn’t even as useful as a simple clench-release therapy method. 351
Worse still, fascial therapists often seem reckless to me: they are so focused on trying to stretch
connective tissues, that they ignore the patients’ comfort and the state of their nervous systems.
This can be disastrous, causing “sensory injury.” One of my readers suffered a particularly serious
incident of this kind. Her story is told in my review.
In this section, I focus on debunking the more specific claim that MFR and MFR-ish therapies are
particularly good for trigger points. Basically, if a therapist tries to tell you that MFR is the only
way to release trigger points, please turn your bollocks detector up to 11.
Fascial therapists will often say that trigger points are being
“held in place” by fascial restriction, and that trigger points can’t
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
Note that “myofascial trigger points” is the
The Complete Guide to Trigger Points & Myofascial Pain (2019)
“release” in this state. They are usually referring to the
phenomenon of contractured trigger points, discussed in detail
above, and it’s accurate insofar as there probably is such a thing
as a “stuck” trigger point, and fascia is certainly involved in that
equation in some way. However, fascial therapists imply that
most or all trigger points suffer from adhesions and therefore
formal, technical term wisely prescribed by
Travell and Simons 352 — the best
“correct” term for the phenomenon of
muscle knots. It is specific and should not
be confused with “myofascial release,”
though obviously the concepts have some
overlap. The “myofascial” part simply
require release, and this is an excessive interpretation: adhesions
refers to the fact that trigger points occur in
are probably a factor only in a minority of older and more severe
muscle tissue. “Myo” and “fascial” are often
trigger points.
combined whenever referring to the
In any case, just because a trigger point is adhered doesn’t mean
“muscular trigger points” and mean
it requires “fascial release.” The adhesions that probably do form
essentially exactly the same thing.
muscular system, but you could say
in older trigger points are a consequence of the trigger point, not
its cause, and it’s unknown whether or not the formation of adhesions even complicates the
problem. It’s certainly possible, even likely, that a trigger point could stop actively contracting and
hurting despite adhesions: like a man in handcuffs who has been straining to break them, and then
stops and relaxes. The problem here is that all this is speculation, and no one really knows —
including MFR therapists — and it really gets my knickers in a twist that they act as if they do
know when they so clearly do not. Gr.
And then there’s the treatment problem. For the sake of argument let’s say that adhesions are a
significant factor in most trigger points — a huge “if.” Is fascial stretching going to fix it? Fascia is
tough stuff, essentially indestructible, and it is probably impossible to loosen it, even by pulling on
it in anatomical locations where you have the leverage to exert some real force. 353 But trigger
points are small and awkward to manipulate:
trying to “stretch” the adhesions in a trigger
point with fingertips or elbows is analogous to
trying to loosen a tight lug nut without a
wrench. Above and beyond that, MFR
therapists face all the same practical problems
in treating trigger points as anyone else.
What about fascial contraction? I’ve also heard
Trying to stretch the adhesions in a trigger
point with your fingertips is analogous to
trying to loosen a tight lug nut without a
wrench.
fascial therapists claim that fascia is actively
“squeezing” the trigger point. For instance, a
client wrote to me once concerned that his trigger points were being perpetuated by “tight fascia”
and that he might need “fascial therapy.” His explanation, given to him by a fascial therapist, was:
“Fascia can have a compressive force of up to 2000 lbs/ sq. inch, and therefore that compression can
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
result in pain.” It certainly would be painful … if it were possible.
Fascia is indeed contractile — it contains a thin scattering of muscular
cells — but only weakly. 354 The forces generated by fascia are
dwarfed by that of muscle itself, in rough proportion to the number
and size of muscle cells involved. Even the largest sheets of connective
tissue in the body (i.e. the thoracolumbar fascia) are able to generate
only modest forces; the fascia right around and inside a trigger point is
mostly microscopic, extremely fine wisps, a lot of it barely more
substantial than cell membranes. Fascia is present throughout muscle,
surrounding increasingly small subdivisions, but most of this is so fine
and delicate that we literally cannot detect it — it’s in every single bite
of steak, for instance, but we don’t notice. We only notice the larger
bits of gristle, which do not wrap trigger points but much larger
sections of muscle. There are simply no normal physiological
Perspective
circumstances under which fascia exerts or is even subjected to
extreme pressures. 355
So please don’t let a therapist tell you that your fascia is dysfunctional
or “squeezing” your muscles and causing garden variety pain
problems and trigger points and needs “releasing.” The idea that
you’ve got muscles that are being aggravated by fascial pressures is
disconnected from anatomical and pathological reality.
By any measure, fascial
contractions are dramatically
less powerful than muscular
contractions. If anything, this
diagram gives far too much
credit to the power of fascia,
which would barely register at
all if depicted more accurately.
Fascial therapists cannot be doing anything special, because they are
clearly no more effective at treating trigger points in general than anyone else, and arguably less so
than by some other methods. What primarily holds trigger points in place — what makes them
what they are — is almost certainly sarcomere activity, not fascial restriction.
Doubtless when you wrench fascia around, I’m sure that you get some “bonus” therapeutic effects
— some relaxation, a little trigger point release just from miscellaneous stimulation of trigger
points, etc. But you can get these benefits (and get them better) from proper trigger point therapy!
There is no reason to believe that “fascial release” is a good way to treat trigger points in particular.
Don’t get “fascial therapy” — just get proper trigger point therapy. Even if fascial therapy works,
“regular” trigger point therapy almost certainly works much better, simply because it isn’t limiting
itself to a single dubious idea about how trigger point therapy should work.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
9.16
Maybe stabbing will help! Dry needling
2018 — Science update: More thorough citing on the topic of dry needling efficacy … and that is probably the last in a year-long series
of updates to this section over 2018. This chapter has been well and truly rebooted.
2018 — Science update: Analysis of more putative “mechanisms of inaction” as presented in three more papers, one ancient, two new
(Melzack, Chou, Cagnie).
2018 — Science update: Added analysis of Couto, one of the more credible positive trials of dry needling available.
2018 — Science update: A new sub-section about Llamas-Ramos et al , a study by dry needling proponents with surprisingly negative
results (even if they didn’t see it that way). Plus a bunch of miscellaneous minor improvements.
2018 — Improvements: Significantly expanded discussion of the rationale for needling with an interesting example and a helpful image.
“Dry needling” is a widely practiced but unproven and controversial method of treating trigger
points with acupuncture needles, popular since the early 2000s and now the subject of many
scientific papers and a handful of books. 356 It is a minimally invasive procedure, with some
inherent risks, from wasted money to worsened pain to (!) lung puncture. Needling is provided
mostly by physical therapists, chiropractors, and a few physicians. It involves puncturing or
lacerating suspected trigger points with fine-gauge, solid needles (acupuncture needles).
There’s no question that needling feels potent to the patient.
Muscle stabbing is funny that way. It is often very intense,
because it is literally lacerating acutely sore locations (albeit with
extremely fine needles). So there are definitely effects, but
whether those effects are helpful, whether they work out well or
badly in the end on average, is just unknown.
Patients have a love/hate relationship with needling. Anecdotes
Acupuncture by another name? Although
the shared hardware makes dry needling
look a lot like acupuncture, these techiques
are mostly cousins, not siblings — all they
really have in common is the
needles. 357 358 It’s “dry” needling to
distinguish it from injections.
about the results are impressively varied, from horror stories to
cure claims, and are rarely neutral. The professional muscle needlers mostly only hear the good
stories from their patients, and are much less aware of the bad ones — because patients are far
more likely to share their complaints with people like me, and they do. 359 Any dry needler who
thinks that all their patients are satisfied has drunk way too much of their own Kool-Aid.
The good news: the most positive results of the best study
One of the most rigorous tests of dry needling I’m aware of was conducted by Couto in 2013. 360
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
They reported that dry needling reduced pain more than a sham 361 over four weeks in 70
women.
It wasn’t a dramatic difference, but it was a clinically significant one. 362 Just. It’s not enough of a
difference to seem like a truly potent treatment, and that’s the damning-with-faint-praise problem
that afflicts so many “positive” studies of pain treatments.
I’m also just not sure I trust these authors, because they seem really biased to me, and statistical
jiggery pokery is nearly inevitable when you combine bias and complexity. 363 But, as reported,
it’s a great result: dry needling really did seem to help women with chronic MPS.
That’s the best, I think, but it’s not the only one. Another notable example is Müller et al , with an
interesting twist: the before/after size of the trigger points was measured some interesting
ultrasound techniques. 364 I’ll bring this one up again in the acupuncture section, because it was
ostensibly a study of acupuncture, but they did treat “up to two relevant ashi points,” which is
basically how trigger points are labelled in the world of acupuncture. As with Couto, the results
were definitely positive.
So that’s the good news … and just about all there is in this chapter. Remember, in the 21st Century
we can always find positive trial results for anything, even some extremely silly things. A couple
promising studies really don’t mean much on their own. The bigger picture has to be considered.
And consider it we will.
Schools of thought and method
There are many sources of dry needling training, certification, and justification, and most of them
have a distinctly amateurish vibe: small businesses looking to cash in on a huge trend, selling a
service for top dollar. Only a few stand out:
The best known needling brand is the American Myopain Seminars, the creation of prolific trigger
point researchers Dr. Jan Dommerholt and Cesar Fernández-de-las-Peñas, who have published
many scientific papers, textbook chapters, and books. 365 This organization is probably bigger
than all the others combined and offers many courses internationally. Whatever they teach and
believe is highly representative of what’s going on in the real world. And yet their publications are
conspicuously missing any clear or satisfying explanation for how needling supposedly works —
they don’t have a clear story about why needling supposedly helps. More on this below.
One of the dry needling pioneers is in my back yard here in Vancouver: Intramuscular Stimulation
(IMS), practiced by certified physicians, physiotherapists, and some acupuncturists. This method
was created long ago by Dr. Chan Gunn, a University of British Columbia pain scientist, discussed
earlier in the book regarding his alternative theory of trigger point biology. IMS is based on several
claims of dubious validity, a mixed bag (or maybe just a mess), but the premise of treatment is
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
mainly about using needles to “make the nerve function normally”… which is amusingly vague
and reminds me of a famous science cartoon in which a complex equation depends on the step
“then a miracle occurs.” 366
Dr. Ma’s Integrative Dry Needling is one of the older dry needling brands, and is laser-focused on
selling a method: efficacy claims, testimonials, and creating the appearance of scientific legitimacy
without the substance. It is billed as “scientific acupuncture,” but the website could not be any less
scientific in spirit. There are testimonials rather than real information. And of course there are many
bold claims like this one: “we all know that all modalities are clinically working” and “IDN
provides the framework upon which to address all types of physical dysfunction.” All?!
So why lacerate trigger points anyway? Mechanisms of inaction
Despite a lot of fancy talk, the rationale for dry needling
boils down to this: “Let’s see if stabbing your muscles
helps!” There is no clear, specific biological rationale for this
method that has actually been validated — it’s all fairly thin
speculation based on the barely-there biology of trigger
points. For instance, a 2011 paper by Jann Dommerholt —
arguably the most credible and sophisticated proponent of
dry needling since the 2000s — unfortunately fails to
explain anything specific about how it supposedly
works. 367
Surely there’s other expert speculation available? Yes,
there’s a long tradition of spitballing about this. One of the
earliest examples was from mighty Melzack himself, a
legendary figure in pain science, the Canadian who
All modern dry needling is done with fine
acupuncture needles, far smaller than the
syringes Dr. Travell used. She thought
acupuncture needles were too delicate!
brought us the “gate control theory of pain” in 1965. In 1981
he used it to try to explain dry needling: “Pain may be relieved by ‘closing the gate’… .” 368
Distinguished as Melzack was (and still is), this is not a viable hypothesis today: gating is real but
trivial, and it’s been a long time since anyone took it seriously as a therapeutic mechanism.
Or maybe they have? In 2012, Chou et al opined that “the most likely mechanism of pain relief
through needle stimulation is hyperstimulation analgesia,” citing Melzack. 369 It’s a bit lame to
even bring it up in 2012, and calling it “the most likely mechanism” is just embarrassing. And even
if this is actually how needling works, it’s a mechanism that isn’t exclusive to needling: any strong
stimulation would do it. If you’re trying to explain the value of needling, you need something
unique to needling, or you might as well just stick to safer methods.
A 2013 paper by Cagnie et al is another good representative example of the few papers dedicated to
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
the biological reasons for needling. The authors acknowledge that “the exact mechanisms of action
of direct needling in the deactivation of trigger points are not yet unraveled” (which amusingly
makes it sound like the “inexact” mechanisms have been unravelled and we’re just waiting for the
details to get hammered out now). They aim to explain the “potential underlying mechanisms,” so
it’s clearly just more speculation, but it’s as good a summary of the possibilities as I have found …
which isn’t saying much. The first third of the paper just reviews basic pain science, and the rest
marches through an assortment of predictable old chestnuts of therapeutic mechanisms cloaked in
technical language: boosting circulation, 370 pain gating again (citing Chou et al , who was in turn
just citing Melzack, who was wrong), and endogenous opioids. 371 They conclude only that the
effects of needling must be “highly complex and recruit central and peripheral networks with
physiologic and psychological responses”… but “it’s complicated” is not even a hypothesis.
Perhaps if we go back to the origins of needling we’ll get some insight? The term “dry needling”
came from Dr. Janet Travell herself. In the original big red books, she used the term to describe
lancing a trigger point with a hypodermic needle, but not injecting anything. (Ouch!) She did not go
into any detail, but her method is distinct from modern dry needling, which is much more directly
inspired by acupuncture. 372 Although Travell never explained her rationale for dry needling, she
did explain why she never used an acupuncture needle: she thought they were too delicate! 373
Her co-author Dr. David Simons did offer a (clearly speculative) rationale, years later: “… because it
mechanically disrupts the integrity of dysfunctional endplates.” 374 Translation: needling breaks the
muscle. And this is another disappointing “highlight” of needling theory, the best that this wellknown text about muscle pain has to say on the subject.
And it’s highly problematic. There’s no evidence of it. 375 The motor endplate is the connection
between a nerve ending and a muscle fibre, the neuromuscular junction, analogous to synapses in
the brain. They tend to be larger than neuron-to-neuron synapses — but we’re still talking about a
super tiny structure here, measured in tens of hundredths of millimetres, roughly an order of
magnitude smaller than an acupuncture needle. To say that it requires “precise localization” to hit
one of those — as Simons does — is an understatement! It’s like trying to stab a raisin with a spear.
If the raisin was under a metre of Jello. Covered by a blanket (of skin). 376
Or with a harpoon, if you’re doing it like Janet did it.
Assuming you want to do such a thing. “Hey guys, look at me—I’m trying to destroy my
neuromuscular junctions!” What could possibly go wrong?
Presumably the goal isn’t to destroy any particular endplate, but a bunch of them in a specific area,
but in that case why bother with a fine needle? Which is still going to miss many of them. You can’t
really have it both ways: the fantasy of precision is directly at odds with the goal of wrecking
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
endplates. If go for precision, you’re simply going to fail. If you want to lacerate endplates, a fine
gauge needle is obviously a poor choice. But it’s not clear that a larger one would do much better.
Even if nature of trigger points was unquestioned and settled — ha! — trying to fix them by
lacerating them seems like a suspiciously bad idea, as likely to aggravate any vicious cycle as
disrupt it.
Four motor endplates, at the ends of
branching motor neurons, attaching to
muscle fibers. Each one is about 3µm
(.03mm) wide, about a tenth the
diameter of an acupuncture needle.
Trying to hit one of these with an
acupuncture needle would be like
trying to use a spear to stab a raisin.
Like religious beliefs, these theories about how needling works can’t all be right. The fact that Dr.
Travell disapproved of acupuncture needles is particularly fascinating and irksome — she is
virtually worshipped by most practitioners, and her book is still the trigger point bible, and yet no
one using acupuncture needles today has offered an explanation of why they are ignoring her
opinion on this. If she was wrong, then it casts doubt on the Mother of Trigger Point Therapy — the
kind of doubt that is absent from nearly all references to her work. If she was right about this, then
almost all modern dry needlers have been barking up the wrong tree, teaching and selling a
technique that the great Dr. Travell thought was silly!
Or perhaps they are all wrong. Because how dry needling might work is all a moot point if it doesn’t
work. So does it work?
Does dry needling actually reduce the soreness of trigger points?
John Ware is an articulate and well-informed PT of my acquaintance, and he is not a fan of dry
needling:
Tender spots certainly exist, but it seems the only purpose for insisting that they exist in a
muscle is to justify jabbing, poking, squeezing or otherwise assaulting them with various
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
implements, including needles.
John Ware, PT, commenting on “The trigger point strikes … out!”
John is not impressed by needling, because, predictably, much evidence of efficacy for dryneedling is either overtly negative or is positive but fails to impress. For instance, directly
contradicting Couto et al (a positive study described above), another good quality and fairly large
2017 test of needling for shoulder pain found no effect at all: everyone did equally well, with or
without needles in their shoulders. 377 So, shocker, we have contradictory results to try to make
sense of. We all saw that coming, right?
There was very little direct evidence about dry needling at all for a long time, and the indirect, halfrelevant evidence from acupuncture research was quite discouraging. 378 But even the direct
evidence, as it has emerged, has been discouragingly weak. A 2009 review of seven shabby little
studies was clearly negative. 379 A 2013 review was probably the first review covering a few more
substantial trials. Although it had a rather sunny bottom line, it’s not as nearly good as it looks
from reading the abstract. Lorimer Moseley, Neil O’Connell, and Daniel Harvie reviewed that
review (Kietrys et al ) of the evidence for Body In Mind. 380 And did it make the grade for these
experts? Here’s how scientists say “booooo”:
Dry needling is not convincingly superior to sham/control conditions and possibly worse
than comparative interventions …
That was truly expert commentary—those guys are heavyweights. What do the authors of the
paper think? They “recommend (Grade A) dry needling, compared to sham or placebo, for
decreasing pain (immediately after treatment and at 4 weeks).” But digging into the actual results,
it doesn’t take me long to start rolling my eyes and sympathizing with the critics: there’s just not
much there. I don’t know why anyone would “recommend” dry needling based on that data.
Same with Cagnie et al : positive conclusion, disappointing data. Mildly encouraging at best,
seriously misleading at worst. 381
Liu et al ? Same! 382 And Liu et al. again in early 2018, this time focusing on back pain? 383 Still
damned with faint praise.
What the evidence so far says seems quite clear to me (and experts like Moseley, O’Connell, and
Harvie): it probably doesn’t work very well! If it did, the evidence would be much better. With the
usual disclaimers that it might work for certain types of patients, or done in a more skilful or
specific way (possibilities that we can never ignore but will probably be murky indefinitely).
But for the average pain client, most of the time, it almost certainly doesn’t work — and to the
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
extent that it seems to, it’s because it’s obviously a champ at generating placebo effects. “Dramatic”
treatments always are. It’s extremely likely that the most potent mechanism involved here is the
only one that needling proponents never mention: DNIC, or “descending noxious inhibitory
control,” which is temporarily treating pain by “distracting” the nervous system with a new kind
of discomfort. 384 Squirrel!
Other noteworthy research
A 2014 study is worth highlighting because the research group leader was César Fernández-deLas-Peñas of Myopain Seminars, and one of the most prolific trigger point researchers — both
extremely knowledgeable and also probably quite biased. 385 And yet this study was pretty
clearly a loss for needling. 386
It was a biggish short-term study of dry needling for trigger points, comparing it to massage in 94
neck pain patients. Pain, disability, range of motion, and sensitivity to pressure were all measured
before and then up to two weeks after treatment. There was no difference on the first three of the
four outcomes measured, and only a small one on the fourth and least important measure
(pressure sensitivity on the tip of the C7 vertebrae, which is an odd choice). In my opinion, that one
difference is not meaningful.
Those results strongly suggests that there is no advantage at all to needling over massage for
trigger points: they are either equally effective for neck pain, or equally ineffective. If massage and
needling both produce similar results, there’s definitely no justification for the greater risks of
needling, especially in the neck.
Speaking of the risks …
Needling risks and harms
Needling is “invasive” — it breaks the skin — and therefore it has risks. All needles are what we’d
call “minimally invasive” compared to surgery, especially hair-thin acupuncture needles, but it’s
still invasive. Bacteria do not need a big hole in the skin to commute from the outside world to
inside you.
Treatment and safety standards for dry needling are basically nonexistent: this is a virtually
unregulated practice, with no clearly established best practices at all. Practitioners are free to do it
pretty much any way that they want. Including without “standard precautions” (the formal term
for infection prevention practices in medical settings).
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Severe adverse events of needling are probably quite rare, but no one has ever actually studied it
well enough to know. The only survey I know of is badly flawed. 387 I am personally aware of
two cases of punctured lungs (pneumothorax, haemothorax) here in Vancouver in the last few
years, and of course any treatment that breaks the skin can lead to infection. This is well-known
risk of acupuncture, “which may not be so uncommon.” 388 It is hard to justify any risk unless the
confidence in the treatment is reasonably high.
How about minor risks? According to Brady et al , about 1% of needling patients get worse instead
of better, and I suspect the real number is much higher. 389 Bruising, bleeding, and pain during
and after treatment are all common (2-8% at a bare minimum). There are a few rarer minor
problems as well headache, nausea, shaking, itching, and numbness.
Needling trigger points is a notoriously painful treatment, often more intense than the deepest
massage — imagine a massage therapist with needles for fingers! In my experience, needling is less
of a problem for people who are already in a
lot of pain and have “nothing to lose,” but for
Needling trigger points is also a notoriously
most others the intensity of the cure may well
be worse than the disease. Vancouver is a
painful treatment, often more intense than
needling hotspot, so I’ve met many patients
who’ve experienced it, and many of those
the deepest massage — imagine a massage
claimed to have been harmed.
therapist with needles for fingers!
For all of the above reasons, I have long felt
that the safety concerns outweigh the
uncertain, minor, and controversial benefits.
Life is risky, and medicine is risky, and that’s fine if the potential reward is clear — but the rewards
are not clear here.
•
Dry needling practitioners have paid a lot for their certification and — here’s a shocker — they
tend to promote it with an enthusiasm that cannot be supported by the evidence. It also distorts
their clinical judgement: they’ve got a big ol’ expensive hammer, and so all they see is nails, and
want to treat every pain problem like it needs a needle.
I do not think dry needling is a good option: it is plausible and interesting theoretically, but also
has risks, costs a lot, and hurts like hell. Few patients should be willing to accept those downsides
without much better evidence that it actually works. This is a treatment mostly for desperate
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
patients.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
9.17
How about trigger point injection therapy?
2018 — Science update: Added a citation, a negative review.
Trigger points may be treatable by injecting them with a saline solution (to dilute the metabolic
waste products), with an anaesthetic or anti-inflammatory medication, or even with Botox, to
paralyze and “deactivate” them. This is different than a nerve block (see next section). None of
these methods is highly reliable. The evidence for them has always been weak. A 2001 review
concluded that “Any effect of these therapies is likely because of the needle or placebo rather than
the injection of either saline or active drug.” 390 Any of them are probably worth considering in
serious cases.
This kind of trigger point therapy is only practiced by physicians, usually directly influenced by
Travell and Simons. The only way to find a physician who can offer these services is start asking
around, be nosey, make calls, ask as many physicians about it as you can find until someone says,
“Oh, yeah, Dr. So-and-So does that … ”
If there is one in your area, a pain clinic may be a good place to start checking.
Definitely be cautious with trigger point injection, though: it’s a little drastic, and not something
you really want to do much of unless you are quite sure it’s going into the right places. Many
doctors who do trigger point injection are less than perfectly qualified, and may inject the wrong
trigger points, or miss them altogether. It’s one thing to miss trigger points with thumbs and
fingers, and quite another to miss with a needle. There are risks associated with injection therapy!
In general, only pursue trigger point injection as a last ditch effort to try to beat stubborn, welldiagnosed trigger points.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
9.18
How about Botox injection therapy?
Botox, of all things — the toxin used to paralyze facial
muscles in plastic surgery — is a potential treatment for
trigger points. It has become a common therapy for severe
trigger points, especially around the head and neck, and
was officially approved for migraine treatment in 2010 in
the UK and the US. 391 That was a big deal. In the
aftermath of the news, anonymous neurologist blogger Dr. Grumpy reported that he was besieged
with calls:
Mary and Annie logged 47 calls from Botox-seeking-patients today, all somehow under
the impression that since it’s now FDA approved I suddenly have an endless Bucket O’
Botox and can inject it at the drop of a hat. I don’t have a drive-thru window. This stuff
costs $525 a bottle, so I don’t keep it lying around.
If Botox works on trigger points, that would lend (much needed) support to the dominant theory of
trigger point formation and tells us that the trigger point mechanism is “intimately associated with
the neuromuscular junction” 392 — if blocking the neuromuscular junction works, then trigger
point dysfunction is not a failure of the muscle cell itself, but a dysfunction of the neuromuscular
junction itself. 393
“The effectiveness of Botox injection is of great theoretic
interest,” Simons wrote in 2001, “but can be easily abused in its
therapeutic applications.” If Botox kills trigger points, it means
that trigger points are definitely powered by a dysfunction at the
neuromuscular junction itself, or on the muscle side of it.
Unfortunately, Botox probably is not as effective as Simons
thought or hoped back then. The evidence was promising at the
time: for instance, one small but well-designed early study
showed that “patients experienced a 30% reduction of pain
following Botox injection, but not following saline injection.” But
most research since then has not found the same clear effects,
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
Botox is a contraction of “botulinum toxin.”
Clostridium botulinum is a bacteria that
produces, as a metabolic waste product, a
really nasty poisonous toxin. 394 Think of
it as a microscopic poisonous frog, exuding
deadly slime through its skin. That poison
can be harvested and used to paralyze
celebrity facial muscles for cosmetic
purposes. There are also many other handy
medical applications for a deadly toxin that
can paralyze muscle.
Botox works by blocking the
The Complete Guide to Trigger Points & Myofascial Pain (2019)
and a 2007 review concluded pretty clearly that “current
evidence does not support the use of [Botox] injection in trigger
points.” 395 That was echoed in 2012 by the Journal of the
American Medical Association, which found that treatment of
chronic daily headaches or migraines was only slightly more
neurotransmitter acetylcholine — the
communicator molecule that flows from
nerve endings to muscle cells to initiate
muscle contraction. Botox occupies the
receptor sites for the acetylcholine molecule,
beneficial than using a placebo. 396 Not strong results at all.
leaving acetylcholine “homeless” and
Rather disappointing for me, in fact, after years of believing that
unable to tell the muscle to contract.
Botox was “probably” a good evidence-based option for
migraine. Probably not.
Only one review is a little more optimistic, but only a little bit.
Zhou and Wang wrote that “there are well-designed clinical
trials to support the efficacy of trigger-point injections with BTXA for MPS.” What a relief! But they emphasize that they are not
The cosmetically desirable effects of Botox
were first discovered here in my own home
town, by Vancouver-based cosmetic
surgeons Drs. Alastair and Jean Carruthers.
I bet they’re doing rather well in their
careers now …
conclusive. 397 Indeed.
What is conclusive is that Botox is so far damned with faint praise — a por fate for a treatment. Its
usefulness and theoretical significance is doubtful at best. Either Botox simply can’t paralyze
trigger points after all, or the principle is sound but the therapy itself is unreliable and fails with
most patients.
I believe, in spite of this evidence, that Botox likely does have a potent therapeutic effect on
patients in ideal conditions — with just the right patient — and the problem with therapy is
practical. It’s difficult to accurately diagnose and precisely locate the most relevant trigger points in
the first place, and even more difficult still to accurately inject them. Botox can’t paralyze a trigger
point it hasn’t actually been injected into! Simons recommends that “for those with the necessary
equipment and skills” a trigger point should be identified “myographically by its spontaneous
electrical activity” — while that’s a great idea, in practice virtually no one has “the necessary
equipment and skills.”
There are huge safety issues. Obviously, you always want to avoid being stabbed with needles if
you can reasonably avoid it … and all the more so when they are filled with an insanely potent
toxin. The risks to the rest of the muscle and to other tissues are serious. 398
And the effect wears off. A paralyzed trigger point doesn’t stay paralyzed, and successfully treated
trigger points can still come back. Botox paralysis does not make a triggery person less triggery, does
not eliminate perpetuating factors, and does not stop a neuromuscular junction from dysfunctioning
permanently. As the poison slowly works its way out of the neuromuscular junction, that patch of
muscle regains the ability to contract and once again form trigger points.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
It’s not clear if Botox works even in principle, although it there’s a good chance it does.
It is definitely unproven as a therapy, and probably fails in most cases.
It’s invasive and risky.
It’s unlikely to have a lasting effect even in the best-case scenario.
Only consider Botox if you are particularly desperate, and if you have especially high confidence in
the skills and trigger point savvy of the physician. In all cases, keep your expectations low.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
9.19
How about nerve blocks?
Perhaps even more drastic than Botox, nerve blocks are performed only by physicians, usually in
pain clinics.
Nerve blocks may often be prescribed by doctors who don’t really understand trigger points, and
are recommending it simply because it’s the only way that they know how to treat certain kinds of
chronic pain. Or, they may know about trigger points, but simply believe that nerve blocking is a
good therapy because it’s the only trigger point therapy they know how to do, and they aren’t
inclined to refer you to someone else.
Is it good therapy?
It probably helps quite a few patients with severe cases, yes, and we could go into a ridiculous
amount of detail and find a bunch of scientific studies about it to analyze and yada yada yada. But
we have a mental shortcut: there are so many safer alternatives to nerve blocks that they are only worth
discussing with your doctor in the worst case scenarios, when essentially everything else has been
tried.
But, of course, I did go into detail for you. Just not here. If you’re still interested …
Do Nerve Blocks Work for Neck Pain and Low Back Pain? Analysis of the science of stopping
the pain of facet joint syndrome with nerve blocks, joint injections, and nerve ablation
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
~ 2,500 words
Don’t let a doctor rush you into a nerve block.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
9.20
How about acupuncture?
Some of the traditional acupuncture points are known as “pain points,”
and supposedly these correspond closely to common myofascial trigger
points — just a theory someone floated once. 399 There probably is
some overlap, but it probably doesn’t mean much either. 400 The idea
is that an acupuncturist might succeed at treating trigger points in this
way, because they are doing something awfully similar to what IMS
therapists do, i.e. dry needling trigger points. There is some limited and
unimpressive evidence that this might be the case. 401 And some better
evidence too. 402
Despite these potential modest benefits, I cannot recommend acupuncture for trigger points.
Acupuncture is an awkward combination of possibly-useful therapeutic techniques and a great
deal more that is probably worthless — remember, most of “ancient Chinese wisdom” is just old
superstition. Not too surprisingly, acupuncture has really been failing to pass fair scientific tests in
the last ten years. Some of the sloppy, low-quality scientific experiments of the past (especially the
Chinese ones!) certainly made acupuncture look promising. But virtually all of that old evidence
has been made obsolete by more recent, better scientific experiments. In particular, acupuncturists
have completely failed to demonstrate any ability to treat pain effectively. This is thoroughly
explored in my article, Does Acupuncture Work for Pain?. The rest of this section picks out some
highlights and considers the relationship between acupuncture and trigger points.
In January, 2009, the British Medical Journal published a new analysis of acupuncture for pain, with
extremely discouraging results. A dozen of the best scientific studies of acupuncture treatments for
pain were carefully analyzed. The treatments were for conditions like osteoarthritis, headache and
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
migraine, low back pain, fibromyalgia, and more. 403
Trigger points would not be involved in all of these pain problems, of course, but they would be
key factors in many of them. If acupuncture had any potential to treat pain via trigger point release
— even “accidentally” by needling “pain” points corresponding to trigger points — then you
would expect to see acupuncture outperform a fake substitute (random needling) by quite a good
margin.
Of course, that’s not what happened. The authors of the paper found a statistically significant but
“small difference between acupuncture and placebo acupuncture.” They concluded that “the
apparent analgesic effect of acupuncture seems to be below a clinically relevant pain
improvement.” They also called the effectiveness of acupuncture “limited, at best.”
Another superb bit of recent science — a particular meticulous German study from mid-2007 —
clearly showed that acupuncture is no better than a placebo when treating back pain. 404 Given
that trigger points are probably an important factor in most back pain, once again we would hope
to see acupuncture creating at least a little more benefit than a placebo! You would hope to see it
even if only because of coincidental needling of trigger points which happen to correspond to
acupuncture’s “pain points.” But it didn’t.
Although a handful of acupuncturists might have the right knowledge and approach, in practice
the majority of them are rather unlikely to consistently treat you in a way that is enough like IMS to
make a difference. The focus of acupuncture simply isn’t on the phenomenon of muscular
dysfunction. The acupuncturist isn’t thinking “trigger point,” but “pain point” — only some of
which even correspond to common trigger points. Consequently, the odds of finding an
acupuncturist who can help you with muscle pain are low.
But the bigger problem for patients is quality control in the
delivery of acupuncture. If we knew that all acupuncturists were
intellectually honest, critical thinking, and highly ethical health
care professionals interested in the scientific evidence, then you
could safely go to them and experiment, with informed consent,
and receive treatments of “pain points” (trigger points) that
might help. But the sad reality is that a great many
acupuncturists are clearly not interested in evidence-based
These are fair tests! I must emphasize
again, these are fair tests. Let’s not have
any talk of acupuncture not being testable
because “testing interferes with the
therapy” — testing is well-designed to
avoid that problem! Either acupuncture can
do what it claims or it can’t. If it can, it
should be an obvious enough effect that
care, 405 because the evidence clearly indicates that they
acupuncturists should be able to easily
shouldn’t be working as acupuncturists any longer.
demonstrate it under reasonable testing
conditions. But they can’t.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
9.21
Acupressure: what if we pressed those points instead of puncturing?
As just mentioned above, there is probably some overlap between common trigger point locations
and alleged acupuncture points. If so, acupuncture would probably be help trigger points if
needling trigger points was helpful — which it doesn’t seem to be.
But what if you replaced the needles with thumbs? What if you pressed instead of puncturing?
Acupressure is a hybrid of acupuncture and massage. It uses massage techniques to stimulate
acupuncture points. But when used to treat pain, it may do so “accidentally” by stimulating some
trigger points, even if there’s nothing in the acupressure texts about the biology of muscle knots.
There’s actually some interesting good news about this.
The Taiwanese test
A 2004 Taiwanese trial compared “acupressure” to physical therapy for back pain. 406 It was
randomized and controlled and involved 146 subjects, which is quite a good number. The
acupressure group had less pain than the physical therapy group in the short and medium term.
How much less? At one month, a pain score of 2.3 versus 5; after six months, 1.1 versus 3.1. More
good numbers.
The researchers concluded that “acupressure is another effective alternative medicine in reducing
low back pain.” The same research group reproduced similar evidence in 2006 and published in the
British Medical Journal, a much more impressive journal. 407 According to the BMJ’s mostly 408
superb commentary, 409 these results were “striking.” I like the last point here, highlighted:
It was well conducted in terms of randomisation, blinding, loss to follow-up, and
analysis. The differences between the groups in standard outcome measures of disability,
pain scores, and functional status are striking. The difference immediately after treatment
and at six months was more than twice that reported in trials of conventional back pain
interventions and of acupuncture. If these results are valid, acupressure would seem to
represent an efficacious treatment for low back pain and we might need to ask why
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Chinese medicine clinicians use acupuncture for back pain, rather than acupressure.
Great question!
Now for the problems
This is Science, so of course there are caveats galore. And Frost does an excellent job of explaining
them. For example:
“Cultural differences are probably important in the experience and reporting of back pain” — true,
and an understatement. This is a major potential way the study could be virtually worthless.
Treatment in the physical therapy group “may have been suboptimal.” Another understatement. (It
included infrared light “therapy.” Seriously?)
And this is the main caveat, and it’s huge: “patients’ expectations and placebo effects are both likely
to play a part in determining the outcome of interventions such as acupressure, and the additional
benefits of acupressure cannot be established from this pragmatic trial.” In other words,
acupressure may have had an unfair advantage: a treatment nearly guaranteed to have a huge
placebo effect compared to shabby physical therapy. Perhaps the results aren’t so striking after all?
“Would the effect be the same if Western clinicians were trained in these techniques, and would
patients in the West with different cultures and lifestyles respond as well?” I’d sure like know.
Clearly the results need to be replicated in a different cultural context.
But I think the most important point of all was not mentioned by Hsieh et al. or Frost: what if it
worked well mainly because of the “pressure” and not so much the “acu”? That is, it got good
some results because it was massage, and some of the “acupuncture points” happened to be trigger
points? That seems like a plausible explanation to me — certainly an optimistic one that fits my
biases nicely!
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
9.22
How about Active Release Techniques® (ART)?
Active Release Techniques® (often also erroneously called Active Release Therapy) is a brand name
for a certain style of “deep tissue” (i.e. hard) massage that incorporates movement. It is not
especially distinctive or innovative from the point of view of a well-trained massage therapist, who
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
may well have an ART-like style — but not be limited to it — without ever bothering to call it ART.
ART is commercially successful, but scientifically bankrupt. It is often portrayed as a kind of
“sports massage” — just look at the sporty, sexy imagery used on the ART website! Oooh, and
testimonials from football players, too! Sign me up! But the sports angle is much more hype than
substance.
In fact, hype is a major part of ART. The official ART website brags that it is “a patented, state of
the art soft tissue system/movement based massage technique.” The mystique of an allegedly stateof-the-art patent makes it sound pretty dang special, but patenting, of course, has absolutely
nothing whatsoever to do with the effectiveness of a therapy — rather, it protects the patent
holder’s right to financially exploit a distinct concept.
ART is inextricably linked with chiropractors. It was created by a chiropractor, 410 most providers
are chiropractors, and it is marketed the way chiropractors market things (aggressively). Actually,
you can pretty much think of ART as “massage for chiropractors” — it is what chiropractors offer
when they want to include some massage therapy skills in their practice, which is commendable in
itself, but also suggests something about its limitations.
The “rationale” for ART is presented like this:
How do overuse conditions occur? Over-used muscles (and other soft tissues) change in
three important ways:
acute conditions (pulls, tears, collisions, etc.),
accumulation of small tears (micro-trauma)
not getting enough oxygen (hypoxia).
This is not an informative or accurate summary of what goes wrong with muscles and soft
tissues. 411 And the implication that ART is somehow an evidence-based solution to these things
is even more absurd! Leahy’s website offers no more detailed explanation. There are testimonials,
naturally, but no references. Leahy might as well just say, “Just trust me, it works!”
Trigger points are the most obvious omission from the marketing language — the most obvious
reason that ART might actually be effective. Trigger points are well known to science, and clearly
aggravated by over-exertion, so it is surprising indeed that Leahy doesn’t claim trigger points for
himself. But in my experience, ART providers don’t generally know any more about trigger points
than most poorly trained massage therapists. Therefore, ART is one of the weakest options
available for trigger point therapy.
I am not entirely critical of ART, believe it or not. On the one hand, ART does seem pretty
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
ridiculous to me — it’s a quaint pretension, imprecise and ham-handed, random muscle mashing
compared to what a good massage therapist does. Chiropractors are as clumsy with it as I would
be if I tried to do spinal adjustments. ART, as usually practiced, is mostly harmless and useless
when it comes to trigger point therapy.
On the other hand, in some ways any kind of massage is like pizza: even when it’s not very good,
it’s still pretty good, and a talented chiropractor who knows anything at all about trigger points
will probably do ART in a way that is “trigger point friendly,” focusing on at least some relevant
muscle knots.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
9.23
Measuring progress in trigger point therapy
How do you know whether or not trigger point therapy is working for you? Clients often ask me
how we are going to know whether or not therapy is “working.” Sometimes it’s easy: you know it’s
working when you feel better! But many cases are not so straightforward …
Consider the example of iliotibial band syndrome, a common injury that stops runners in their
tracks (see Save Yourself from IT Band Syndrome!). Resting is a crucial part of therapy … yet you
can’t tell whether or not it’s healing until you try to run: if you run and you have pain, you’ve
answered the question and aggravated the problem at the same time. How are you supposed to tell
what’s happening without risking aggravation?
Here are some technical indicators that we use to evaluate progress.
Reduced trigger point sensitivity As trigger points “release” and recover in the day or two after
treatment, they become less sensitive. In my own practice, I invariably increase my pressure to
compensate for reduced sensitivity, resulting in what seems to be the same sensitivity for the
patient. However, if therapy is succeeding, I am actually using more pressure to get the same
sensitivity as during the last treatment. These differences can be estimated reasonably accurately
(“good enough for government work”) over time, or it can be measured more accurately using an
algometer, 412 a device for measuring the amount of pressure applied to tissue. For instance, an
algometer can tell you that you are applying exactly 4.2kg of pressure to the muscle. If 4.2kg of
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
pressure produced pain that was 6 out 10 last week, but only 4 out of 10 this week, that’s actually
quite a reliable method of evaluating progress.
As useful as algometers are, I’ve never yet used one myself,
something I intend to correct soon. Meanwhile, clients are
somewhat at my mercy — they have to take my word for it when
I tell them that I am using “twice as much pressure as last week.”
Even I don’t know for sure. But, after years of experience, I do
have a pretty good sense of it. �� And any significantly reduced
sensitivity is generally fairly obvious to both practitioner and
patient. If you’re having trouble detecting a reduction in
sensitivity, it’s probably because there hasn’t been a significant change.
Reduced local twitch response. Another good indicator of trigger point release is reduction in a
phenomenon called “local twitch response” (LTR), previously discussed. A nasty trigger point
often twitches when stimulated with precise pressure. If the LTR goes down, the trigger point is
probably getting better.
“Peeling the onion.” A classic sign of progress that doesn’t
necessarily seem like progress is, believe or not, new and different
symptoms replacing the old ones. Previously I explained the
difference between a true negative reaction to treatment and a
“healing crisis.” A healing crisis can involve genuinely painful
processes in a tissue that is actually recovering. “Peeling the
onion” involves painful side effects of successful treatment!
The human nervous system seems to “prioritize” problems,
letting you know about them — in the form of pain and other
symptoms — in their order of importance, a hierarchy of pain
An onion-peeling example: Consider the
case of a man with severe chronic low back
pain — he’d had symptoms on the right
side for about thirty years. After three
treatments, suddenly the pain switched
sides — just hopped across the spine, a
perfect mirror image. He had never felt pain
on the left side ever before. This is a real
case. This really happens! And it is usually
an excellent sign of progress, of things
shifting and changing. The good news in his
awareness. As one “layer” of a problem begins to resolve,
new symptom was that his body, after 30
patients routinely experience a sudden shift in the quality or
years of being totally preoccupied with
location of symptoms. We call this “peeling the onion” —
right side low back pain, suddenly had an
revealing layers of pain and dysfunction.
opportunity to let him know that there was
Change in
surprising! “Flabbergasted” would be a fair
tissue
texture are
not
indicators
also an issue with the left side. Hardly
word to describe his reaction to this
The human nervous system seems to
“prioritize” awareness of pain problems.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
amazing turn of events.
The Complete Guide to Trigger Points & Myofascial Pain (2019)
of progress.
Changes in
the texture of muscle tissue are not reliable indicators of progress. Trigger points are all too capable
of remaining hard and rigid even when feeling quite a bit better — and vice versa (feeling worse
without hardening).
Any reaction at all is better than no reaction, as a general rule of thumb. I often tell patients that
the worst sign is no sign at all: in almost all cases, something should change in the first few
appointments, either for better or for the worse. But if nothing at all happens by after the third
treatment, that particular therapy (or style of applying it) is probably not going to do the trick for
you. Or, it might still work … but inefficiently, slowly, expensively. Of course, a serious negative
reaction isn’t a sign of progress! See the section about troubleshooting negative reactions if you
need to figure out the difference between a “good” negative reaction — a healing crisis that will
pass — and a genuine negative reaction.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
Part 10
FINAL THOUGHTS
How is a lemon like a trigger point?
Is there anything more tragic than a lost cure? It is a matter of historical fact, for instance, that the
solution to scurvy — that scourge of the oceans, vitamin C deficiency — was known but then
effectively forgotten, or disbelieved, for three centuries, specifically due to medical arrogance.
Physicians of that era had some bizarre new pre-scientific ideas about what caused scurvy and
what could cure it. Being influential gentlemen, they were consulted by the admiralties of Europe’s
emerging national navies, and their strange cures were adopted as policy — in place of ancient folk
wisdom that fresh fruits and vegetables were an effective cure. And so, just in time for the Age of
Sail, millions of sailors and passengers suffered horribly and died. 413
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
How is a lemon like a trigger
point?
Both have been ignored by
doctors! For three centuries
during the height of the Age of
Sail, the cure for scurvy, once
widely known to sailors, was
forgotten & disbelieved by the aristocratic doctors of
Europe’s great navies. Trigger points exist in a similar kind
of medical blind spot today.
The cure for myofascial trigger points is similarly neglected today. The disease itself is ignored. The
clinical importance of muscle knots could easily be included in the top ten under-rated medical
discoveries of 20th century medical science. It is hard to overstate how much suffering and
economic cost could have been prevented if only the research of Drs. Janet Travell and David
Simons had been embraced by more doctors, physiotherapists, chiropractors and massage
therapists.
Instead, what is known about trigger points remains strangely neglected — a minor miracle left on
a high, dusty shelf, waiting to be embraced by future generations of health care professionals.
Meanwhile, the consequences are not as dire as the loss of the cure for scurvy … but it seems no
less tragic and unnecessary to me.
Part 11
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
APPENDICES
How was that for you?
Thanks for reading. If you were not satisfied with the tutorial, please write to me about it. Constructive
criticism is always welcome. And you’re welcome to a refund — all you have to do is ask.
If you are satisfied, here are some ways to show it:
Word of mouth! Please recommend this tutorial to friends for purchase. Write a micro-review for Facebook
or Twitter. For easy cutting and pasting, here’s a shortened address:
https://www.PainScience.com/trigger-points
Publish a link! If you have a blog or website, this is by far the most helpful thing you can do. Just copy and
paste this HTML:
<a href="https://www.painscience.comhttps://www.painscience.com/tutorials/trigger-points.php">trigger points
tutorial</a>
A gratuity! If you feel that this tutorial was worth more than you paid for it — perhaps it has saved you
from spending a lot more on an irrelevant therapy? — then please donate $5, $10 or maybe even $20 to “the
cause.” (If you'd prefer a different amount, PayPal is the way to go at this time.)
Give $5
CURRENCY
Give $10
?
Give $20
USD – US–Dollars
USD
US D 11.1
Appendix A: Trigger Point Reference Materials or: Diagrams, Diagrams, Diagrams!
Many excellent trigger point reference books and charts have existed for decades, and more are
being published all the time — there are even trigger point reference iPhone apps now, surprise
surprise. So when I set out to write this book it seemed crazy to re-invent that particular wheel. I
wanted to focus on explaining trigger points, not guiding you to them — a decade ago, there simply
was no good book for patients about the concepts, and today this is still the only one I know of.
And, as explained early in this e-book, trigger point reference materials may confuse patients as
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
much as they help. And so descriptions and diagrams of trigger point locations are deliberately left
out of this tutorial.
And yet they are on this website.
And there certainly is some need and demand for trigger point reference material. It has its place,
and there are some excellent options available. Here they are:
The Perfect Spots, my own short series of muscle-by-muscle reference articles. The usual chatty,
sassy style of these articles makes them unique among trigger point references. See below for more
information and a quick reference guide to the spots.
Books. The big red books by Janet Travell and David Simons are the obvious best choice for
professionals: the diagrams are beautifully illustrated, and the content is incredibly detailed. For
patients, the 3rd edition of Clair and Amber Davies’ The Trigger Point Therapy Workbook is basically
a translation of the Travell & Simons texts for patients, focusing on the most clinically significant
trigger points.
Apps. There are many of these apps now. Unfortunately, I don’t recommend any of them at this
time: I think they all have significant problems.
Wall charts. Trigger point charts are of minimal interest to patients as a product — overkill. But
they are interesting, and I found them endlessly useful as a massage therapist, not only as a
reference for myself, but particularly as a way to show patients the relationship between trigger
points and pain in another location. Many times I saw “the light go on” in this way — there’s
something really compelling about a nice wall chart. For any professional, and some keen patients,
I prefer and recommend the Travell and Simons' Trigger Point Flip Charts.
Online charts, “symptom checkers.” Just point to your pain. The MyofascialTherapy.org trigger
point symptom checker is a database of diagrams and information about trigger points in many
muscles. Click on a body diagram where you have symptoms, browse through a selection of
pictures showing the possible origins of your pain, and then drill down into more detailed
information. It’s free to use, and you get what you pay for: an old and very basic tool that wasn’t
built well to begin with, and has never been updated (useless on mobile, for instance). It’s basically
just copied from Travell & Simons (decades-old clinical impressions and speculation, in other
words).
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
11.2
Appendix B: The Perfect Spots
Below are the “perfect spots”: thirteen classic trigger points, the easiest to find and most useful,
accounting for perhaps 60% of all common pain problems. These are “Perfect Spots” for massage,
the most satisfying and therapeutically significant places on the human body to apply pressure.
What exactly makes a spot perfect?
a common trigger point
unusually relevant to a common problem
reasonably easy to find and treat
good therapeutic “bang for buck”
unusually relaxing, satisfying and/or prone to producing “good” pain as opposed to “bad” pain
The Perfect Spots are described in a series of (free) articles. See below for a quick reference guide to
the spots. This guide is also available in each spot article. The title of each article summarizes the
spot in terms of the pain problem it is most relevant to. But look closer for more detailed
information about where the spot is, where it can cause pain, and other conditions it may be
tangled up with.
A pain in the butt
And hip. And hamstrings. Gluteus medius & minimus are a
common but often unsuspected cause of pain.
Diagrams like this one illustrate the perfect spots series,
helping you locate possible sources of your pain. The Perfect
Spots articles are the most popular on PainScience.com.
1
Perfect Spot No. 1 — Massage Therapy for Tension Headaches
Under the back of the skull must be the single most pleasing and popular target for massage in the human
body. No other patch of muscle gets such rave reviews. It has everything: deeply relaxing and satisfying
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
sensations, and a dramatic therapeutic relevance to one of the most common of all human pains, the
common tension headache. And no wonder: without these muscles, your head would fall off. They feel just
as important as they are. (Click/tap heading to read more.)
for pain: almost anywhere in the head, face
and neck, but especially the side of the head,
behind the ear, the temples and forehead 2
related to: headache, neck pain,
migraine muscle(s): suboccipital muscles
(recti capitis posteriores major and
minor, obliqui inferior and superior) Perfect Spot No. 2 — Massage Therapy for Low Back Pain
This Perfect Spot lives in the “thoracolumbar corner,” a nook between your lowest rib and your spine —
right where the stability of the rib cage and thoracic vertebrae gives way to the relative instability of the
lumbar spine. It consists of trigger points in the upper-central corner of the quadratus (square) lumborum
muscle and in the thick column of muscle that braces the spine, the erector spinae. (Click/tap heading to read
more.)
for pain: anywhere in the low back, tailbone,
lower buttock, abdomen, groin, side of the
hip 3
related to: low back pain,
herniated disc muscle(s): quadratus lumborum,
erector spinae Perfect Spot No. 3 — Massage Therapy for Shin Splints
Perfect Spot No. 3 is in your shins — seemingly an unlikely place for muscle knots! But there is meat there,
and if you’ve ever had shin splints then you know just how vulnerable that meat can be. Even if you’ve
never suffered so painfully, your shins probably still suffer in silence — latent trigger points in the upper
third of the shin that don’t cause symptoms, but are plenty sensitive if you press on them. (Click/tap heading
to read more.)
for pain: in the shin, top of the foot, and the
big toe 4
related to: shin splints, drop foot,
anterior compartment syndrome,
medial tibial stress syndrome muscle(s): tibialis anterior Perfect Spot No. 4 — Massage Therapy for Neck Pain, Chest Pain, Arm Pain, and
Upper Back Pain
Deep within the Anatomical Bermuda Triangle, a triangular region on the side of the neck, is the
cantankerous scalene muscle group. Massage therapists have vanished while working in this mysterious
area, never to be seen again. The region and its muscles are complex and peculiar, and many lesser-trained
massage therapists have low confidence working with them. (Click/tap heading to read more.)
for pain: in the upper back (especially inner
edge of the shoulder blade), neck, side of the
face, upper chest, shoulder, arm, hand 5
related to: thoracic outlet
syndrome, lump in the throat,
hoarseness, TMJ syndrome muscle(s): the scalenes (anterior,
middle, posterior) Perfect Spot No. 5 — Massage Therapy for Tennis Elbow and Wrist Pain
Just beyond your elbow, all the muscles on the back of your forearm converge into a single thick tendon, the
common extensor tendon. At the point where the muscles converge, in the muscles that extend the wrist and
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
fingers, lies one of the more inevitable trigger points in the body: Perfect Spot No. 5. It is constantly
provoked both by computer usage today and by the use of a pen in simpler times — and by the occasional
tennis match, then and now. (Click/tap heading to read more.)
for pain: in the elbow, arm, wrist, and hand 6
related to: carpal tunnel
syndrome, tennis elbow (lateral
epicondylitis), golfer’s elbow
(medial epicondylitis), thoracic
outlet syndrome, and several
more muscle(s): extensor muscles of the
forearm, mobile wad (brachioradialis,
extensor carpi radialis longus and
brevis), extensor digitorum, extensor
carpi ulnaris Perfect Spot No. 6 — Massage Therapy for Back Pain, Hip Pain, and Sciatica
When you have back pain, buttock pain, hip pain, or leg pain, much or even all of your trouble may well be
caused by trigger points in the obscure gluteus medius and minimus muscles, a pair of pizza-slice shaped
muscles a little forward of your hip pocket. Other muscles in the region are usually involved as well, such as
the gluteus maximus, piriformis, and the lumbar paraspinal muscles. However, the gluteus medius and
minimus are a bit special: their contribution to pain in this area is particularly significant, and yet people
who have buttock and leg pain rarely suspect that much of it is coming from muscle knots so high and far
out on the side of the hip. (Click/tap heading to read more.)
for pain: in the low back, hip, buttocks
(especially immediately under the buttocks),
side of the thigh, hamstrings 7
related to: sciatica, trochanteric
bursitis, low back pain muscle(s): gluteus medius and
minimus Perfect Spot No. 7 — Massage Therapy for Bruxism, Jaw Clenching, and TMJ
Syndrome
Your masseter muscle is your primary chewing muscle — not the only one, but the main one — and it
covers the sides of the jaw just behind the cheeks. It’s also the main muscle that clenches your jaw and
grinds your teeth, unfortunately, and it’s one of the most common locations for trigger points in the human
body. It is probably an accomplice in most cases of bruxism (that’s Latin for “grinding your teeth”) and
temporomandibular joint syndrome (jaw joint pain), plus other unexplained painful problems in the area.
(Click/tap heading to read more.)
for pain: in the side of the face, jaw, teeth
(rarely) 8
related to: bruxism, headache,
jaw clenching, TMJ syndrome,
toothache, tinnitus muscle(s): masseter Perfect Spot No. 8 — Massage Therapy for Your Quads
A lot of quadriceps aching, stiffness and fatigue emanates from an epicentre of “knotted” muscle in the
lower third of the thigh, in the vastus lateralis, a huge muscle — one of your biggest — that dominates the
lateral part of the leg. Stretching it is effectively impossible, but massage is an option: although often
shockingly sensitive, Perfect Spot No. 8 can also be quite satisfying. It also often complicates or contributes to
other problems in the area, especially runner’s knee (iliotibial band syndrome). (Click/tap heading to read
more.)
for pain: in the lower half of the thigh, knee related to: iliotibial band
syndrome, patellofemoral pain
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
muscle(s): quadriceps (vastus
lateralis, vastus intermedius, vastus
The Complete Guide to Trigger Points & Myofascial Pain (2019)
syndrome 9
medialis, rectus femoris) Perfect Spot No. 9 — Massage Therapy for Your Pectorals
The “pecs” are popular: of 700+ muscles, the pectoralis major is one of just a dozen or so that most people can
name and point to. It also harbours one of the most commonly-encountered and significant trigger points in
the human body, and can produce pain much like a heart attack in both quality and intensity. (Click/tap
heading to read more.)
for pain: anywhere in the chest, upper arm 10
related to: “heart attack,”
respiratory dysfunction muscle(s): pectoralis major Perfect Spot No. 10 — Massage Therapy for Tired Feet (and Plantar Fasciitis!)
The tenth of the Perfect Spots is one of the most popular of the lot, and right under your feet — literally. It
lies in the center of the arch muscles of the foot. This is one of the Perfect Spots that everyone knows about.
No massage is complete without a foot massage! (Click/tap heading to read more.)
for pain: in the bottom of the foot 11
related to: plantar fasciitis muscle(s): arch muscles Perfect Spot No. 11 — Massage Therapy for Upper Back Pain
This “spot” is too large to really be called a “spot” — it’s more of an area. The thick columns of muscle
beside the spine are often littered with muscle knots from top to bottom. Nevertheless, there is one section of
the group where massage is particularly appreciated: from the thick muscle at the base of the neck, down
through the region between the shoulder blades, tapering off around their lower tips. There is no doubt that
this part of a back massage feels even better than the rest — even the low back, despite its own quite perfect
spots, cannot compete. (Click/tap heading to read more.)
for pain: anywhere in the upper back, mainly
between the shoulder blades 12
related to: scoliosis muscle(s): erector spinae muscle
group Perfect Spot No. 12 — Massage Therapy for Low Back Pain (So Low That It’s Not In
the Back)
At the top of the buttocks lies a Perfect Spot for massage: a sneaky but trouble-making brute of a trigger
point that commonly forms in the roots of the gluteus maximus muscle. It’s below the lowest part of the low
back, but it often feels like low back pain. This is the kind of spot that the Perfect Spots series is all about: not
only does it tend to produce a profound, sweet ache when massaged, but the extent of the pain that spreads
out around it is almost always a surprise. It feels like a key to much more than expected. (Click/tap heading
to read more.)
for pain: in the lower back, buttocks, hip,
hamstrings related to: low back pain,
sciatica, sacroiliac joint
dysfunction https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
muscle(s): gluteus maximus The Complete Guide to Trigger Points & Myofascial Pain (2019)
13
Perfect Spot No. 13 — Massage Therapy for Low Back Pain (Again)
Some of the Perfect Spots are perfect because they are “surprising” — it’s delightful to find a place to
massage that feels highly relevant your pain in an unexpected location. Others are perfect because they are
exactly where you expect them to be — and what a relief it is to be able to treat them. Perfect Spot No. 13 is
perhaps the ultimate, the quintessential example of a trigger point that is usually “right where I thought the
problem was”: in the “pit” of the low back, at the bottom of the thick columns of back muscle beside the
spine. (Click/tap heading to read more.)
for pain: in the low back, buttocks,
hamstrings 14
related to: low back pain,
sciatica, sacroiliac joint
dysfunction muscle(s): erector spinae muscle
group at L5 Perfect Spot No. 14 — Massage Therapy for Shoulder Pain
I avoided adding Spot 14 to this series for many years, because it’s a bit tricky to find. But precision is not
required: although there is one specific spot that’s especially good, nearly anywhere under the ridge of bone
on the shoulder blade is worthwhile, and often a surprising key to pain and stiffness everywhere else in the
shoulder, especially all the way around on the other side, facing forward. (Click/tap heading to read more.)
for pain: any part of the shoulder, and upper
arm related to: frozen shoulder,
supraspinatus tendinitis muscle(s): infraspinatus, teres
minor GO TO TOP • CONTENTS • END • NOTES • BOTTOM
11.3
Appendix C: Trigger Point Therapy Resources
This is a list of resources relevant to chronic pain in general, but muscle pain in particular. I
avoided publishing this section of the tutorial for many years, because I am generally not
impressed by the resources available (to both patients and professionals), especially online
resources. I remember a slightly testy conversation with someone from an American organization
(that shall rename nameless):
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
THEM You say it’s hard for patients to find good trigger point therapy. You shouldn’t say that! We certify
good trigger point therapists!
ME You have about fifty practitioners in your directory, concentrated in a handful of major cities, with
a certification no one has ever heard of, for a country of more than 300 million people spread over
almost 10 million square kilometres. That’s one certified therapist for about every 60,000 people
and 200,000 square miles. If “needle in a haystack” is the new “easy to find,” then sure, I’ll say
that your certified therapists are easy to find.
THEM Well, you still shouldn’t say that it’s hard to find them!
ME Call me when your organization has grown by at least an order of magnitude and your website
doesn’t look like it was built by high school students.
Years later that organization still has only a few dozen certified therapists in its directory, and yet it
remains one of the few and largest directories of its kind. If you live in a big city, there’s a fair to
middlin’ chance that you can find one of those therapists. But certification of trigger point
therapists is generally an amateurish and fragmented mess, with many businesses and
organizations competing to be the standard. (Even this document is part of the mess: a sanityinducing part of the mess, hopefully, but nevertheless a good example of how everyone and their
dog is out there trying to provide “the best” information/training/therapy in this field.)
For inclusion in this section, an organization or business must be defining the field in some way,
and they must have a strong online presence.
The relevance of each listing to professional readers and/or patients is shown with the PRO and
PATIENT icons. For instance, although professional associations are rarely of much interest to
patients, they may provide directories of professionals to help patients find practitioners.
National Association of Myofascial Trigger Point
Therapists (NAMTPT) PRO
PATIENT — The only
organization dedicated to representing professionals
specializing in myofascial pain and trigger point therapy.
NAMTPT provides resources for both patients and
professionals, such as a trigger point therapist directory (
just over 100 therapists) and a symptom checker.
The International Myopain Society (IMS) PRO — A
With apologies to my international
readers, this section is mostly
American-o-centric. If you are aware
of important resources and
organizations elsewhere in the world,
please let me know.
nonprofit health professionals organization dedicated to
the promotion of information about soft-tissue pain
disorders like myofascial pain. IMS publishes the
MYOPAIN, a Journal of Myofascial Pain and Fibromyalgia.
American Society of Pain Educators (ASPE) PRO — A nonprofit organization that trains
Certified Pain Educators (CPEs). A CPE educates clinical peers, patients, families, and caregivers
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
on ways to relieve pain by the safest means possible. ASPE training is not focused on muscle pain.
American Academy of Pain Management (AAPM) PRO
PATIENT — The largest association
of pain professionals in the United States with 6000 members. Similar to the ASPE in that members
do not focus on muscle pain in particular: they are included here because they are chronic pain
experts in general (although, interestingly, in 2016 they did “spontaneously” form a new “interest
group” about myofascial therapy). They provide a directory of members and listings of pain
clinics.
Massage Therapy Foundation (MTF) PRO — A nonprofit organization to advance the
profession of massage therapy, founded by the American Massage Therapy Association. The MTF
website has a strong focus on research and they publish the International Journal of Therapeutic
Massage & Bodywork, which routinely publishes papers about myofascial pain syndrome. Their
resources page offers a series of excellent short ebooks by authors I know and vouch for, and I
particularly recommend Tracy Walton’s 5 Myths & Truths About Massage Therapy (written for
therapists).
The Pressure Positive Company PRO
PATIENT — The best and oldest American manufacturer
of good quality massage tools, Pressure Positive has also been a superb corporate citizen,
contributing to the advancement of trigger point therapy in many ways, such as collaborating with
writers like myself and supporting and promoting scientific research — admirable qualities in a
field so often afflicted with pseudoscientific hype. Their website provides many useful resources
for both patients and professionals.
Trigger Point Therapy Workshops — PRO
PATIENT A small trigger point workshop provider,
for both professionals and patients, notable mainly because the founder is Amber Davies, NCTMB,
daughter of Clair Davies and author of The Trigger Point Therapy Workbook — a popular primer on
this topic (see my review).
Certification Board for Myofascial Trigger Point Therapists — PRO
PATIENT A small
professional organization for trigger point therapists dedicated to “advancing the professional
standards of myofascial trigger point therapists through the establishment and maintenance of
criteria and procedures for certification.” They offer a modest directory of a few dozen trigger
point therapists around the United States.
Neil Asher Continuing Education for Manual Therapists. “Neil Asher Technique” is branded
approach to trigger point therapy, and the website is mostly built around a directory of NAT
certified therapists.
David G. Simons Academy (DSGA) PRO
PATIENT — Dr. Simons co-authored the famous big
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
red texts — the seminal text on myofascial pain syndrome — with Dr. Janet Travell. DGSA is
named in his honour, and has offered courses in dry needling and manual trigger point therapy
worldwide since 1995 (although they seem to be primarily serving Europe). They are hardly the
only provider of such workshops, but I single them out because I specifically appreciate their
attitude towards certification: they offer to teach skills, not certification levels in a branded
treatment “system.” (I don’t necessarily object to branding of training, but I prefer this more
academic approach to training.) They maintain a decent bibliography of trigger point research. (See
also Seminarios Travell & Simons, offering trigger point courses in Spain led by Orlando Mayoral
— there is a regular exchange of experience between DGSA and Orlando Mayoral.)
Myopain Seminars PRO
PATIENT — A post-graduate continuing education company
focusing on myofascial trigger points, manual trigger point therapy, dry needling, and trigger
point injections. Like DSGA, Myopain Seminars is focused more on teaching skills and knowledge
and not a branded certification program, but they do have a directory of graduates of their courses
(see their find a clinician feature) and more than a dozen faculty members all “provide high-level
diagnostic and management services” for pain patients that may be of interest to many readers of
this book. I have a friendly occasional correspondence with founder Dr. Jan Dommerholt, the
author of several influential books and papers on this topic; although we don’t necessarily agree on
everything — I’m not a fan of dry needling, primarily — I think of him as a mentor and have
learned a great deal from him.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
11.4
Reader feedback … good and bad
Testimonials on health care websites reek of quackery, so publishing them has always made me a
bit queasy. But my testimonials are mostly about the quality of the information I’m selling, and I hope
that makes all the difference. So here’s some highlights from the kind words I’ve received over the
years … plus some of the common criticisms I receive, at the end. These are all genuine
testimonials, mostly received by email. In many cases I withold or change names and identifying
details.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
I enjoyed your trigger point tutorial and read the whole thing again last Friday. I
also sent it to two friends who are having problems. It’s the education your site
has armed me with that is most valuable to me.
~Melinda Alltree, Vancouver
I purchased the low back tutorial recently and got the free trigger point one also.
Many thanks. They are great! I had already accessed the perfect spot series and
have been working on my trigger points. It is very pleasing to have the full discussion of
the physiology , and I now have a much better idea about the whole ghastly business.
~Leah Brannen, Saskatoon, Canada
I bought two of your eBooks last week, and I’m enjoying going through them.
Your presentation is excellent. It’s far too early too say, of course, but I think I’ve
already begun to benefit from your approach. One of the things I like most about your
approach is your respect for “science,” as opposed to “merchandising.” You've put so
much into those two eBooks, it's going to take time to do them the justice they deserve.
~David Calderisi, Toronto, Ontario
David diligently followed up a month later with the following comment: “By now I’m convinced your
research and recommendations are right on the money. Thanks. I’ve recommended you to a few people
who, like myself, have had back problems on and off for years. Thanks for having provided such a useful
tool.” ~ Paul
One trigger point therapy treatment completely relieved a nasty stubborn hip
pain that I'd had for five months!
~Jan Campbell, retired French language teacher, Palm Springs,
recovered easily from several months of hip pain
You saved me from having to look any further for the information I have been so
desperately seeking about trigger point, and basic massage techniques. I found
your info educational and entertaining, and appreciated your wit as well. I’m not
surprised to discover that you are Canadian — I’ve always enjoyed the Canadian sense of
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
humor!
~Laura Gallagher
Outstanding, excellent work! I really want to commend you. I teach trigger
points, and I will be recommending your tutorial to my students. Thanks very
much.
~John Harris, medical massage therapy instructor, Santa Barbara, coauthor of Fix Pain: Bodywork Protocols for Myofascial Pain Syndromes
I have been suffering from lower back pain for the last 5 weeks and found your
page to be very informative and interesting. I really can’t thank you enough
actually because for the first time I’m really starting to feel like I’m on the right track here.
~Glenn Hill, Canterbury, Australia
I am really enjoying your trigger points tutorial. It’s great to have a lot of extra,
professional information to work with. I have found a serious shortage of
information on the web, so it was easy to pay for your tutorial given the clear quality
conveyed by the introduction.
~Daniel Jalkut, software developer, Somerville, Massachusetts
One more noteworthy endorsement, with regards to this whole website and all of my books,
submitted by a London physician specializing in chronic pain, medical education, and patientadvocacy (that’s a link to his excellent blog):
I’m writing to congratulate and thank you for your impressive ongoing review of
musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards
Hospital in Hoxton. I originally stumbled across your website whilst looking for
information about pain for my medical students, and have recommended your tutorials
to them. Your work deserves special mention for its transparency, evidence base, clear
presentation, educational content, regular documented updates, and lack of any
commercial promotional material.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
— Dr. Jonathon Tomlinson, MBBS, DRCOG, MRCGP, MA, The
Lawson Practice, London
What about criticism and complaints?
Oh, I get those too! I do not host public comments on PainScience.com for many reasons, but
emailed constructive criticism, factual corrections, requests, and suggestions are all very welcome. I
have made many important changes to this tutorial inspired directly by critical, informed reader
feedback.
But you can’t make everyone happy! Some people demand their money back (and get it). I have
about a 1% refund rate (far better than average in retail/e-commerce). The complaints of my most
disatisfied customers have strong themes:
Too negative in general. Some people just can’t stomach all the debunking. Such customers often
think that I dismiss “everything” … which I disagree with.
Too negative specifically. Some are offended by about a treatment option that they personally use
and like. Or sell.
Too advanced. Although I work hard to “dumb” the material down, quite a few people still just
find it too dense and dorky.
Too simple. Some people think they already know everything about the topic. Maybe they do, and
maybe they don’t. I always wish I could give these readers a pop quiz. �� In my experience, all
truly knowledegable people get that way by embracing every new persective and source of
information.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
11.5
Acknowledgements
Thanks to every reader, client, and book customer for your curiosity, your faith, and your feedback
and suggestions, and your stories most of all — without you, all of this would be impossible and
pointless.
Writers go on and on about how grateful they are for the support they had while writing one measly
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
book, but this website is actually a much bigger project than a book. PainScience.com was originally
created in my so-called “spare time” with a lot of assistance from family and friends. Thanks to my
wife for countless indulgences large and small; to my parents for (possibly blind) faith in me, and
much copyediting; and to friends and technical mentors Mike, Dirk, Aaron, and Erin for endless
useful chats, repeatedly saving my ass, plus actually building many of the nifty features of this
website.
Special thanks to some professionals and experts who have been particularly inspiring and/or
directly supportive: Dr. Rob Tarzwell, Dr. Steven Novella, Dr. David Gorski, Sam Homola, DC, Dr.
Mark Crislip, Scott Gavura, Dr. Harriet Hall, Dr. Stephen Barrett, Dr. Greg Lehman, Dr. Jason
Silvernail, Todd Hargrove, Nick Ng, Alice Sanvito, Dr. Chris Moyer, Lars Avemarie, PT, Dr. Brian
James, Bodhi Haraldsson, Diane Jacobs, Adam Meakins, Sol Orwell, Laura Allen, James Fell, Dr.
Ravensara Travillian, Dr. Neil O’Connell, Dr. Tony Ingram, Dr. Jim Eubanks, Kira Stoops, Dr.
Bronnie Thompson, Dr. James Coyne, Alex Hutchinson, Dr. David Colquhoun, Bas Asselbergs …
and almost certainly a dozen more I am embarrassed to have neglected.
I work “alone,” but not really, thanks to all these people.
I have some relationship with everyone named above, but there are also many experts who have
influenced me that I am not privileged to know personally. Some of the most notable are: Drs.
Lorimer Moseley, David Butler, Gordon Waddell, Robert Sapolsky, Brad Schoenfeld, Edzard Ernst,
Jan Dommerholt, Simon Singh, Ben Goldacre, Atul Gawande, and Nikolai Boguduk.
Thank you finally to Dr. Tim Taylor, MD, author of this book’s vital sections about medical factors
that perpetuate pain, new as of the summer of 2010. More than a collaborator, Tim is an idealistic
and decisive volunteer, who didn’t just offer to contribute to this book, but made it happen quickly
and well and all for the sake of helping people. In twenty years of writing and publishing, I have
never seen a collaboration go that smoothly, and I am extremely grateful for it.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
11.6
What’s new in this tutorial?
Regular updates are a key feature of PainScience.com tutorials. As new science and information
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
becomes available, I upgrade them, and the most recent version is always automatically available
to customers. Unlike regular books, and even e-books (which can be obsolete by the time they are
published, and can go years between editions) this document is updated at least once every three
months and often much more. I also log updates, making it easy for readers to see what’s changed.
This tutorial has gotten 149 major and minor updates since I started logging carefully in late 2009
(plus countless minor tweaks and touch-ups).
July — Improved: Extensive editing and improvements throughout all the basic treatment sections. I added
many key points and tips while staying within the scope of “basic” (a tricky balance), mining years of writing
on this topic for a wide variety of refinements and carefully boiling them down to their essentials. Several
ideas I consider obsolete were also removed. The Quick Reference Guide was also updated to match.
[Section: Basic Trigger Point Therapy (Mostly Self-Massage): What can you do about garden variety trigger points?]
June — Upgraded: Added more detail about greater trochanteric pain syndrome, making the section a little
more useful to many readers. [Section: Case study: “Bursitis” strikes again!]
May — Revised: Significantly expanded and modernized (for the first time since it was originally written, I
think). [Section: From the frying pan of injury pain to the fire of trigger point pain.]
May — Rewritten: Heavily revised to basically be an abdridged version of the article Morning Back Pain,
focusing on trigger points. This section had been aging poorly, full of unsubstantiated speculation and
dubious premises. It’s on much firmer footing now. [Section: Morning symptoms: an uncomfortable daily
mystery for many people.]
May — Editing: Some clarifications about the mechanism of “flushing” and whether uncomfortable massage
intensity can be justified for that reason. [Section: Pain in three flavours: the good, the bad, and the ugly.]
May — Edited: Clarified, modernized, and expanded a little bit, especially integrating new information about
the effect of massage of tissue fluids and circulation. [Section: Yet more information about exactly how to rub
(pressing and holding).]
April — Rewritten: Totally revised and tripled in length, this chapter is “like new.” I also moved it to the
diagnosis section of the book to give it greater importance. [Section: Many other causes of chronic widespread
pain that should not be ignored.]
March — Edited: A thorough editing, especially to the information about frozen shoulder, part of an ongoing
effort to upgrade differential diagnosis information in the book. [Section: Could it be ________? Regional pains
that trigger points get confused with.]
March — Edited: Thoroughly edited for clarity. Stronger focus on the many ways palpation can go wrong.
[Section: Identifying your trigger points by feel: tissue texture and other palpable signs.]
February — Revision: A substantial editing of this topic for the first time in years, eliminating a fair bit of
quaint naivete and credulity from the good ol’ days when I still didn’t know just how deep these waters run.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
[Section: Adhesions and contracture: when trigger points freeze in place.]
February — Science update: Extended the discussion of vulnerability to include “sensitization.” [Section: Can
you damage your nerves when self-massaging? .]
February — Editing: This chapter now plays nicer with related sub-topics, and I’ve emphasized the differential
diagnosis context a little more. [Section: Nerve pain is overdiagnosed.]
January — Addition: Added excerpt from a comedic and interesting article about a patient with Ehlers–Danlos
syndrome who’s shoulder was dislocated by a massage. [Section: Hypermobility and Ehlers-Danlos syndrome.]
2018 — Additions: Added an informative and entertaining example. [Section: Trigger point diagnosis is not
reliable … but it also may not matter that much.]
2018 — Expanded: Added substantially to the section with exploration of two examples of peripheral
neuropathy that may be mistaken for trigger points (but only if you’re not very good at this stuff). [Section:
Quintner: “It’s the nerves, stupid”.]
2018 — Editing: Some minor clarifications and additions. [Section: Hypermobility and Ehlers-Danlos syndrome.]
2018 — Editing: A light re-write, de-emphasizing the dubious link to trigger points. [Section: All the noise!
Trigger points and crepitus (joint popping and more).]
2018 — Science update: Added a citation, a negative review. [Section: How about trigger point injection therapy?]
2018 — Science update: More thorough citing on the topic of dry needling efficacy … and that is probably the
last in a year-long series of updates to this section over 2018. This chapter has been well and truly rebooted.
[Section: Maybe stabbing will help! Dry needling.]
2018 — Science update: Analysis of more putative “mechanisms of inaction” as presented in three more
papers, one ancient, two new (Melzack, Chou, Cagnie). [Section: Maybe stabbing will help! Dry needling.]
2018 — New section: A new standard chapter for most PainScience.com tutorials summarizing several key
concepts about placebo. [Section: Some important things to keep in mind about placebos.]
2018 — Science update: Added analysis of Couto, one of the more credible positive trials of dry needling
available. [Section: Maybe stabbing will help! Dry needling.]
2018 — Revised: The Quick Reference Guide hadn’t been updated for a loooong time, and I finally got to it. It
could still use more modernization and careful synchronization with book content, but it is greatly
improved. (Fun fact: this update also eliminated some the final traces of branding for the old
SaveYourself.ca domain name, three-and-a-half years after it was retired.) [Section: Basic Trigger Point
Therapy (Mostly Self-Massage): What can you do about garden variety trigger points?]
2018 — Science update: A new sub-section about Llamas-Ramos et al , a study by dry needling proponents with
surprisingly negative results (even if they didn’t see it that way). Plus a bunch of miscellaneous minor
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
improvements. [Section: Maybe stabbing will help! Dry needling.]
2018 — Improvements: Significantly expanded discussion of the rationale for needling with an interesting
example and a helpful image. [Section: Maybe stabbing will help! Dry needling.]
2018 — Improvements: Miscellaneous clarifications and elaborations, especially about schools of thought and
mechanisms of effect. How does dry needling supposedly work? It’s hard for proponents to answer that
question directly. [Section: Maybe stabbing will help! Dry needling.]
2018 — Miscellaneous improvements: Added much more information about endangerment sites, discussion
of the potential relevance of neuritis, extensive clarifications and editing, and some footnotes. [Section: Can
you damage your nerves when self-massaging? .]
2018 — Science update: Added a few new citations about the efficacy of needling. Made some improvements
to the information on risks added last month. [Section: Maybe stabbing will help! Dry needling.]
2017 — Science update: Added more and better information about risks of dry needling. [Section: Maybe
stabbing will help! Dry needling.]
2017 — New section: No notes. Just a new section. [Section: Hypermobility and Ehlers-Danlos syndrome.]
2017 — Science update: Added a substantive footnote explaining the relationship between ulcers, stress, and
H. pylori infection as one of the best examples of a “stress-sensitive condition.” [Section: Slow checklist: a more
detailed diagnostic checklist for myofascial pain syndrome.]
2017 — Full science review: Another huge update, though mostly “under the hood” — I have now completed
a comprehensive informal review of all the available science, about 16 papers. The section now includes a
large table of papers with links to all the summaries. Most readers are not going to want/need to click on all
those links and read them all, but their availability is important. [Section: Massage efficacy according to science.]
2017 — Edited: Miscellaneous minor science updates; reduced confidence about the effect of trigger points on
resistance training. [Section: Strengthening: should you take your trigger points to the gym?]
2017 — Rewritten: Totally revised discussion of the effect of trigger points on strength; in particular, my old
opinions are now clearly labelled as speculation, rather than presented as fact. [Section: Four: Weakness (why
muscles with trigger points might be weak).]
2017 — Science update: A new citation, thorough discussion of Rathbone, and extensive related editing. The
bottom line has been tweaked: I think the reliability evidence is encouragingly non-bad. [Section: Trigger point
diagnosis is not reliable … but it also may not matter that much.]
2017 — Science update.: Cited and discussed evidence that statin myalgia could be a nocebo—that is, not
actually a real problem. [Section: Pain-causing drug side effects: statins (cholesterol-reducing drugs) and
bisphosphonates (for osteoporosis).]
2017 — Major upgrade: Extensive new analysis of the scientific evidence of efficacy for massaging trigger
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
points (mostly inconclusive). But I provide much more detail now, fully reviewing several noteworthy
studies, and there’s more to come. The section has roughly quadrupled in length. [Section: Massage efficacy
according to science.]
2017 — New section: An odd new section about trigger points in animals, with some interesting tangents and
perspective. [Section: Trigger points in animals.]
2017 — Science update: Added brief discussion of an interesting theory about the effect of stretching on
inflammation in connective tissue. [Section: Stretching: Stretching is generally over-rated … but it might be good
for trigger points.]
2017 — New section: A much more thorough discussion of vibrating massage tools. [Section: Thumping trigger
points with vibrating massage tools.]
2017 — Clarification: Made it much clearer that changes in blood acidity with respiratory alkalosis are minor
and transient. Miscellaneous minor edits. [Section: Breathing deeply is free, safe, and possibly good therapy for
trigger points.]
2017 — Science update: Added citation to Webb et al , plus related edits. [Section: Massage efficacy according to
science.]
2017 — Addition: Added a profound and very cool example of abnormal anatomy that confounds diagnosis of
hard lumps in tissue. [Section: Identifying your trigger points by feel: tissue texture and other palpable signs.]
2017 — Correction: Small but important correction about the value of opioids in severe cases that resemble
fibromyalgia. [Section: The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids.]
2017 — Minor improvements: Clarified several points and added a link to a new PainScience.com article
dedicated to fibromyalgia. [Section: A brief note about the relationship between fibromyalgia and myofascial pain
syndrome.]
2017 — Minor addition: Added a fun example of mistaken lump identity, and clarified warnings about how
easily this can happen. [Section: Identifying your trigger points by feel: tissue texture and other palpable signs.]
2017 — Minor maintenance: Some modernization, cleanup, and especially another “symptom checker” option.
[Section: Appendix A: Trigger Point Reference Materials or: Diagrams, Diagrams, Diagrams!]
2017 — Science update: Arcane but neat “bonus elaboration on the thalamic-convergence theory.” [Section:
Referred pain science (advanced).]
2017 — General improvement: Purged some defunct resources, added a couple new ones, and made several
corrections (broken links etc). [Section: Appendix C: Trigger Point Therapy Resources.]
2016 — Science update: Added a few new citations about the prevalence of vitamin D deficiency and it’s
correlation with chronic pain. [Section: Vitamin D deficiency.]
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
2016 — Rewrite: A new way of looking at how trigger points cause the sensation of “stiffness” and what
happens when we try to stretch them out. [Section: Like a knot in a bungie cord.]
2016 — Modest revision: Reorganized presentation of the practical and theoretical challenges with stretching
trigger points. [Section: The bad news about stretching for trigger points.]
2016 — Major update: Almost all of the stretching sections have been edited, revised, and modernized.
[Section: Stretching: Stretching is generally over-rated … but it might be good for trigger points.]
2016 — Minor editing: Made the point of the section more clearly. [Section: The spray-and-stretch method, if it
works, implies that stretch alone may not work.]
2016 — Edited: Thorough revision and modernization. Although I revised this section just five years ago, it
needed it again! [Section: Slow checklist: a more detailed diagnostic checklist for myofascial pain syndrome.]
2016 — Simplified: This section has been simplified, and now only covers key points about opioids and the
relevance of opioids to MPS specifically. Detailed information about opioids has been moved to a separate
article, Opioids for Chronic Aches & Pains. [Section: The nuclear option: “Hillbilly heroin” (Oxycontin), codeine
and other opioids.]
2016 — Major rewrite: Thorough revision of the introduction to sarcomeres, inspired by the book Life’s Ratchet,
about molecular machines. [Section: Micro muscles and the dance of the sarcomeres.]
2016 — Correction: Removed overconfident statements about the clinical significance of the effects of
psychoactive drugs, plus related minor updates. [Section: Slow checklist: a more detailed diagnostic checklist for
myofascial pain syndrome.]
2016 — Safety update: Updated for consistency with new CDC guidelines. Thorough editing of the section.
[Section: The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids.]
2016 — New section: No notes. Just a new section. [Section: Lidocaine patches.]
2016 — Important new related reading: Although not an update to the book itself, I’ve published some
important related articles about the scientific controversy over the explanation for trigger points: (1) a
heavily referenced review of the evidence that a trigger point is a “tiny cramp”; (2) a summary of the
academic controversy about trigger point science; (3) the story of my own doubts and how they’ve changed
over the years (this is the “main” article on this theme; it was around before but has been revised heavily).
All of this stuff is inside baseball, and not of interest to most readers, but it’s critical to my credibility as an
author on this topic — it shows that I’ve really done my homework, and I’m not ignoring the concerns of
skeptical experts — so for now I’ve made everything freely available to all site visitors instead of integrating
them into the book. Nevertheless, the book has already been heavily influenced by this work, and will
continue to be.
2016 — Minor update: Added a good new example of a trigger point “whisperer” myth. [Section: The myth of
the trigger point whisperer.]
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
2016 — Minor update: Finally added lacrosse ball recommendation. [Section: Massage tools: 7 free (or very cheap)
and tools from objects not originally intended for massage.]
2016 — Science update: More evidence about more serious side effects of statins, and controversy about
prevalence. [Section: Pain-causing drug side effects: statins (cholesterol-reducing drugs) and bisphosphonates (for
osteoporosis).]
2016 — Science update: Beefy tune-up for the “pillars” of trigger point science: several new and carefully
written footnotes, linking to many painstakingly summarized papers for readers who really want to delve.
It’s a bigger update than it looks like on the surface. [Section: The science of trigger points: It’s a little half-baked,
but at least it’s not boring.]
2015 — Edited: Yet more modernization and clarification. [Section: Massage quality control issues (“But I’ve
already tried massage therapy … ”).]
2015 — Edited: Modernization and clarification. [Section: Pain in three flavours: the good, the bad, and the ugly.]
2015 — Edited: Modernization and clarification. [Section: The Pressure Question: how much is too much?]
2015 — Edited: Modernization and clarification. [Section: Two: Good pain (why pressing on trigger points hurts like
hell but feels like heaven).]
2015 — Edited: Tuned for consistency with my current views. [Section: Two case studies: highly-trained therapists
failing miserably.]
2015 — Science update: Added a footnote about trigger points being associated with jaw pain. [Section: Trigger
points may explain many severe and strange aches and pains.]
2015 — Revised: Just modernizing and clarifying. [Section: How to find good trigger point therapy .]
2015 — Science update: Some referencing about central sensitization, especially this “fun” fact: muscle pain
may be especially good at causing CS. [Section: Referred pain science (advanced).]
2015 — New Section: Better late than never, I’ve added a summary of the expanded integrated hypothesis
from Gerwin et al. (2004). [Section: The dominant theory of trigger points spelled out in a little more technical
detail.]
2015 — New section: No notes. Just a new section. [Section: Acupressure: what if we pressed those points instead of
puncturing?]
2015 — Science update: Added three good references and a diagram about how much “wiggle” room nerve
roots have. [Section: Nerve pain is overdiagnosed.]
2015 — Science update: Two new science reviews considered and cited. [Section: How about Botox injection
therapy?]
2015 — Rewritten: Completely revised for the 3rd edition of the Workbook: I no longer recommend it. [Section:
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
A brief detour: why not The Trigger Point Therapy Workbook?]
2014 — New citation: Added an important new reference to a scientific paper critical of conventional wisdom.
[Section: The shabby state of trigger point science.]
2014 — Minor update: New footnotes about the theory of acupuncture/trigger point overlap. [Section: How
about acupuncture?]
2014 — Science update: And, so sorry, it’s bad news. [Section: Maybe stabbing will help! Dry needling.]
2014 — Science update: Added evidence about the effect of massage on fibromyalgia. [Section: The relationship
between trigger points and other physiological disorders and diseases, especially fibromyalgia.]
2014 — Editing: General revision for quality. Added the cheek-bite analogy story for colour. [Section: One: The
vicious cycle (why trigger points are stubborn).]
2014 — Editing: General revision for quality. [Section: Micro muscles and the dance of the sarcomeres.]
2014 — Minor update: Added a story about phantom limb pain. [Section: Referred Pain Science (basic) .]
2013 — Minor update: Minor but fascinating new item about the myth of anaesthetic paralysis and the
dominance of the CNS over muscle tone — the kind of nifty item I just love to add to the book! [Section: The
surprising futility of muscle relaxants such as Robax-whatever, Valium and other benzodiazepines.]
2013 — New section: An introduction to one of the most important theoretical challengers to the traditional
explanation for trigger points. [Section: Quintner: “It’s the nerves, stupid”.]
2013 — Science update: Good news update: new study shows a clear reduction in nonspecific musculoskeletal
pain after vitamin D supplementation. [Section: Vitamin D deficiency.]
2013 — Minor update: Upgraded risk and safety information about Voltaren Gel. [Section: Voltaren® Gel, an
intriguing new option.]
2013 — Minor update: Modernized and expanded a bit, a couple new references, and a generally much better
explanation of what fibromyalgia is. [Section: A brief note about the relationship between fibromyalgia and
myofascial pain syndrome.]
2012 — Science update: Some more evidence showing the role of smoking in chronic pain. [Section: Smoking.]
2012 — Science update: Added references showing connections between smoking and chronic pain. [Section:
Smoking.]
2012 — Minor update: Added a funny sidebar about bad anatomy. [Section: Don’t get hung up on anatomy, and
be persistent .]
2012 — Minor update: A minor case study and some science to help establish that muscle can indeed be the
source of pain. [Section: The science of trigger points: It’s a little half-baked, but at least it’s not boring.]
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
2012 — New section: No notes. Just a new section. [Section: What about stretching the antagonist muscle?]
2012 — Minor update: Added an item about “mobile” bumps that people often mistake for trigger points.
[Section: Negative checklist: signs/symptoms that are probably not caused by trigger points.]
2012 — Edited: Now more accurate and clearer. Edits in preparation for audiobook version. [Section:
Predictably unpredictable: trigger point symptoms are erratic by nature.]
2012 — Major update: New evidence that massage can cause “rhabdomyolysis” makes it quite a lot easier to
understand a lot of negative reactions to trigger point therapy. This is valuable perspective, and the section
has been heavily revised to exploit it. [Section: Troubleshooting negative reactions to treatment.]
2012 — Minor update: This introduction now does a better (and more honest) job of mentioning some trigger
point controversies, and links to an important companion article about them, for keener readers, Trigger
Point Doubts. [Section: The science of trigger points: It’s a little half-baked, but at least it’s not boring.]
2012 — Minor update: A minor but good: clearer, better language. Editing continues as I work on the
audiobook version. [Section: “Out of nowhere”: a signature symptom of trigger points.]
2012 — Minor update: More editing for clarity and thoroughness. This also happens to be one of the first edits
I’m doing to prepare for audiobook production. [Section: Slow checklist: a more detailed diagnostic checklist for
myofascial pain syndrome.]
2012 — Science update: I revised the warning away from hydration, and included some fun new myth-busting
evidence about hydration and cramping. [Section: Reality checks: some self-treatments that don’t work at all (or
not nearly as well as you would hope).]
2012 — New section: No notes. Just a new section. [Section: Neutral positioning: find a comfortable muscle length
and rest there.]
2012 — Minor update: Added an item about non-pain symptoms, like itching. [Section: Negative checklist:
signs/symptoms that are probably not caused by trigger points.]
2012 — Minor update: Important new, skeptical footnote about the dangers of the powerful narcotic drugs.
[Section: The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids.]
2012 — Modest expansion (again). And the sassy new “muscle stabbing” section name.: [Section: Maybe
stabbing will help! Dry needling.]
2011 — Science update: Added an interesting citation about the correlation (or lack thereof) between tissue
hardness and sensitivity. [Section: Identifying your trigger points by feel: tissue texture and other palpable signs.]
2011 — Trivial update: Added minor but odd note about “sensory annoyances” and hats. Yes, hats. [Section:
Diagnosis: How can you tell if trigger points are the cause of your problem?]
2011 — Products added: Three new product reviews, and some miscellaneous revision of the section. [Section:
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Beyond the tennis ball: commercial massage tools.]
2011 — Updated: Added new references to fascia science about the toughness and contractility of fascia, and
some interpretation. This is also supported by a substantial new free article, Does Fascia Matter? [Section:
How about myofascial release and fascial stretching?]
2011 — New section: No notes. Just a new section. [Section: Smoking.]
2011 — Minor update: Added a paragraph about magnesium. [Section: Vitamin B1, B2, folate, and magnesium
deficiencies.]
2011 — New section: No notes. Just a new section. [Section: The myth of the trigger point whisperer.]
2011 — New section: Some new thoughts about how stretching for trigger points might work — quite different
from the mainstream theory — inspired some new stretching science. [Section: What about neurology? Stretch
tolerance.]
2011 — Major rewrite: This might as well be a new section — not only did I re-write it, I gave it a completely
new purpose. Previously the “bamboo cage” was a minor metaphor used to illustrate a possible mechanism
for sensitization of muscle tissue. Now it is the basis of an extended and (I think) interesting exploration of
how the concept of trigger points might actually be debunked. Pretty weighty stuff, but delivered with a
major effort to make it interesting to any reader. Hope you enjoy it! [Section: “The bamboo cage” — what
immobilization torture can tell us about the nature of muscle pain and massage.]
2011 — Minor update: Added an interesting observation about how Vitamin D supplementation might work.
[Section: Vitamin D deficiency.]
2011 — Minor update: Miscellaneous editing and improvements, plus a couple new items. [Section: Slow
checklist: a more detailed diagnostic checklist for myofascial pain syndrome.]
2011 — Minor update: Added some basic information about the damage that “ugly pain” can actually do,
inspired by a recent anecdote received from a reader. [Section: Pain in three flavours: the good, the bad, and the
ugly.]
2011 — Science update: The Vitamin D advice provided to readers has not changed, but the science
supporting it has been dramatically beefed up — more science, new science, better summarized — to
confirm that D supplementation is a safe and sensible option for patients. See also the separate article,
Vitamin D for Pain. [Section: Vitamin D deficiency.]
2011 — Major update: Major improvements to the table of contents, and the display of information about
updates like this one. Sections now have numbers for easier reference and bookmarking. The structure of the
document has really been cleaned up in general, making it significantly easier for me to update the tutorial
— which will translate into more good content for readers. Care for more detail? Really? Here’s the full
announcement.
2011 — Minor update: Edited to distinguish more clearly between “dependence” and “addiction,” to reduce
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
alarmism about addiction or contributing to the excessive stigma against opioids. (Thanks to reader Evelyn
D. for pointing out the issue to me — a good example of how readers contribute to the improvement of this
tutorial.) [Section: The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids.]
2011 — Minor update: Updated the disclaimer (sidebar) about my “conflict of interest.” I no longer have it,
since I am retired from my massage therapy practice. [Section: Getting Help: How do you find good therapy for
your trigger points?]
2011 — Minor update: Added evidence showing that trigger point therapy improved ankle range of motion.
[Section: Massage efficacy according to science.]
2011 — Minor update: Added a checklist item about muscle wasting. [Section: Negative checklist:
signs/symptoms that are probably not caused by trigger points.]
2010 — Major update: Previously this section discussed ultrasound rather generally, without much discussion
of the science; it is now beefed up with a thorough, fun discussion of the somewhat squishy evidence.
[Section: How about ultrasound therapy? (ESWT and “Sonic Relief™”).]
2010 — Minor update: Added an interesting footnote about the Google Book Ngram for “trigger points.”
[Section: Introduction.]
2010 — Many minor repairs: A large batch of minor errors and glitches were corrected today, thanks to the
sharp eyes of readers Effie and Doris.
2010 — Modest expansion: [Section: Maybe stabbing will help! Dry needling.]
2010 — New section: Not just for customers: this particular section is a short version of a new free article.
[Section: Case study: A cautionary tale of stretching: that time I almost ripped my own head off.]
2010 — Major update: Numerous repairs and upgrades to all of Dr. Taylor’s sections of the book, especially
links to the clinics that Dr. Taylor recommends, some new charts, and a colorful anecdote about drinking
blood (seriously). Thanks to several readers, and especially Elaine M., for their assistance with this. It’s quite
amazing how the new chapter is driving immediate refinements. People read it and write to ask questions,
and that spurs little email debates between me and Dr. Taylor, a trip to PubMed for more evidence or detail,
or a clarification wrangle with the language ... and the results get put into the book within hours or even
minutes … so cool! As reader Bill C. put it, “Your books are alive!” It does kind of feel like that. [Section:
Medical Factors That Perpetuate Pain: The effect of statin drugs, nutritional and hormonal deficiencies, infections, and
inflammatory diseases.]
2010 — Many new sections: An important new chapter (with several sections) by Dr. Tim Taylor. This is the
first major collaborative effort on PainScience.com, and I’m extremely proud of it, and pleased with how
well it went. [Section: Medical Factors That Perpetuate Pain: The effect of statin drugs, nutritional and hormonal
deficiencies, infections, and inflammatory diseases.]
2010 — New section: Happy to add a whole small new section about evidence of the efficacy of trigger point
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
therapy. [Section: Massage efficacy according to science.]
2010 — Minor update: I’ve done a bunch of work to continue integrating Dr. Taylor’s new chapter into the
book: discussing perpetuating factors wherever they are relevant, and linking to the chapter. Thus there are
many more spots in the book now where the importance and relevance of Dr. Taylor’s contribution is
emphasized.
2010 — New cover: At last! E-book finally has a “cover.”
2010 — Corrected: Fixed some wrong science about hydrogen bonding and tissue adhesions. Hat tip to reader
and chemist K.D. for the good catch. [Section: Adhesions and contracture: when trigger points freeze in place.]
2010 — Minor update: Updated the muscle relaxant section with a summary of a bizarre experiment with
muscle relaxants that had quite surprising results. [Section: The surprising futility of muscle relaxants such as
Robax-whatever, Valium and other benzodiazepines.]
2010 — Minor update: Added a nice anecdote from a doctor about a trigger point that was almost mistaken for
a possible tumor. [Section: Trigger points may explain many severe and strange aches and pains.]
2010 — New section: This is a major upgrade to the presentation of PainScience.com’s own Perfect Spots series
of articles. They have always been here, but perhaps not presented in as useful a way as they could have
been. I’ve also made many upgrades to the articles themselves over the last 2 months. [Section: Appendix B:
The Perfect Spots.]
2010 — New section: Reviews and recommendations of other sources. [Section: Appendix A: Trigger Point
Reference Materials or: Diagrams, Diagrams, Diagrams!]
2010 — Major update: A weakness of this tutorial has finally been eliminated: reference material! Where are
the trigger points? Although this is still not an encyclopedia of trigger points, and it never will be (by
design), the book now helps readers find specific trigger point information in three new ways, in three new
sections.
2010 — Many minor repairs: No specific update today, but a particularly large dose of editing love, with my
thanks to reader Elaine M. for pointing out several errors that got me started. Elaine received some free
product for her assistance, of course, and so can you if you send me any more than a few error reports.
2010 — Minor update: Improved description of physiatrists (a medical speciality). [Section: Types of therapists
and doctors and their relationship to trigger point therapy.]
2010 — New section: Finally, I’ve added a (free) appendix of online resources related to trigger point therapy.
Better late than never. [Section: Appendix C: Trigger Point Therapy Resources.]
2010 — Tiny update: Tiny-but-interesting: I added some pretty good evidence that a muscle relaxant was no
better for injured neck muscles than ibuprofen. [Section: The surprising futility of muscle relaxants such as
Robax-whatever, Valium and other benzodiazepines.]
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
2010 — New section: No notes. Just a new section. [Section: The evolution of muscle pain: does muscle “burn out”?]
2010 — Minor update: A little revision, slight expansion. [Section: The all-powerful acne analogy.]
2010 — Major update: Section heavily revised, improved, and expanded. [Section: Worst Case Scenario 2: Rare
but extremely severe cases of myofascial pain syndrome.]
2010 — Major update: Section heavily revised, improved, and expanded. [Section: Worst Case Scenario 1: Being
triggery.]
2010 — Minor update: A small but significant update on nutrition, based on Bischoff-Ferrari et al , which
basically boils down to a recommendation to take vitamin D — it might help. [Section: Troubleshooting
negative reactions to treatment.]
Older updates — Listed in a separate document, for anyone who cares to take a look.
GO TO TOP • CONTENTS • END • NOTES • BOTTOM
11.7
Notes
This depends on many other factors. For instance, if you can clearly see that you’ve been struck by two paintballs, 15cm apart,
you’re brain is probably not going to experience one mighty paintball sting — brains are not idiots, and they can use lots of
data sources to generate higher fidelity perception. BACK TO TEXT
Holbert MD, Pedler A, Camfermann D, Harvie DS. Comparison of spatial summation properties at different body sites. Scand J
Pain. 2017 Oct;17:126–131. PubMed #28850365. These researchers compared summation in the neck and back to the extremities,
and found that it works about the same way: in any region, painful sites separated by as much as 15-20cm will be “summed”
by the brain, making the entire area feel painful. BACK TO TEXT
Taylor AJ, Kerry R. When Chronic Pain Is Not "Chronic Pain": Lessons From 3 Decades of Pain. J Orthop Sports Phys Ther. 2017
Aug;47(8):515–517. PubMed #28760092. BACK TO TEXT
There are good criticisms of this paper from a couple of my favourite experts and writers, pointing out in a letter to the journal
that one of the “fashionable” paradigms impugned here, the biopsyschosocial model, “includes the considerations [the “bio”
part] that eventually cured the patient’s pain.” I like the criticism and I like the authors’ response — I see only healthy debate
here. BACK TO TEXT
Here’s a funny quote:
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Rocket science isn’t all that difficult. It’s not brain surgery.
~ a rocket scientist
BACK TO TEXT
Big promises are common on the internet, and it’s a problem when a treatment method or product is presented as being “good
for” nearly any kind of pain problem. There are too many kinds of pain for any one idea to work for all of them. BACK TO TEXT
Sorry to be the bearer of bad news. The reality is harsh, a major downer. I will get back to this: the difficulties pain patients face in
getting good, effective care is a serious and complicated problem. I’ll deal with it in considerable detail later on in the book. In
particular, I’ll do my best to substantiate the accusation that a lot of care is poor quality — which many professionals take
exception to, of course. BACK TO TEXT
There is a bit of “neato” in any good research. Making it understandable and interesting for all kinds of readers is simply a matter
of expressing that. BACK TO TEXT
Is pain really on the rise? It’s not certain that this is the case, nor clear why it would be, but there is plenty of suggestive evidence.
A 2005 study in England (Harkness et al ) examined then-and-now data, comparing with the 1950s, reporting a “much higher”
prevalence of body pain. In 2010 (Jiménez-Sánchez et al ), surveys of the Spanish population were mined for rates of serious
musculoskeletal pain since the early 90s, finding that it “increased from 1993 to 2001.” A 2017 study (Wallace et al ) found that
knee arthritis doubled in the 20th Century compared to 19th and prehistoric humans, but not because we’re heavier and living
longer — something else is doing it. BACK TO TEXT
Commenting on two fascinating 2008 research papers (Chen and Shah), Dr. David Simons wrote, “Currently, consideration of
the possibility of a myofascial trigger point component of the pain complaint is commonly not effectively included in the
differential diagnosis and therefore is missed cold turkey, which can be very expensive for the health care system (expensive
examinations looking for a phantom diagnosis) and disastrous to the patient (wrong diagnosis, wrong treatment).” BACK TO
TEXT
Simons writes, “Many authors through the years have ‘discovered’ a ‘new’ muscle pain syndrome … .” For instance, the popular
Dr. John Sarno is still stubbornly calling it “tension myositis syndrome” to this day, the term he invented when he
“discovered” MPS. Such discoveries are akin to Columbus ‘discovering’ America … much to the surprise of the natives. MPS
has been named for the anatomical neighbourhood that a particular researchers happens to find it in. It has been thoroughly
confused with fibromyalgia. It has been called fibrositis and muskelharten and myofascitis and myelgelosis. It has been stuck
with the labels non articular or soft-tissue, rheumatism, osteochondrosis, and tendomyopathy. Every last one of them is a
historical artifact. BACK TO TEXT
Other muscle injuries are often confused with trigger points. But a trigger point is not a regular whole-muscle spasm, or a
“muscle strain” (torn muscle), which is an actual rip in muscle tissue that occurs suddenly and is instantly very painful. The
differences will seem more obvious as you learn more about trigger points. BACK TO TEXT
This may seem obvious, but it’s actually disputed by some people, believe it or not. Like everything in biology, “it’s
complicated,” but I think the argument was settled by a little science experiment in 2004 (Graven-Nielsen et al ), which showed
that subjects could still feel pressure and painful pressure on muscles even with anaesthetized skin. I’ll bring this up again
later on when we get deeper into the biology of TrPs. BACK TO TEXT
Smith DR. Prevalence and Distribution of Musculoskeletal Pain Among Australian Medical Students. Journal of Musculoskeletal
Pain. 2007 Aug 29;15(4).
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
It’s amazingly difficult to find hard data on the prevalence of musculoskeletal problems. However, this Australian study of
medical students found that almost 90% of them had some kind of body pain problem, mostly in the neck, lower back and
shoulders — and these are young people. It may not be an exaggeration to say that virtually the entire population of planet Earth
has musculoskeletal pain!
BACK TO TEXT
Travell J, Simons D, Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Lippincott, Williams &
Wilkins; 1999. p. xi. Or, as stated more eloquently and authoritatively by Drs. Travell and Simons, “Myofascial trigger points
are a frequently overlooked and misunderstood source of the distressingly ubiquitous musculoskeletal aches and pains of
mankind.” BACK TO TEXT
Much more recently than in the previous footnote, in 2008, Dr. Simons writes: “Currently, consideration of the possibility of an
MTP component of the pain complaint is commonly not … included in the differential diagnosis and therefore is missed cold
turkey, which can be very expensive for the health care system (expensive examinations looking for a phantom diagnosis)
and disastrous to the patient (wrong diagnosis, wrong treatment).” BACK TO TEXT
Calandre EP, Hidalgo J, Garcia-Leiva JM, Rico-Villademoros F, Delgado-Rodriguez A. Myofascial trigger points in cluster
headache patients: a case series. Head & Face Medicine. 2008 Dec 30;4(32):32. PubMed #19116034. PainSci #55349.
Although this research was “preliminary and uncontrolled” and is not powerful enough to prove anything, its results were
certainly noteworthy — the sort of results that can inspire more research, hopefully. All of 12 patients with chronic cluster
headaches (a kind of severe primary headache, nicknamed “suicide headaches”) had myofascial trigger points, and treating
them (with injection) produced “significant improvement in 7 of the 8 chronic cluster patients.” The authors speculate that
trigger points are not the cause of cluster headaches, but a nasty complicating factor: “chronic pain or repeated acute pain
sensitize muscular nociceptors creating active trigger points which, in turn, contribute to potentiate headache pain. This kind
of vicious cycle explains why the number of active trigger points has been found to be higher in patients with chronic primary
headaches than in healthy subjects or in patients experiencing less frequent headache attacks.”
This is just one interesting example of research on this topic. For a bigger picture view, see the next note.
BACK TO TEXT
Do TP, Heldarskard GF, Kolding LT, Hvedstrup J, Schytz HW. Myofascial trigger points in migraine and tension-type headache.
J Headache Pain. 2018 Sep;19(1):84. PubMed #30203398.
There is extensive evidence that people who get headaches — both migraine and tension headache — also have a lot of
trigger points in the musculature of the head and neck. Unfortunately, we still have no idea which came first, the chicken or
the egg: headaches might be causing trigger points, or trigger points might be causing headache. There is evidence pointing
each direction, and of course all of it is generally low quality. However, the simple correlation is relatively unambiguous. We
know that much at least.
Although the authors of this review are likely somewhat biased — “believers” in the clinical significance of trigger points,
and interpreting the evidence through that lens — their conclusions are appropriately cautious, acknowledging the
limitations of the evidence.
BACK TO TEXT
I believe that trigger points may be a by-product of the “volatility” of muscle. It’s a truism of engineering that the chance of a
breakdown goes up with the number of moving parts. Muscle tissue is more powerful and biologically complex than most
people give it credit for, and like any finely-tuned machine, perhaps it breaks down easily. I suspect that we get trigger points
as a relatively small price to pay for having high-functioning muscle tissue, an evolutionary compromise. Higher function
would require an escalating risk of dysfunction. Reduced function would probably result in fewer trigger points … but also in
weaker and less responsive muscle. BACK TO TEXT
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
InteriorsAndSources.com [Internet]. Office Place RSIs Decreased in 1994; 1996 Sep [cited 10 Nov 9].
Estimates of the incidence of repetitive strain injuries generally range from 3-6% of all cases requiring time away from work.
In comparison, MPS is ubiquitous. In my own clinical experience, treating RSIs represent a negligible fraction of my work,
whereas MPS is either a cause or complicating factor in nearly every case I treat — including the RSIs! In 1996, Interiors and
Sources magazine reported that, “the total number of serious injuries or illnesses attributed to all repetitive motion was just ...
four percent of the total number of cases requiring time away from work. Of those, the majority of cases or 53 percent were
recorded in the manufacturing sector ... ‘Clearly, most repetitive motion injuries are not occurring in the offices of America,’
said PJ Edington and executive director of the Center for Office Technology (COT). ‘And the so-called epidemic of officerelated repetitive motion injuries reported in the media has been a clear case of misdiagnosis.’”
BACK TO TEXT
There are several types of shin splints, and most of them have nothing to do with trigger points. However, the meaty part of the
shin — the tibialis anterior muscle — is often the culprit. At least a few seemingly unbeatable cases of shins splints can be
easily treated … if you know where and how to rub the tibialis anterior muscle. BACK TO TEXT
Most importantly, the rubber has never hit the road in the form of well-designed clinical trials of outcomes for patients: that is,
do people actually get their pain problems solved by good quality trigger point therapy, well enough and often enough to be
worth the costs? If treating trigger points works well as a therapy, then there should have been such studies more or less easily
proving it many years ago — but there still aren’t. That’s a concern at this point in history. BACK TO TEXT
I’d put them somewhere in the middle of the range: trigger points are nowhere near as bad as a lot of common pseudoscience
and quackery gets, but they certainly do fall well short of “proven” and well understood. At worst, they may even be a bad
idea — a “legitimate misunderstanding,” an idea that was reasonable 20 years ago but which now needs to be retired or
heavily revised. BACK TO TEXT
Quintner JL, Bove GM, Cohen ML. A critical evaluation of the trigger point phenomenon. Rheumatology (Oxford). 2015
Mar;54(3):392–9. PubMed #25477053.
Quintner, Cohen, and Bove think the most popular theory about the nature of trigger points (muscle tissue lesions) is “flawed
both in reasoning and in science,” and that treatment based on that idea gets results “indistinguishable from the placebo
effect.” They argue that all biological evidence put forward over the years is critically flawed, while other evidence leads
elsewhere, and take the position that the debate is over. (They also point out that the theory is treated like an established fact
by a great many people, which is definitely problematic.) However, their opinion is extreme, and most experts do not think
we should throw out all the science so far (see Dommerholt et al ).
(See more detailed commentary on this paper.)
This controversial opinion is discussed in more detail later.
BACK TO TEXT
PS Ingraham. A Historical Perspective On Aches ‘n’ Pains: We are living in a golden age of pain science and musculoskeletal
medicine … sorta. PainScience.com. 2841 words. BACK TO TEXT
Simons D. Foreword of The Trigger Point Therapy Workbook. 1st ed. New Harbinger Publications; 2001. The full quote reads:
“Muscle is an orphan organ. No medical speciality claims it. As a consequence, no medical specialty is concerned with
promoting funded research into the muscular causes of pain, and medical students and physical therapists rarely receive
adequate primary training in how to recognize and treat myofascial trigger points. Fortunately, massage therapists, although
rarely well-trained medically [BC being one of the obvious exceptions, see Massage Therapy In British Columbia, Canada —
PI], are trained in how to find myofascial trigger points and frequently become skilled in their treatment.” BACK TO TEXT
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Travell J, Simons D, Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Lippincott, Williams &
Wilkins; 1999. Vol 1, p13. BACK TO TEXT
Doctors are unqualified to care properly for most common pain and injury problems, especially the stubborn ones, and this has
been proven by other doctors: Stockard et al found that 82% of graduates lacked “basic competency” in this area. For more
information, see The Medical Blind Spot for Aches, Pains & Injuries: Most physicians are unqualified to care for many
common pain and injury problems, especially the more stubborn and tricky ones. BACK TO TEXT
“Structuralism” is the excessive focus on crookedness and “mechanical” problems as causes of pain. It has been the dominant
way of thinking about how pain works for decades, and yet it is source of much bogus diagnosis. Structuralism has been
criticized by several experts, and many studies confirmed there are no clear connections between biomechanical problems
and pain. Many fit, symmetrical people have severe pain problems! And many crooked people have little pain. Certainly
there are some structural factors in pain, but they are generally much less important than messy physiology, neurology,
psychology. Structuralism remains dominant because it offers comforting, marketable simplicity. For instance, “alignment” is
the dubious goal of many major therapy methods, especially chiropractic adjustment and Rolfing. See Your Back Is Not Out
of Alignment: Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain.
BACK TO TEXT
And it certainly felt like it at times. BACK TO TEXT
Travell J, Simons D, Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Lippincott, Williams &
Wilkins; 1999. BACK TO TEXT
Mense S, Simons DG, Russell IJ. Muscle pain: understanding its nature, diagnosis and treatment. 1st hardcover ed. Lippincott
Williams & Wilkins; 2000. A dense text, important reading for professionals. BACK TO TEXT
And not impossible reading, either. Over the course of a decade, I have seen several keen patients tackle Travell and Simons’
massive red texts and get good value from them. The diagrams are exceptionally clear, and the writing is generally quite
good. It’s not out of the question for patients to try to work with them. But they are expensive reference books, filled with
jargon, and intended for clinicians who are dealing with every area of the body on a daily basis. BACK TO TEXT
Here’s Dr. Fred Wolfe’s technical but readable definition of fibromyalgia, from a 2013 blog post. Dr. Wolfe is a rheumatologist
with a long history of expertise about trigger points and fibromyalgia:
Fibromyalgia is a name given to a clinical syndrome whose main features currently are the presence of chronic
pain simultaneously in many areas of the body together with multiple somatic symptoms. In particular,
persistent and substantial fatigue , sleep disturbance and cognitive difficulties are among the most common of
the symptoms. Decreased pain threshold is almost always found, and is strongly correlated with the extent of
body pain. Because the symptoms and their intensity are variable, the boundaries of fibromyalgia are somewhat
indistinct . The identification of fibromyalgia is based on the overall severity of symptoms. The gold standard for
necessary severity was set by the 1990 American College of Rheumatology (ACR) criteria: roughly, it is the level
of symptoms found in persons with ≥11/18 tender points when examined by capable examiners. As fibromyalgia
symptoms at less than criteria level are often found before fibromyalgia is diagnosed, it is uncertain when
fibromyalgia begins. There are no consistent clinical laboratory or imaging abnormalities.
BACK TO TEXT
Ehrlich GE. Pain is real; fibromyalgia isn't. J Rheumatol. 2003 Aug;30(8):1666–7. PubMed #12913918.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
PainSci #54771.
The Complete Guide to Trigger Points & Myofascial Pain (2019)
When one has tuberculosis, one has tuberculosis, whether or not it is diagnosed. The same is true for cancer,
rheumatoid arthritis, hookworm infestation — really, of the gamut of diseases. But not for fibromyalgia (FM). No
one has FM until it is diagnosed.
BACK TO TEXT
The tender points are a diagnostic tool. They aren’t sore because there’s something wrong in that location: they are sore because
FM makes everything sore, and it just happens to be most obvious at those carefully chosen spots. BACK TO TEXT
Staud R. Are tender point injections beneficial: the role of tonic nociception in fibromyalgia. Curr Pharm Des. 2006;12(1):23–27. “
… interventions aimed at reducing local FM pain seem to be effective but need to focus less on tender points but more on
trigger points (TrP) and other body areas of heightened pain … .” BACK TO TEXT
Li YH, Wang FY, Feng CQ, Yang XF, Sun YH. Massage therapy for fibromyalgia: a systematic review and meta-analysis of
randomized controlled trials. PLoS One. 2014;9(2):e89304. PubMed #24586677. PainSci #53919.
This is a review of massage therapy for fibromyalgia that epitomizes the “garbage in, garbage out” problem with metaanalysis: there was virtually no research on this topic worth analyzing to begin with, and trying to pool the results of several
weak studies is meaningless. To the extent that the study results are generally inconclusive and ambiguous, the conclusions of
any review are going to have more to do with the authors’ opinions and biases than hard data. In this case, they report
“significant” positive results without mentioning that they only mean “statistically significant,” and the effect size is barelythere — clinically insignificant. They also boast about traditional Chinese massage in the abstract, which is odd. And they fail
to note that a much of the data did not even measure the effect on pain, just mood. So here’s my conclusion: whoop-de-doo.
There’s really nothing here, except maybe massage for fibromyalgia being damned by faint, ambiguous praise.
I’ve written several more paragraphs about this paper in Does Massage Therapy Work?
BACK TO TEXT
Travell et al., op.cit. (Virtually all information in this article is drawn from Travell and Simons, so I won’t cite page references for
every instance.) The subscapularis case is a good example of how MPS is probably much more clinically significant than RSIs:
not only is MPS a causal or complicating factor in many RSIs, it frequently imitates them and is the correct diagnosis! This is
why at least some RSIs do not respond to conventional treatment. BACK TO TEXT
It’s possible to richly reference this section with individual scientific papers backing up every single example of trigger points
mimicking some other health problem. This kind of information is everywhere in the MPS literature. For now, here’s just one of
many, a 1995 paper, “Myofascial pain syndromes — the great mimicker”. BACK TO TEXT
There’s a large body of research about this, but Rocha is a good recent example. In 2007, these researchers found that “in 56% of
patients with tinnitus and MTPs, the tinnitus could be modulated by applying digital compression of such points, mainly
those of the masseter muscle.” And how many people with tinnitus had trigger points? Quite a few. The researchers found “a
strong correlation between tinnitus and the presence of MTPs in head, neck and shoulder girdle.” BACK TO TEXT
Fernández-de-Las-Peñas C, Galán-Del-Río F, Alonso-Blanco C, et al. Referred pain from muscle trigger points in the masticatory
and neck-shoulder musculature in women with temporomandibular disoders. J Pain. 2010 Dec;11(12):1295–304.
PubMed #20494623.
This study compared 25 healthy women to 25 others with temporomandibular disorders (TMD). Trained examiners looked
for trigger points (without knowing which group they were in), specifically in the neck and jaw muscles. According to the
criteria they used, they found more and worse trigger points in the women with TMD (where by “worse” I mean larger areas
of referred pain). The trigger points in the neck produced more referred pain that those in the jaw muscles.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
BACK TO TEXT
This is one I know well from personal experience: a couple of times per year, I get a disturbing achy lump in my throat, a hitch in
my swallow. It used to get me worried and anxious and thinking about going to the doctor. Then I discovered that it’s closely
associated with a recurring patch of sensitivity in the muscles under my jaw, in the upper throat … and it can be massaged
away in about a minute. I have been doing this successfully for several years now. BACK TO TEXT
The iliopsoas muscle (“illy-oh so-ass”) is a two-in-one hip flexing pair, mostly only palpable through the guts. Its clinical
importance is often curiously exaggerated, but sometimes it does need a massage. For more information, see Psoas, So What?
Massage therapy for the psoas major and iliacus (iliopsoas) muscles is not that big a deal. Except when it is. BACK TO TEXT
As discussed above, such “structural” misdiagnoses are a common red herring, and almost always wrong. Mistaking a gluteus
maximus trigger point for sacroiliac joint pain is a particularly common diagnostic error. See Massage Therapy for Low Back
Pain (So Low That It’s Not In the Back) for more about this particular area. BACK TO TEXT
This is one of the “perfect spots” for massage: spot #12, specifically. SHOW SPOT 12 DIAGRAM For more information, see
Massage Therapy for Low Back Pain (So Low That It’s Not In the Back). BACK TO TEXT
Perhaps just a couple of magic touches. Here’s another question I received by e-mail: “If a massage therapist told you that all he
had to do was touch a trigger point with one finger, then touch you somewhere else on the body far from the trigger point
with his other hand, that the trigger point would vanish instantly. Is that true?” BACK TO TEXT
For instance, what if trigger points are present as a complication of the early stages of an undiagnosed disease like multiple
sclerosis? This is possible! There are many medical factors that make treatment impossible or nearly so. A much more
common example is smoking, which makes treatment so difficult that my co-author, Dr. Tim Taylor, will not accept smokers
as patients. BACK TO TEXT
There are literally hundreds of obscure problems that can cause or significantly complicate pain, but you can narrow it down
to a few dozen if you stick to the more common ones that are notorious for evading diagnosis and causing mainly pain.
Classic examples include drug side effects, vitamin D deficiency, sleep disorders, spinal cord irritation (myelopathy), the
early stages of some diseases, “inflammaging” (the slow but steady ramping up of widespread inflammation as we age and
get out of shape, metabolic syndrome), and so on.
And trigger points!
For a more thorough tour through the all the hair-raising possibilities, see 30 Surprising Causes of Pain. I’ll also discuss many
of these as they relate to trigger points.
BACK TO TEXT
Injury pain primarily hurts in almost exactly the same way every time you disturb the injured tissue. There are exceptions (of
course), but it’s a good rule of thumb. BACK TO TEXT
It’s also possible that some trigger points are nerve pain, in some cases. But more about that later. Most classic “nerve pain” —
the pain of peripheral neuropathy and radiculopathy (injured or irritated nerves and nerve roots) — is relatively obvious, and
much less common than the patches of sensitive soft tissue we call “trigger points.” BACK TO TEXT
Seriously! It sounds odd, and it is, but hats can be surprisingly irritating to the nervous system — the head is a sensitive area —
and it’s fairly common for hats to be an underestimated factor in chronic headaches, neck pain, and stiffness from the
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
shoulders up. (Collars too. One of the worst cases of neck pain I ever encountered was a “collar case” — any substantial coat
collar just drove him nuts.) BACK TO TEXT
In this case, my best guess is that it was a lipoma. These small benign subcutaneous cysts are often mistaken for muscle knots,
but they feel more slippery and are generally much more obvious (a well-defined lump). But they are usually anchored like a
barnacle and don’t move around. While I’ve never actually seen one come loose and travel around under the skin, I can
imagine it well enough and I have heard of it before. BACK TO TEXT
Rathbone AT, Grosman-Rimon L, Kumbhare DA. Interrater Agreement of Manual Palpation for Identification of Myofascial
Trigger Points: A Systematic Review and Meta-Analysis. Clin J Pain. 2017 Aug;33(8):715–729. PubMed #28098584. BACK TO TEXT
Lucas N, Macaskill P, Irwig L, Moran R, Bogduk N. Reliability of physical examination for diagnosis of myofascial trigger points:
a systematic review of the literature. Clinical Journal of Pain. 2009 Jan;25(1):80–9. PubMed #19158550. BACK TO TEXT
Myburgh C, Larsen AH, Hartvigsen J. A systematic, critical review of manual palpation for identifying myofascial trigger points:
evidence and clinical significance. Arch Phys Med Rehabil. 2008 Jun;89(6):1169–76. PubMed #18503816. BACK TO TEXT
Gerwin RD, Shannon S, Hong CZ, Hubbard D, Gevirtz R. Interrater reliability in myofascial trigger point examination. Pain. 1997
Jan;69(1-2):65–73. PubMed #9060014. BACK TO TEXT
Wow, did I really just say that? Yep, I did — and I stand by it. For instance, consider this: the low back musculature is often so
full of trigger points that treatment is like shooting fish in a barrel. You don’t need to be accurate — just steamroll the whole
column of muscle over and over again from every angle, and rest assured you’re treating trigger points the whole time, and
worry about precision later, or never. I often see patients getting hung up on trying to exactly locate their trigger points when
they could be doing more useful things.
Another example: stretching for trigger points is generally not a fantastic therapy, but at least you don’t need to know exactly
where the trigger point is — if it’s in the muscle you’re stretching, congratulations, you’re treating the trigger point. Same
with one of the most respectable therapies for trigger points, “spray and stretch,” which is technical but does not require exact
targeting.
And the most important example of all: locating and pressing on trigger points is often futile and generally much less
important than addressing perpetuating factors, especially the medical ones, which will be discussed in detail below.
BACK TO TEXT
For contrast, it is not appealing idea to stretch a damaged muscle, like a muscle strain, for instance. The nervous system usually
strongly warns you away from that. BACK TO TEXT
I will never forget the most dramatic example I ever saw: a huge, visible lump in the trapezius muscle of a violin player. He was
afraid it was a tumor, but he’d already been cleared medically of that diagnosis, and it responded partially to massage and
taking a break from the violin. BACK TO TEXT
A lipoma is a gelatinous cyst. They can get fairly large, and they usually feel separate from other tissue, a bit slippery, like a tiny
water balloon sliding around just under the skin. By contrast, a trigger point will feel embedded in the muscle, not something
that can move around on top of the muscle. Lipomas are extremely common in the low back, especially around the low back
dimples, and they are routinely mistaken for both trigger points and tumours. BACK TO TEXT
Acetaminophen (Tylenol) seems to produce mixed results which do not indicate much one way or the other. The psychoactive drugs
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
(anti-depressants, alcohol, marijuana, amphetamines, opioids, benzodiazapenes) often seem to help, but the emphasis is on
seem, because they affect mood more than anything else: “It is my impression that ‘pain-killing’ drugs improve the patient’s
mood rather than take away the pain.” (Sarno) Muscle relaxants do not work very well at all (substantiated later in the
tutorial), so their success or failure is also disappointingly uninformative. BACK TO TEXT
Weren’t ulcers proved to be caused by a bacteria? That they were. Helicobacter pylori was famously hunted down in 1983 by
Australian scientists Barry Marshall and Robin Warren. Although its link with ulceration was initially met with much
skepticism, science came around relatively quickly — convinced by evidence, just like it’s supposed to work. By the mid-90s it
was widely accepted that H. pylori infection causes ulcers, and Marshall and Warren got a Nobel prize in 2005 (acceptance
speech).
But! Most people infected with the bacterium have no symptoms, and there are many variables that determine the severity of
the infection and whether or not it leads to ulcer. Stress is one of those factors (see Guo et al. and Jia et al.). Thus ulcer is very
likely both an H. pylori infection and a “stress-sensitive” condition.
BACK TO TEXT
Heat is reassuring, and comfort is a universal analgesic — it will take the edge of most kinds of pain. BACK TO TEXT
Definitely not always. Temperature sensitivity is variable in fibromyalgia patients. Some are cold sensitive! Other are sensitive to
either extreme. But heat-sensitivity is a strong theme. BACK TO TEXT
The most severe cases of myofascial pain syndrome could conceivably lead to such extremes of inactivity and alterations in
biomechanics that you might lose some muscle, but that’s an indirect consequence of the worst case scenario: a complication,
not a symptom. BACK TO TEXT
This is similar to the phenomenon of referred pain. Painful nerve signals converging on the spinal cord routinely leads to
confusion about the location of sensation. Occasionally it may cause confusion about the type of sensation as well. BACK TO
TEXT
Andersen H, Ge HY, Arendt-Nielsen L, Danneskiold-Samsøe B, Graven-Nielsen T. Increased trapezius pain sensitivity is not
associated with increased tissue hardness. J Pain. 2010 May;11(5):491–9. PubMed #20015697. BACK TO TEXT
Like all the others, it’s far from perfect, though — there are “taut bands” all over the place in the body, in normal anatomy and in
healthy muscle. BACK TO TEXT
Mense S, Simons DG, Russell IJ. Muscle pain: understanding its nature, diagnosis and treatment. 1st hardcover ed. Lippincott
Williams & Wilkins; 2000. p224. This is surely the weakest sign of a trigger point on its own. “The tenderness might be caused
by myofascial trigger points, fibromyalgia, enesopathy, bursitis, tendinitis, etc. The response observed is strongly dependent
on the amount of pressure applied.” I would add that some anatomy is just naturally more sensitive to pressure than others.
One way of reducing so much doubt is to use an algometer or algesiometer — a pressure-measuring device, not all that
inexpensive — to get objective measurements of pressure. BACK TO TEXT
But, please bear in mind that trigger points often form in response to other problems — thus, they can feel like other problems
that are actually also present! BACK TO TEXT
See PS Ingraham. You Might Just Be Weird: The clinical significance of normal — and not so normal — anatomical variations.
PainScience.com. 3466 words. . BACK TO TEXT
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Alport B, Horne D, Burbridge B. Heterotopic ossification of the quadratus lumborum muscle. J Radiol Case Rep. 2014 Jan;8(1):41–
6. PubMed #24967013. PainSci #53716. BACK TO TEXT
That’s an odd bit of imagery, I know. It’s inspired by a patient of mine who’s a bit of a comedian. Every time I find a trigger
point in his muscle, he tends to say something amusing and creative. One of my favourites is the “alien baby” thing. I hit a
trigger point, and he says, “Alien baby! Yep. Trying to claw out of my muscle. Definitely an alien baby.” Pretty good
description of trigger point pain, I think! BACK TO TEXT
Any study of carpal tunnel syndrome quickly reveals that it is a total mess of scientific contradictions. It is not a straightforward
condition. As already noted previously, the prevalence of all repetitive strain injuries is probably over-estimated, but carpal
tunnel syndrome is the most “popular.” Everyone who gets a little wrist pain thinks they have CTS, and seemingly their
doctors and therapists agree. And yet I’ve routinely seen excellent results simply from massaging the forearms — the majority
of cases, for sure. Insofar as I trust my own clinical experience, this may be the most obvious category of treatment successes.
BACK TO TEXT
Torun F, Dolgun H, Tuna H, et al. Morphometric analysis of the roots and neural foramina of the lumbar vertebrae. Surgical
Neurology. 2006 Aug;66(2):148–51; discussion 151. PubMed #16876606. BACK TO TEXT
Takasaki H, Hall T, Jull G, et al. The influence of cervical traction, compression, and spurling test on cervical intervertebral
foramen size. Spine (Phila Pa 1976). 2009 Jul;34(16):1658–62. PubMed #19770608. BACK TO TEXT
Sari H, Akarirmak U, Karacan I, Akman H. Computed tomographic evaluation of lumbar spinal structures during traction.
Physiother Theory Pract. 2005;21(1):3–11. PubMed #16385939. BACK TO TEXT
Lauder TD. Musculoskeletal disorders that frequently mimic radiculopathy. Phys Med Rehabil Clin N Am. 2002;13(3):469–485.
PubMed #12380546.
From the abstract: “Treatment of concomitant musculoskeletal disorders in patients with radiculopathy improves patient
satisfaction and outcomes.”
“Radiculopathy” is the trouble caused by irritation of the spinal nerve roots, the big bundles of nerve tissue that exit the spine
between each pair of vertebra. BACK TO TEXT
My therapist readers might reasonably ask: Is it possible that the pressure on the side of the hip was causing a reactive
contraction in the piriformis muscle, resulting in an impingement of the sciatic nerve … and fooling me? Yes, this is possible.
But I doubt it. This patient did not have a “twitchy” piriformis, as so many people with piriformis syndrome do. She was
generally relaxed, optimistic, and not in much pain — already about 50% recovered. I find it unlikely that her piriformis
muscle could be so prone to spasm at this stage. Nor could I palpate any reactive spasm in the piriformis during treatment,
not even when prodding the piriformis directly. It tolerated stretch well, and was not even particularly high-toned at rest.
BACK TO TEXT
Fibromyalgia is associated with morning pain because people with FM rarely feel rested. The condition either causes or is caused
by fragmented sleep and a lack of deep restorative sleep. Fatigue makes any pain worse, and this is probably felt mostly
acutely in the morning, gradually (and imperfectly) yielding to the stimulations of the day: exercise, sunlight, coffee, people,
noise and so on. And the morning-ness of fibromyalgia pain could also just be “one of those things,” an unexplained rhythm
of the disease. BACK TO TEXT
Steffens D, Ferreira ML, Latimer J, et al. What triggers an episode of acute low back pain? A case-crossover study. Arthritis Care
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Res (Hoboken). 2015 Mar;67(3):403–10. PubMed #25665074. In 2015, Steffens et al discovered that most “back attacks” —
episodes of acute back pain — occur in the first few hours of the day. Although their study wasn’t perfect, the results were
too strong not to take seriously. Notably, “awkward posture” was quite a bit more likely to be associated with acute back pain
than much more traditional bogeymen like heavy lifting, even difficult or obviously poor lifting. BACK TO TEXT
There’s no direct evidence for this. It’s a claim that has often been made my clinicians and experts on the topic. Although no one
knows exactly what makes trigger points flare up (or go away), extremes of activity and stimulation — too much and too little
— are plausible possibilities that seem to be consistent with what patients often report. BACK TO TEXT
Zhang H, Lü JJ, Huang QM, et al. Histopathological nature of myofascial trigger points at different stages of recovery from injury
in a rat model. Acupunct Med. 2017 Dec;35(6):445–451. PubMed #29109129. PainSci #52259. An animal study showing more
trigger points around injuries in rats than in healthy rats. BACK TO TEXT
Ettlin and Fernández-Pérez are both small observational studies basically showing that people with whiplash have more trigger
points. Not convincing to a skeptic, but better than nothing. BACK TO TEXT
Muscle has a large behavioural repertoire, reacting in many ways to many different situations. There are undoubtedly
competing and confused reflexes: situations where the body isn’t quite sure how to respond, and handles it differently over
time and as conditions change. The classic idea of a “protective spasm,” for example, would obviously be disastrous around a
fragile bone fracture. Protective paralysis is more likely with some injuries, and a neurological ban on movement can be quite
potent. For a discussion of other possibilities, see Cramps, Spasms, Tremors & Twitches.
For our purposes here, it’s enough to emphasize that muscular reactions to injury are complex and not well-understood,
probably often stressful, fatiguing. Another possibility is the irritation of stagnancy. Injuries often constrain joints to strictly
limited ranges of motion — like being stuck in an uncomfortable position for too long. All of the contortions that we learn
when we are injured, all the limping and squirming and fidgeting and careful avoidance of certain movements, requires
unfamiliar and often intense and precise muscle activity.
This stressful challenge is the most likely explanation for why trigger points tend to form around injuries.
BACK TO TEXT
If your only sore spot is the injury site, that’s not a complication of the injury, that’s just the injury. Injured tissue itself can remain
sore almost indefinitely, a semi-permanent sensitization. If you poke the exact spot where a tendon ruptured a year ago, it
may well still be quite ouchy, regardless of whether or not there are other sore spots nearby. BACK TO TEXT
This complicated sub-topic is discussed in detail in my frozen shoulder tutorial. The key reference is Khan et al . BACK TO TEXT
The famous rule — “correlation does not imply causation” — is an important idea, but also a misleading oversimplification. At
the very least it’s missing a word, and it should be “correlation does not necessarily imply causation.” Or you could just
rephrase it entirely. Edward Tufte, an American statistician who made the same point quite a while ago, suggested that a
good informal re-wording would be, “Correlation is not causation but it sure is a hint.” Because correlation actually does
“imply” causation, and many (if not most) events that occur in sequence that appear to be causally related are in fact causally
related. Their correlation is not a coincidence. Clapping makes noise, braking stops cars, hot coals burn fingers. BACK TO TEXT
Much of this list is cribbed from the Big List o’ Misdiagnoses in Myofascial Pain and Dysfunction, chapter 2, page 37. However, I’ve
added some of my own over the years. BACK TO TEXT
Deyo RA, Weinstein DO. Low Back Pain. N Engl J Med. 2001 Feb;344(5):363–70. PubMed #11172169. “ … disk and other
abnormalities are common among asymptomatic adults.” See also Boden, Jensen, Weishaupt, Stadnik, and Borenstein! BACK
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
TO TEXT
Ong A, Anderson J, Roche J. A pilot study of the prevalence of lumbar disc degeneration in elite athletes with lower back pain at
the Sydney 2000 Olympic Games. Br J Sports Med. 2003 Jun;37(3):263–6. PubMed #12782554. PainSci #56840.
In this study of 31 Olympic athletes with low back pain and/or sciatica, only about half of them had signs of degeneration,
bulging, or reduction of disc height.
My point here is that half of them did not have structural problems, in spite of their symptoms. These are elite athletes, not
malingerers! If they say they hurt, they hurt. Yet MRI failed to identify a problem in half of them. BACK TO TEXT
Deyo RA, Weinstein DO. Low Back Pain. N Engl J Med. 2001 Feb;344(5):363–70. PubMed #11172169.
symptoms and imaging results is weak.” BACK TO TEXT
“The association between
Beattie PF, Meyers SP. Magnetic resonance imaging in low back pain: general principles and clinical issues. Phys Ther. 1998
Jul;78(7):738–53. PubMed #9672546. PainSci #56987.
From the abstract: “Lumbar MRI has a high technical capacity to detect degenerative disk disease, bulging and herniated
disks, and distortions in the thecal sac or nerve roots associated with these conditions. The diagnostic accuracy, however, of
most lumbar anatomic impairments related to the symptoms of LBP is low or unknown. Although lumbar MRI remains as an
excellent tool to study morphology, findings must be related to data from clinical examinations to provide meaningful
judgments.”
BACK TO TEXT
PS Ingraham. MRI and X-Ray Often Worse than Useless for Back Pain: Medical guidelines “strongly” discourage the use of MRI
and X-ray in diagnosing low back pain, because they produce so many false alarms. PainScience.com. 2415 words. BACK TO
TEXT
Slow- and moderate-intensity compression of most healthy nerves is completely painless, while unhealthy or injured nerves can
easily be irritated by light pressure or even brushing of the skin. Of course, if you hit a healthy nerve hard enough, it will
zing! Your “funny bone” is the most obvious example: the ulnar nerve at the elbow is all too easy to smash against a backstop
of bone! But ordinary pressures on most nerves really does not cause any significant pain, I promise — I press on nerves all
the time. So this raises an important question: why would nerves ever hurt if they haven’t actually been traumatized? If an
injured nerve hurts, it’s probably because it’s ischemic (oxygen-starved) or irritated by other abnormal tissue chemistry. See
Kobayashi, Wilson, and Mackinnon. BACK TO TEXT
Hollmann L, Halaki M, Haber M, et al. Determining the contribution of active stiffness to reduced range of motion in frozen
shoulder. Physiotherapy. 2015 2018/06/19;101:e585. PainSci #53197.
Five capsular release surgery patients had their passive range of motion checked before and after being put under general
anaesthesia. All five of them had “significantly more passive shoulder abduction” when they were knocked out … which
would be impossible if their shoulder joint capsules were actually contractured or adhered or full of cement or had any
physical limitation. The improvement in ROM ranged from a minimum of 44˚ all the way up to a 110˚ boost (all the way back
to normal). The researchers reasonably concluded:
Passive range of motion loss in frozen shoulder is not be fully explained by a true capsular contracture alone.
Passive ROM loss in FS is not be fully explained by a true capsular contracture alone. Passive shoulder abduction
ROM assessed in awake patients with FS does not accurately reflect the true available ROM of the affected
shoulder. It appears that active stiffness or muscle guarding is a major contributing factor to reduced ROM in
patients with FS.
If I was the surgeon, I would have found it ethically hard to justify operating on these shoulders after seeing that.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
It’s really a shame it was such a small study. We really need someone to do the same thing with five times as many patients.
For a full discussion of this, see PS Ingraham. Frozen Shoulder Guide: A readable self-help manual for one the strangest of
all common musculoskeletal problems, adhesive capsulitis. PainScience.com. 21467 words. . BACK TO TEXT
Travell J, Simons D, Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Lippincott, Williams &
Wilkins; 1999. Volume 1, p513. Travell and Simons write, “Scalene muscle trigger points are frequently the key to [treatment
of] forearm extensor digitorum trigger points.” BACK TO TEXT
Why would someone complain of carpal tunnel syndrome when the classic signs and symptoms are missing? Carpal tunnel
syndrome is one of those conditions that enjoys a such a grandiose reputation, such over-the-top “popularity” as an ailment
concept, that it is suspected to be the cause of virtually any wrist problem, regardless of how completely wrong the symptoms
are. Something wrong with your wrist? Must be carpal tunnel syndrome! BACK TO TEXT
Widespread could mean either that you constantly feel pain in many locations (such as “most joints, most of the time”) or that
you have a high frequency of regional pains that can occur pretty much anywhere. BACK TO TEXT
Holman AJ. Fibromyalgia and Positional Cervical Cord Compression Differ Only By Autonomic Nervous System
Consequences: A Double-Blinded, Prospective Study. Arthritis Rheumatol. 2015;67(suppl 10).
This paper presents evidence “minor” irritation of the upper spinal cord may cause “potent sympathetic arousal in humans”
— firing up the same branch of our nervous system that handles emergencies. Thirty-one of fifty-four patients with
fibromyalgia and positional cervical cord compression showed clear signs of sympathatic arousal.
BACK TO TEXT
Scheper MC, de Vries JE, Verbunt J, Engelbert RH. Chronic pain in hypermobility syndrome and Ehlers-Danlos syndrome
(hypermobility type): it is a challenge. J Pain Res. 2015;8:591–601. PubMed #26316810. PainSci #52758. Hypermobility is “highly
prevalent among patients diagnosed with chronic pain.” BACK TO TEXT
“The essential difference between HSD and hEDS lies in the stricter criteria for hEDS compared to the HSD.” But it’s very
tricky, and those criteria all very new (see the 2017 EDS International Classification). BACK TO TEXT
Rodgers KR, Gui J, Dinulos MB, Chou RC. Ehlers-Danlos syndrome hypermobility type is associated with rheumatic diseases.
Sci Rep. 2017 Jan;7:39636. PubMed #28051109. PainSci #52757.
hEDS patients may see multiple subspecialists without realizing a connection between their joint symptoms and multisystemic involvement of the disease; they are often dismissed as hypochrondriacs, and report feelings of isolation from the
lack of diagnosis.
Perhaps due to a lack of gravitas surrounding the hEDS diagnosis, management of the disease varies among practitioners,
and clinical workup does not often extend beyond the joint and skin examination.
BACK TO TEXT
BBC [Internet]. Clarke A. The masseuse who pulled my arm out; 2017 Aug 18 [cited 19 Jul 10]. BACK TO TEXT
That’s a “diagnosis of elimination,” and syndromes are generally diagnosed that way — when you’ve eliminated all other
possible explanations for the pain, you’re left with some unexplained symptoms that get summed up as a syndrome. Maybe
they all have the same cause, or maybe it’s three overlapping undiagnosed problems. Tricky! BACK TO TEXT
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Some would argue that attributing the pain to muscle is itself a form of creativity. It seems like muscle, but we don’t really
know — and there are certainly some very “trigger pointy” sensations that seem a lot less like they are coming from muscle.
BACK TO TEXT
Tumors in particular have a number of distinctive features that make them easy to distinguish from trigger points. Although
most doctors may not be good at diagnosing musculoskeletal problems, they certainly do have the expertise to spot ominous
diseases and conditions. BACK TO TEXT
Unger DL. Does knuckle cracking lead to arthritis of the fingers? Arthritis Rheum. 1998 May;41(5):949–50. PubMed #9588755.
PainSci #53245.
BACK TO TEXT
A sudden onset of extreme pain is always disturbing, of course. But there’s nothing like getting such pain in the abdomen,
chest, low back, eye, or groin to put a particularly freaky edge on the experience. Of course, there’s also always the possibility
of other ominous problems in some of these areas, so the fear of such pains is obviously not irrational. You need to be aware
of both possibilities. And few people realize that trigger points really can be “that bad.” BACK TO TEXT
Fast-activating trigger point experience #1: The first was while walking down a steep hill, an activity that is fairly challenging
for the tibialis anterior (shin) muscle. The pain stopped me in my tracks. It appeared in the space of perhaps two strides, and
just about knocked me over — I had to grab a friend’s shoulder for support. I couldn’t bear weight on that leg at all for about
a minute. Then I limped slowly to the bottom of the hill, sat on a park bench, and massaged the tibialis anterior for a few
minutes until the pain faded. I felt it throbbing now and then for a couple days and have not been bothered by it since. It was
as transient as it was nasty. BACK TO TEXT
Fast-activating trigger point experience #2: More recently — still unpleasantly fresh in my memory — I had an even more
arresting spike of trigger point pain in my upper right neck. It was an extraordinary experience, both for its intensity and
because of the nauseating quality of the pain. Again, the onset was as quick as turning your electric guitar amplifier up to
“11.” There was no possibility of doing anything else until it was resolved. My adrenal glands went berserk, I broke into a
cold sweat. It felt like I’d been stabbed in the neck with a poison dagger. If not for my experience with muscle pain, I surely
would have “panicked.” But, despite the awfulness of the pain, it was obvious that it was muscular — this is a trouble spot
for me, and I’d had less severe experiences with the same problem a few times before.
And so I attacked the spot with immediate, vigorous massage, instinctively using the “stripping” technique: sliding my
thumb tips in a strip the length of the affected muscle fibers. Interestingly, it was somewhat like being in a tug-of-war. It was
pulling one way, I the other. I had a clear impression that I was “fighting” the muscle, trying to squeeze the evil out of it, to
physically resist a localized spasm. If you’ve ever fought a cramp with stretch, it felt like that, but on a small scale.
I must have won. After what seemed like a few minutes of cold sweating and frantic self-massage — probably only about 90
seconds — it started to ease up. A couple minutes later, most of the pain was gone. The adrenalin reaction lasted longer than
the pain.
BACK TO TEXT
I wish I could take a photomicrograph of my own trigger points, or anyone’s trigger points. Or sample the tissue fluid. Or use
the new MRI technique. Or measure their electrical activity. But, unfortunately, these procedures are not available to anyone,
at all: some, like photomicrographs, are advanced and expensive techniques that can be only done for the purposes of
research. (Also, though I'm not sure about this, I think it's possible that photomicrographs can only been done on dead,
excised animal muscle! I don't know if it's possible to take photomicrographs of living tissue. If any of my readers knows
more about this, please let me know). There’s some hope that the MRI method will become practical for clinical use, but even
that is likely to be years off. It’s strange, isn’t it? We can put a man on the moon, but we can’t use high tech to diagnose
muscle knots yet … BACK TO TEXT
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Only a single biopsy study of trigger points in humans has even been done — Reitinger et al — but it’s an important piece of
evidence. That single study found “enlarged and darkly-staining muscle fibers compared to elsewhere in the muscle.” The
difference is obvious even to the untrained eye. BACK TO TEXT
Since the mid-2000s, two key imaging technologies have been used to reveal taut bands of muscle tissue containg focal nodules
that previously could only be (unreliably) identified by feel. Vibration sonoelastography (VSE) and magnetic resonance
elastography (MRE) both detect tissue stiffness (“elasto”!) in different ways. MRE is a well-understood and validated
technology (see Mariappan). It was used by Chen et al in 2007 and 2008 to hunt for trigger points. Sikdar et al did the same
with VSE in 2009. All of these studies produced good evidence of stiff (“tight”) tissue at the location of suspected trigger
points. Simons believed these technologies “may open a whole new chapter in the centuries-old search for a convincing
demonstration of the cause of MTP symptoms.” BACK TO TEXT
Infrared thermography has also been used to look for a “heat signature” of trigger points on the skin, but this evidence is less
of a slam dunk than the two elastographies, MRE/VSE (see previous note). Dibai-Filho et al found that there is so far “no
agreement on skin temperature patterns in the presence of MTrPs” in a few existing studies. (On the bright side, they think
their own methods could do the trick: see their other paper on this.) BACK TO TEXT
The electrical signature of a trigger point is called endplate noise or spontaneous electrical activity (SEA). End plate potentials
(EPPs) are the waves of electrical activity that spread out from the point where motor neurons attach to muscles (which have
a distinctive saucer-like appearance). EPPs can be measured with electrodes on the skin, or a probe inserted into the muscles.
This is electromyography (EMG). The only direct EMG evidence of this phenomenon to date is from Simons et al way back in
2002, and Kuan et al in 2007, two small but decent studies both finding EPPs around putative trigger points. (Other
researchers have done experiments based on the assumption that EPPs are associated with trigger points, producing indirect
but somewhat supporting evidence: see Hsieh et al and Ge et al .) BACK TO TEXT
Two recent-ish scientific papers, one in 2005 (2005) and then a bit more convincingly in 2008 (2008), claim to have shown that
the tissue fluid in and around a trigger point is painfully “poisonous” — full of molecules associated with metabolic
exhaustion and pain … which is what we’d expect to find if the main theory of how trigger points work is correct. In 2011,
Hsieh et al found the same and dug a little deeper. Unfortunately, there have been no more attempts to replicate this evidence,
which is a good example of how the science of trigger points is exasperatingly half-baked. Although these two papers are a
great start, we could really use more and better data. BACK TO TEXT
Photomicrographs, for instance, are an extremely technical beast, and pictures at such an alien scale can be really difficult to
interpret. In particular, we tend to overestimate the significance of what we see using high-tech tools — a very well-known
problem with MRI scanning. If you look for something eyebrow-raising, it’s not hard to find it. In the case of trigger points,
there might or might not really be something there, and even if there is, it still doesn’t necessarily mean what we think it
means. Just sayin’ … and giving you a hint of how deep this rabbit hole goes. BACK TO TEXT
Dr. Travell died in 1997. Her life’s work was remarkable. Her daughter published a lovely article about her in 2003. See “Janet
G. Travell, MD: a daughter's recollection”. BACK TO TEXT
Google has a fascinating tool, the Books Ngram Viewer, which creates a graph to show how often words and phrases have
appeared in print over the years. The Ngram for “trigger points” vividly shows how obscure the term was until the mid1970s. Interestingly, after a peak early this century, the term is now somewhat in decline — though I wonder if that has more
to do with the decline of printed usage than actual usage. I suspect the internet is to blame for the “decline.” BACK TO TEXT
Most popular therapies are based on commercial empires with guru-like founders who had an appealing idea and some
marketing savvy, and rarely any medical or scientific credentials. Right or wrong about how trigger points worked, Travell
and Simons are credible people, more interested in understanding than selling a therapy concept. For instance, they never
named or trademarked a therapy based on the idea of trigger points, even though they easily could have, and probably gotten
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
rich. I cannot over-emphasize the difference. BACK TO TEXT
I’ll repeat the story I told in the introduction here, because it’s so relevant: once upon a time I had a minor surgery to remove a
benign cyst from my nipple. The surgeon used a local anaesthetic and refused to let me watch, hiding the procedure behind a
shield. Halfway through, a searing pain ripped into me. It was one of the sharpest pains I’ve ever experienced. In fact, it
wasn’t “like” being stabbed: I had been stabbed. The surgeon said, “Very sorry about that. I slipped and poked your pectoralis
major muscle with my scalpel, and only the superficial tissue is anaesthetized. Don’t worry, it won’t happen again. That was a
really rare slip.” And, thankfully, it did not happen again. The experience vividly demonstrated that muscle can suffer! BACK
TO TEXT
Graven-Nielsen T, Mense S, Arendt-Nielsen L. Painful and non-painful pressure sensations from human skeletal muscle.
Experimental Brain Research. 2004 Dec;159(3):273–83. PubMed #15480607.
This study attempted to determine if painful and non-painful pressure sensations from muscles actually exist. It is possible
that much of what seems like “deep” sensation could in fact be an illusion of depth, somewhat like a “3D” image projected on
a flat screen. The authors put it this way: “Painful and non-painful pressure sensations from muscle are generally accepted to
exist but the peripheral neural correlate has not been clarified.” This is a challenging question to study, because it’s difficult to
eliminate skin sensation as a factor. However, these researchers went to a lot of trouble to do just that, with “anaesthetised
skin combined with a block of large diameter muscle afferents.” And it turns out that, even with anaesthetized skin, people
can still feel pressure and pain. Although not conclusive, this evidence does suggest that muscle knows when it’s being
poked!
BACK TO TEXT
Of course, the existence of nice laminated wall charts proves nothing by itself. There are such charts available for many kinds of
ineffective therapies! Any practitioner who hangs a nice chart on their wall looks more credible, whether there is any basis to
the chart or not. However, trigger point charts are a by-product of perfectly respectable research, and the pain patterns can
easily be demonstrated for patients by any competent therapist. BACK TO TEXT
Gerwin RD, Dommerholt J, Shah JP. An expansion of Simons' integrated hypothesis of trigger point formation. Curr Pain
Headache Rep. 2004 Dec;8(6):468–75. PubMed #15509461. BACK TO TEXT
The only way to go deeper is to talk about how molecular machines work — how proteins can extract order from the chaos of
the molecular storm, the violent vibrations of nanoscale particles (Brownian motion). That’s way above my pay grade, but I
can recommend an excellent book on the topic: Life's Ratchet: How molecular machines extract order from chaos, by Peter
Hoffman. Chapter 7, “Twist and Route,” is about the molecular machinery of movement and muscle: the motor proteins
kinesin, myosin, and dynein. “There is not one type of kinesin, myosin, or dynein doing one type of job. Instead, like a fleet of
customizable trucks, there are superfamilies of molecular motors, with eighteen known classes of myosins, ten classes of
kinesins, and two classes of dyneins.” This rabbit hole goes deep. BACK TO TEXT
This was a tough (but fun) image to come up with. Sarcomeres are about 2.5 microns long, give or take, depending on whether
they are contracted or not. That means you can put about 20,000 of them end-to-end in a 5cm long muscle cell, which is pretty
much equivalent to grains of wheat stacked about 15,000 deep into a fifty-foot silo. But the comparison gets confusing when
comparing diameters. Muscle cells are only about 40–100 microns wide, which makes them about a thousand times longer
than they are wide. A fifty foot grain silo with matching proportions would only be about a half inch wide! More like a grain
pipe. Still, sarcomeres are also extremely skinny, just like cells. Laid end-to-end, you could fit only about 40 across the
diameter of a muscle cell. But sarcomeres are so skinny that the number you can fit side to side across a muscle cell skyrockets
and becomes, once again, comparable to the number of grains across the width of a silo. So you really can think of a
sarcomere as being the size of a “grain” in a muscle cell “silo.” BACK TO TEXT
Water molecules are ridiculously small. They are measured on the scale of angstroms, which are 10,000 times smaller than
microns. So if you’ve got yourself a sarcomere 2.5 microns long, you could line up about 25,000 1-angstrom water molecules
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
in there. BACK TO TEXT
Actually, there is nothing “just” about it: how sarcomeres control muscle elongation — what we call an eccentric contraction,
which occurs in the biceps when lowering a barbell, for instance — is one of the biggest puzzles in muscle physiology. There
is no known mechanism for how a sarcomere’s overlapping proteins can partly hang on to each other, yet still allow
themselves to pull apart. See Eccentric Contraction. BACK TO TEXT
In 2001, “the smallest consistent biomechanical event ever demonstrated” was a 2.3-nanometre long step in the length of a
sarcomere (see Blyakhman). That is an impressive one-thousandth the size of the sarcomere, but still ten to one hundred times
larger than the scale of the smallest units involved, the ions and other smaller non-protein molecules that mediate all of this.
The field is advancing steadily, but remains limited by the speed of the flourescence techniques used to show the movement
of different atomic parts of the molecular machine. BACK TO TEXT
Coordination across orders of magnitude of scale is one of the “holy grails” of robotics — one of the everyday miracles of
biology that is extremely difficult to imitate in technology. BACK TO TEXT
Previously referenced, Shah JP, Danoff JV, Desai MJ, et al. Biochemicals associated with pain and inflammation are elevated in
sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 2008;89(1):16–23. PubMed #18164325.
BACK TO TEXT
Reducing dislocated joints; stretching muscle cramps; warming up freezing hands and feet, or restoring circulation to a leg that
has fallen asleep; and nearly anything that relieves awful pressure, like lancing boils and cysts or hematomas under toenails,
or childbirth, or evacuation of impacted bowels — all very painful, but also very relieving. BACK TO TEXT
Trigger points often feel kind of poisonous, just exactly as though we can feel the toxicity of the metabolic wastes. Despite this,
the feeling is usually a relief, kind of like throwing up when you know that you need to. BACK TO TEXT
Technically such utterances are known as “vocal sign,” because they are distinctive enough to be diagnostic. Among all the
common musculoskeletal problems, only pressing on trigger points tends to produce such “vocal signs.” You’re not going to
get this reaction if you push on a bursitis. BACK TO TEXT
Stanton T, Moseley L, Wong A, Kawchuk G. Feeling stiffness in the back: a protective perceptual inference in chronic back pain.
Scientific Reports. 2017;7(1):9681. PainSci #52938. Three related experiments “challenge the prevailing view by showing that
feeling stiff does not relate to objective spinal measures of stiffness.” BACK TO TEXT
For example, there may be an association between trigger points and pinched nerve roots in the neck (see Sari). Sometimes, the
only symptom of radiculopathy is weakness … and it could also be causing trigger points. BACK TO TEXT
Celik D, Yeldan I. The relationship between latent trigger point and muscle strength in healthy subjects: a double-blind study. J
Back Musculoskelet Rehabil. 2011;24(4):251–6. PubMed #22142714. BACK TO TEXT
Isn’t it also just a matter of leverage? Good question. Partly, yes, but it’s probably not a major consideration. The biceps tendons
attaches so close to the joint that there is not much change in mechanical advantage as it moves through the range. From a
completely straight elbow, there is a “getting started” penalty because the biceps has very little lever to pull on at first.
However, this is overcome quickly as the elbow starts to flex, while sarcomere overlap is a much more linear equation: every
degree of movement means more sacromere overlap and a proportionate increase in available power. So, regardless of
leverage, the lower end of the range is generally much weaker mostly because of the sarcomeres. BACK TO TEXT
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Mense S, Simons DG, Russell IJ. Muscle pain: understanding its nature, diagnosis and treatment. 1st hardcover ed. Lippincott
Williams & Wilkins; 2000. p99. As previously mentioned, note again that, according to Simons and Mense (p 259), the popular
idea of “protective spasm” or a vicious cycle of pain, spasm, and then more pain (pain-spasm-pain) is actually a
“physiologically and clinically untenable concept.” BACK TO TEXT
A great example of this was a client who spent several years coping with a complex array of symptoms around the pelvis
before the severity of the situation escalated to the point that it was finally discovered that she had a substantially separated
pubic joint (diastasis symphysis pubis). Surprisingly, the joint itself was never particularly painful — but it was likely the
ultimate cause of the severe trigger points in the region. BACK TO TEXT
It makes sense, it’s plausible. But please please please let it not be true! BACK TO TEXT
Muscle is characterised by particularly extreme and highly energetic performance, routinely functioning at the limits of what
biology will allow, to the point where it’s often injured by the sheer intensity of its metabolic activity. See Post-Exercise,
Delayed-Onset Muscle Soreness. BACK TO TEXT
Two other excellent examples, one obvious, one obscure.
First example: immunity. The immune system is the ultimate balancing act in the human body. Too little immunity and the
microscopic invaders eat you for lunch. Too much immunity, and you eat yourself for lunch: autoimmune disease. (And, by the
way, this is why the popular idea of “strengthening your immune system” is impossible and misguided — in principle the
only possible improvement to immune function is to regulate or balance it, not strengthen it. Something that actually
“stimulates immunity” would increase your risk for very nasty diseases like rheumatoid arthritis.)
Second example: the appendix. Why do humans get appendicitis all the time? Should it have been bred out of the species?
Unfortunately, no, because the appendix is stuck in an evolutionary compromise. Smaller appendices not only start to lose the
subtle benefits of an appendix (it isn’t useless), but also get more appendicitis. Thus it cannot be bred out of the species,
because anyone born with a smaller appendix is more likely to die of appendicitis before passing on their genes. An elegant
trap, no? And a great example of biological compromise and catch-22!
BACK TO TEXT
A jet plane that leaks fuel by design? Sound too incredible to be true? From Wikipedia: “To allow for thermal expansion at the
high operational temperatures the fuselage panels were manufactured to fit only loosely on the ground. Proper alignment
was only achieved when the airframe heated due to air resistance at high speeds, causing the airframe to expand several
inches. Because of this, and the lack of a fuel sealing system that could handle the thermal expansion of the airframe at
extreme temperatures, the aircraft would leak JP-7 jet fuel onto the runway before it took off.” BACK TO TEXT
Muscle fibres do not normally contract all at once, as most people imagine. Instead they are organized into groups called
“motor units,” one per motor nerve. Instead of firing all at once, the groups alternate like pistons. At any given time,
thousands of motor units are in different phases of contraction and relaxation. The units are so small and the switching
system is so fast that their coordinated action seems to be completely smooth to us. There is an interesting exception, though:
if you get tired enough that a lot of motor units start failing to contract, the switching system fails because there aren’t enough
motor units available for smooth contraction. This is why muscles start to shudder and quiver with very intense exertion!
Cool, eh? The switching system is mind-boggling in its efficiency and complexity, and a fantastic example of how much more
physiologically complex muscle tissue is than most people realize. BACK TO TEXT
For a trait to evolve, you have to be born with it, and it has to give you some advantage, making you more likely to survive,
find a mate, and pass on the trait to your lucky progeny. All post-breeding-age traits are therefore not strongly subject to
evolution (there could be some group-selection and young-rearing effects, but these are much less strong than traits that
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
directly affect your own survival). Being born with knees that never get arthritis would be a bloody marvelous genetic trait to
have, but it doesn’t make you any more likely to breed than anyone else; people with knees that go bad at age forty have
given the trait to their children before they really start to suffer. There’s little evolutionary advantage to traits that express
themselves later in life. BACK TO TEXT
Yes, Substance P-for-pain. Seriously. It’s a neurotransmitter involved in pain biology, and so they called it substance P-for-pain.
Sounds like a MacGuffin in a B-movie. Or an A-movie: Avatar’s “unobtainium,” a precious sci-fi mineral that defies gravity,
is one of the most glaring and infamous MacGuffin’s in modern mainstream cinema. But I digress! (And digress, and digress.)
BACK TO TEXT
It would probably be too biologically expensive to have a receptor for every nerve ending. It just isn’t necessary — what good
did it do a caveman to be able to precisely locate organ pain? He couldn’t do anything about it! Knowing where pain is on
your skin, now that is some seriously valuable information. But it’s probably just not worth maintaining a complex
neurological system for localizing internal pain. So perhaps we ended up with more nerve endings than receptors. BACK TO
TEXT
Woolf CJ. Central sensitization: Implications for the diagnosis and treatment of pain. Pain. 2010 Oct;152(2 Suppl):S2–15.
PubMed #20961685.
PainSci #54851.
Pain itself often modifies the way the central nervous system works, so that a patient actually becomes more sensitive and
gets more pain with less provocation. That sensitization is called “central sensitization” because it involves changes in the
central nervous system (CNS) in particular — the brain and the spinal cord. Victims are not only more sensitive to things that
should hurt, but also to ordinary touch and pressure as well. Their pain also “echoes,” fading more slowly than in other
people.
For a much more detailed summary of this paper, see Sensitization in Chronic Pain.
BACK TO TEXT
Mense S. Muscle pain: mechanisms and clinical significance. Deutsches Ärzteblatt international. 2008 Mar;105(12):214–9.
PubMed #19629211. PainSci #54165. “Low frequency activity in muscle nociceptors is sufficient to induce central sensitization.”
Central sensitization leads to increased excitation in the spinal cord and to referral of muscle pain. BACK TO TEXT
Suzuki R, Dickenson A. Spinal and supraspinal contributions to central sensitization in peripheral neuropathy. Neurosignals.
2005;14(4):175–81. PubMed #16215300. BACK TO TEXT
Both Travell and Simons, showing their quality, are thoroughly on the record acknowledging the limits of their knowledge.
Their books are crammed with suggestions for further research to try to clear up the many loose ends. Both of them actively
wrote about it in this way, often poking holes in their own work, true scientists until their deaths. BACK TO TEXT
Hard to back that up, but I got it initially from my trigger point therapy mentor, Judy Smith, in about 1998, and have asked
many other practitioners about it since then — I think virtually every single professional I’ve ever asked about it has agreed
that, yes, connective tissue somehow seems to have MTP-like sensitivity, and how can that be, exactly? BACK TO TEXT
This has already been mentioned a couple times, but it’s an important point. The source is Mense S, Simons DG, Russell IJ.
Muscle pain: understanding its nature, diagnosis and treatment. 1st hardcover ed. Lippincott Williams & Wilkins; 2000. p.
259. BACK TO TEXT
Quintner JL, Cohen ML. Referred pain of peripheral nerve origin: an alternative to the "myofascial pain" construct. Clin J Pain.
1994 Sep;10(3):243–51. PubMed #7833584. PainSci #54775. BACK TO TEXT
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Quintner JL, Bove GM, Cohen ML. A critical evaluation of the trigger point phenomenon. Rheumatology (Oxford). 2015
Mar;54(3):392–9. PubMed #25477053. BACK TO TEXT
It’s particularly unlikely because I wasn’t biased in that direction. I was biased in the other direction. I never really believed
trigger points were reliably attached to any specific anatomy. This was one of my earliest skeptical tendencies as a massage
therapist. And so, if anything, I was looking for any other correlation that might make more sense — and I just didn’t find
any. I still could have missed it, but not because I was oblivious to the possibility … or motivated to avoid it. BACK TO TEXT
AcademyOfClinicalMassage.com [Internet]. Lowe W. Reconsidering Hip and Iliotibial Band Pain; 2015 November 6 [cited 18
Dec 1]. BACK TO TEXT
Roberts G. Curing Meralgia Paresthetica: How to Recover from Meralgia Pain. 2nd ed. Pain Management Press; 2014. I
correspond with the author a bit. Nice fella, seems to have the right priorities. Haven’t gotten around to actually reading the
book. BACK TO TEXT
Aota Y. Entrapment of middle cluneal nerves as an unknown cause of low back pain. World J Orthop. 2016 Mar;7(3):167–70.
PubMed #27004164. PainSci #53097. A report on “a case of severe low back pain, which was completely treated by release of
the middle cluneal nerve.” Exploratory surgery identified nerves “entrapped in adhesions.” They cut them free… and that
was the ticket. The patient was decisively cured. Which is pretty cool. BACK TO TEXT
My father is a Vietnam veteran, so I don’t use the example of bamboo cage torture lightly. Is it a real thing? When I first
thought of it, I wasn’t sure where I’d even heard of the idea. My father is not only a veteran but a war historian, so I asked if
he could check into this for me. It seems that “tiger cages" were used in WWII, and then again in Vietnam by the North
Vietnamese. There are other similar methods. One torture that was used on captured pilots combined severe joint strain with
immobilization — their hands were tied behind them, and they were lifted off the floor by a rope and left to hang there,
which is a more extreme version of the more common stress positions method, which is much more widely used (at that last
link, there’s a picture of a A Viet Cong prisoner being tortured this way by Americans). Of course, regardless of whether
bamboo cages were used in this way, it’s obvious that severe confinement and immobilization would indeed be torture. BACK
TO TEXT
Gunn CC. Neuropathic Myofascial Pain Syndromes. 3rd ed. Lippincott Williams & Wilkins; 2001. BACK TO TEXT
Mense S, Simons DG, Russell IJ. Muscle pain: understanding its nature, diagnosis and treatment. 1st hardcover ed. Lippincott
Williams & Wilkins; 2000., p. 61. BACK TO TEXT
See Woolf. BACK TO TEXT
Merlie JP, Isenberg KE, Russell SD, Sanes JR. Denervation supersensitivity in skeletal muscle: analysis with a cloned cDNA
probe. J Cell Biol. 1984 Jul;99(1 Pt 1):332–5. PubMed #6547444. PainSci #55245. “In adult skeletal muscles, acetylcholine
receptors are highly concentrated in the postsynaptic membrane, but virtually absent from the rest of the muscle's plasma
membrane. After denervation, however, [they] appear over the entire muscle fiber surface.This phenomenon, called
denervation supersensitivity, has been studied extensively, with the aim of learning how nerves cause long-term changes in
their targets.” BACK TO TEXT
For a truly astonishing example of just how much “context matters”, consider the example of Simeon Stylites, who immobilised
themselves voluntarily on pillars, or in some case entombed in walls, for years for the purported purpose of religious clarity
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
— a form of extreme (extreme, extreme, extreme) devotional meditation, I suppose. They were presumably able to tolerate
their immobilization thanks to religious fervor — an exotic mental context, telling them that the immobilization was actually
a good thing. Hat tip to reader Mark H. for this superb bit of lateral thinking. BACK TO TEXT
Todd Hargrove has written about the psychological dimension of this in his series on Barrett Dorko’s ideomotion therapy.
“Dorko hypothesizes that the corrective movements produced by pain are often inhibited by other mental activity, the most
likely culprit being mental activity devoted to social concerns. For example, the social need to use appropriate body language
could inhibit corrective movements that would send the wrong signals.” It’s a strong theme in my writing as well; I do go on
about the relevance of personal growth and emotional maturity to pain and recovery, what I call “healing by growing up.”
BACK TO TEXT
Csapo R, Maganaris CN, Seynnes OR, Narici MV. On muscle, tendon and high heels. J Exp Biol. 2010 Aug;213(Pt 15):2582–8.
PubMed #20639419.
PainSci #55265.
Chronic heel wearers, for instance, do have shortened calf muscles, stiffer Achilles tendons, and a smaller ankle range of
motion. It doesn’t actually seem to cause much of a problem, but the tissue does shorten.
(See more detailed commentary on this paper.)
BACK TO TEXT
Harvey LA, Katalinic OM, Herbert RD, et al. Stretch for the treatment and prevention of contractures. Cochrane Database Syst
Rev. 2017 Jan;1:CD007455. PubMed #28146605. PainSci #52742.
This is a Cochrane review of static stretch for the treatment and prevention of contractures. The verdict? A clear thumbs
down. Based on “high-quality evidence” they concluded that “stretch is not effective for the treatment and prevention of
contractures.”
“Regular stretch does not produce clinically important changes in joint mobility, pain, spasticity, or activity limitation in
people with neurological conditions.” BACK TO TEXT
Furia JP, Willis FB, Shanmugam R, Curran SA. Systematic review of contracture reduction in the lower extremity with dynamic
splinting. Adv Ther. 2013 Aug;30(8):763–70. PubMed #24018464. PainSci #52971. “Dynamic splinting is a safe and efficacious
treatment for lower extremity joint contractures.” BACK TO TEXT
Jerosch-Herold C, Shepstone L, Chojnowski AJ, et al. Night-time splinting after fasciectomy or dermo-fasciectomy for
Dupuytren's contracture: a pragmatic, multi-centre, randomised controlled trial. BMC Musculoskelet Disord. 2011 Jun;12:136.
PubMed #21693044.
PainSci #52736.
150 patients received physical therapy for their Dupuytren’s contracture, with or without night splint usage. There was no
difference by any measure, and so “routine addition of night-time splinting for all patients after fasciectomy or
dermofasciectomy is not recommended.”
BACK TO TEXT
“Resting tone” is the tension, texture and tightness of a relaxed muscle. All muscles are contracting all the time, even when
they are relaxed. Think of it like a car engine idling. BACK TO TEXT
I also think it would mostly be impossible to infer the location of a trigger point from behaviour. A limp, for instance, might
narrow it down to the leg, but no further. BACK TO TEXT
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
They can’t contradict us. Animals are much easier to exploit as extensions of our identity. Many people profess to “love
animals,” when in fact what they love is themselves, and the pet is a “mini me” onto which much is projected and from which
little is truly received. They interpret their pet’s behaviour in terms of what they want, and the pet can’t say, “No, that’s not
what I meant, that’s not how I feel!” The ultimate expression of this is seen in the more extreme “crazy cat ladies” and other
pet hoarders who care much more about their obsession than they do about the animals they exploit and neglect. These
people are mentally ill, but similar behaviour is often seen in sane humans. BACK TO TEXT
For a more thorough discussion of animal placebo, see Placebo Power Hype: The placebo effect is fascinating, but its “power”
isn’t all it’s cracked up to be. Basically, there's a huge reporting bias: people who treat animals are extremely likely to suffer
from a bad case of wishful thinking when interpreting animal responses to their treatments. Also, animals are profoundly
influenced by human hope and expectations and feelings, to our human non-verbal cues. BACK TO TEXT
Clever Hans is the canonical example of animal sensitivity to subtle human cues: the horse who seemed to be able to do
arithmetic and other intellectual tasks. What he was actually doing was much more remarkable in some ways: “responding
directly to involuntary cues in the body language of the human trainer, who had the faculties to solve each problem,” the
“Clever Hans effect.” And that effect actually wasn’t just limited to his trainer, either — he could usually get the answer by
watching the reactions of any person who was watching. BACK TO TEXT
In general, the idea that massage can “detoxify” tissue is probably mostly wrong. For instance, it was established clearly by a
science experiment in 2009 (see Wiltshire et al ) that, contrary to the popular claim, massage does not help to move lactic acid
out of muscle tissue, but in fact actually “impairs lactic acid and hydrogen ion removal from muscle following strenuous
exercise by mechanically impeding blood flow.” However, the density of waste metabolites is probably quite high in a very
small target area, which probably makes it easier to tinker with. In a bubble bath, it is easy to clear the bubbles away from a
small patch of water, but impossible to get rid of all the bubbles in the bath — a simple scale effect. Similarly, it’s probably
possible to disturb and dilute the tissue chemistry of a small segment of muscle tissue, even though it’s difficult or even
impossible to have a much of an impact on the chemistry of an entire muscle. There is no evidence that squishing actually
detoxifies the trigger point, though. It’s just a reasonable hypothesis, and I’d really like to see some science experiments about
this! See also Why Drink Water After Massage? BACK TO TEXT
Gulick DT, Palombaro K, Lattanzi JB. Effect of ischemic pressure using a Backnobber II device on discomfort associated with
myofascial trigger points. Journal of Bodywork and Movement Therapies. 2011 Jul;15(3):319–25. PubMed #21665108.
PainSci #54988.
BACK TO TEXT
I once basically cured a fellow of a neck crick caused by a prominent trigger point in his neck, only to get an angry phone call
from him later that day saying that he was worse than ever — but after a little discussion, it turned out that the first thing he
did after his appointment was practice his diving off a 10-metre platform — a post-therapy activity that was practically
custom designed to bring his neck crick roaring back! BACK TO TEXT
A good example is the mandibular notch, which is just under the cheekbone and in front of the jaw joint. It’s full of nerves, but
completely safe to massage — indeed, it’s a particularly nice spot to massage. See Massage Therapy for Bruxism, Jaw
Clenching, and TMJ Syndrome. BACK TO TEXT
PS Ingraham. Toxic Muscle Knots: Research suggests myofascial trigger points may be quagmires of irritating molecules.
PainScience.com. 1784 words. BACK TO TEXT
Costigan M, Belfer I, Griffin RS, et al. Multiple chronic pain states are associated with a common amino acid-changing allele in
KCNS1. Brain. 2010 Sep;133(9):2519–27. PubMed #20724292.
Mark your calendars: 2010 was the year researchers confirmed a gene as “one of the first prognostic indicators of chronic pain
risk,” doubling or tripling the odds that a low back pain patient will recover in a timely fashion from nerve root injury.
Screening for this gene is not yet something that is clinically available, but it probably will be someday, and then you will
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
know: the universe really does hate you.
BACK TO TEXT
Hsu PC, Chiu JW, Chou CL, Wang JC. Acute Radial Neuropathy at the Spiral Groove Following Massage: A Case Presentation.
PM R. 2017 Apr. PubMed #28400223. BACK TO TEXT
Drinking alcohol in the evening will certainly help you fall asleep, but will also compromise sleep quality as the night goes on
and will tend to make you wake up early. This is almost certainly a much greater risk factor for muscle pain than any benefit
you got from the alcohol. So moderation is critical: if you’re using alcohol to knock yourself out at night, you’re almost
certainly causing more trouble than you’re solving. BACK TO TEXT
Having a prominent website, and running my consultation service, I have had the opportunity to be in contact with a much
wider range of cases than I ever would have been exposed to in private practice. BACK TO TEXT
Over-the-top enthusiasm is a serious flaw in the book, then and now. It’s a serious flaw in nearly all writing about trigger point
therapy. It undermines medical acceptance of trigger points as a legitimate health concern, and it sets patients up for
disappointment. BACK TO TEXT
Case in point: sometime recently I spent a good ten minutes looking for and missing a trigger point in the tensor fasciae latae
muscle on the side of the hip. My client was chatting away happily, and I wasn’t getting all the verbal cues I needed from
him. I spent much of that ten minutes assuming that I was basically already there, until I finally got a word in edgewise and
asked him what he was feeling. To my mild horror, it turned out that I’d been barking up the wrong tree. That ten minutes
cost him $16, and it was basically completely useless except as “overhead” — more than the usual amount of paid fumbling
that is unavoidable in this kind of therapy. My goal as a therapist is to reduce that overhead as much as humanly possible,
but there are inevitably some incidents like this, time that is wasted in every other sense. BACK TO TEXT
Case in point: after no less than several years of working with a patient regularly, one day we stumbled upon a different
approach to her chronic pain that was distinctly more effective. She called me the next day and said, “Wow, that worked
better than usual.” That was a couple years ago, and we have been using the new approach ever since, consistently obtaining
much better results than anything we saw for the first few years. The innovation also led to direct and clear improvements in
her self-treatment methods, to the point where — hallelujah — she has stopped coming to see me regularly, and turns up only
once in a while for a little “extra help.” But it took me years of regular therapy to stumble on what is, in retrospect, a minor
adjustment in my technique that I could have tested at any point. I estimate that this client paid me something like $8,000 for
fumbling around with an approach that was wrong for her. BACK TO TEXT
Case in point: many times I have provided what I hope is helpful, expert guidance to patients as they try to work out the
problems in their life that may be contributing to chronic pain, whether it’s serious insomnia, or a nasty computer
workstation. Doubtless most of them would graciously credit me with providing valuable perspective and advice in this
endeavour — at least to my face. But I am aware of many who essentially did it all themselves, with only the slightest tweaks
and encouragement from me, and one in particular who really did not need me, but thought that he did. This was a young
man with a particularly uncomfortable work situation. From the start, I tried to encourage him to tackle the fairly obvious
problems on his own — really, how much help does someone need fixing their desk? — but he insisted on paying me to walk
him through it. His enthusiasm and determination was infectious, and for a few sessions I took his money and we had
animated, detailed conversations about ergonomics and self-care. But soon enough it felt like exploitation. Was I helping him?
Sure. Was it worth my fee for a young man earning barely more than minimum wage? Not even close. I “fired” him soon
after. BACK TO TEXT
Furlan AD, Giraldo M, Baskwill A, Irvin E, Imamura M. Massage for low-back pain. Cochrane Database Syst Rev. 2015
Sep;9:CD001929. PubMed #26329399.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Previous versions of this meta-analysis of massage therapy for back pain (Furlan 2002 and Furlan 2008) are among the most
cited scientific papers about massage therapy. This one is unlikely to wear that crown, because it has a pessimistic conclusion
— a change of tune from the optimism of the previous versions. In 2008, the authors concluded that “massage might be
beneficial.” In 2015, based on 25 studies instead of a thirteen, they wrote, “We have very little confidence that massage is an
effective treatment.” This is a reasonable change, considering that the evidence available is that they “judged the quality of
the evidence to be ‘low’ to ‘very low’, and the main reasons for downgrading the evidence were risk of bias and imprecision.”
Every study of this topic has serious flaws, even the biggest and most rigorous (eg Cherkin). The evidence is inconclusive at
best.
BACK TO TEXT
The Touch Research Institute has conducted about many dozens of small studies showing the positive effects of massage and
touch therapies on many conditions. It’s all a little too good to be true (or all true). I think the Touch Research Institute designs
studies in such a way that a positive spin on touch therapy is inevitable. For instance, many of their papers are particularly
afflicted by two statistical errors: confusing statistical and clinical significance (or just ignoring the difference when
convenient), and comparing the wrong things to arrive at so-called “significance.” Also, conclusions in the abstracts of these
papers are often so broadly stated as to be uninteresting: one of their studies concludes, for instance, that the subjects “report
satisfaction.” Satisfaction is not a meaningful outcome. People are often satisfied with snake oil — that doesn’t mean it works!
Some of these scientific papers seem more like press releases, produced by a professional association to promote the
profession of massage therapy. I no longer take TRI studies seriously. BACK TO TEXT
“Palpably active” is a problematic choice of words, because by definition an “active” trigger point is defined by what the patient
feels. So a trigger point might be palpable and active, but it can’t be palpably active. Hopefully just a writing problem and not a
comprehension problem, but it’s just one of many problems with this study. BACK TO TEXT
Hou CR, Tsai LC, Cheng KF, Chung KC, Hong CZ. Immediate effects of various physical therapeutic modalities on cervical
myofascial pain and trigger-point sensitivity. Arch Phys Med Rehabil. 2002;83(10):1406–1414. PubMed #12370877.
This paper reports that ischemic pressure can relieve the pain of myofascial trigger points in the neck, and that it is more
effective in combination with a variety of other treatments such as hot pack, active ROM (like Mobilize!), stretch with spray.
Unfortunately, it’s not a great experiment. Adjusting the conclusions to account for its several weaknesses, it really tells us
nothing except that brief bouts of pressure did suspiciously little to a bunch of putative trigger points.
This paper is discussed in detail in my trigger points book (paywall).
This experiment also involved tests several combinations of other therapies — like hot packs, TENS, and stretch and spray —
which was actually the main goal of the study, but I’ll focus just on their “stage 1” where they tested pressure alone, because
that’s the closest thing to a test of just massage. BACK TO TEXT
Gemmell H, Miller P, Nordstrom H. Immediate effect of ischaemic compression and trigger point pressure release on neck pain
and upper trapezius trigger points: A randomised controlled trial. Clinical Chiropractic. 2008;11(1):30 – 36. PainSci #52943.
BACK TO TEXT
The rationale for the change is rather simplistic: they decided that depriving a trigger point of oxygen was counter-productive,
since in theory the trigger point is partly caused by a lack of oxygen in the first place. BACK TO TEXT
Gulick DT, Palombaro K, Lattanzi JB. Effect of ischemic pressure using a Backnobber II device on discomfort associated with
myofascial trigger points. Journal of Bodywork and Movement Therapies. 2011 Jul;15(3):319–25. PubMed #21665108.
PainSci #54988.
BACK TO TEXT
“The detection of MTrPs was accomplished via manually palpating for taut muscle bands in the upper and mid-back in a
double-blind process as per the procedure described by Sciotti et al.” As Sciotti et al wrote, “it should be recognized that the
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
ability to precisely document TrP location appears critical to the success of future studies.” (In their 2001 study, they
concluded that, using this method, “this study demonstrates that two trained examiners can reliably localize latent TrPs.”
However, this result has been cast into doubt by several other studies, as highlight by reviews like Rathbone et al . Of course.)
BACK TO TEXT
The rough threshold for clinical significance — for being enough to matter — is an improvement of a couple points on a 10point pain scale, which is about a 40% improvement (if you started in the middle of the scale, which is a fair if rough basis for
comparison). So that 38% improvement in pressure tolerance is somewhere around the threshold of clinically significance.
Neither bad nor good. BACK TO TEXT
It was paid for by a company that makes and sells massage tools, The Pressure Positive Company. It’s a modest family
business, and I’ve known them for years. This is a classic example of a conflict of interest driven entirely by sincere, earnest
interest in the subject — the same bias that can compromise science often comes from the same enthusiasm needed to pay for
it in the first place. BACK TO TEXT
Grieve R, Cranston A, Henderson A, et al. The immediate effect of triceps surae myofascial trigger point therapy on restricted
active ankle joint dorsiflexion in recreational runners: a crossover randomised controlled trial. J Bodyw Mov Ther. 2013
Oct;17(4):453–61. PubMed #24139003. BACK TO TEXT
Morikawa Y, Takamoto K, Nishimaru H, et al. Compression at Myofascial Trigger Point on Chronic Neck Pain Provides Pain
Relief through the Prefrontal Cortex and Autonomic Nervous System: A Pilot Study. Front Neurosci. 2017;11:186.
PubMed #28442987.
PainSci #53617.
BACK TO TEXT
Hou 2002, op. cit. This paper was described in thoroughly in an earlier chapter and its findings largely dismissed due to
significant flaws. However, for whatever it’s worth, the study purports to show that “either low pressure (pain threshold) and
a long duration (90 seconds) or high pressure (the average of pain threshold and pain tolerance) and short duration (30
seconds)” resulted in “immediate pain relief and myofascial trigger point sensitivity suppression.” BACK TO TEXT
Speaking of my wife, bless her charming idiosyncrasies: she thinks that “Thumper” sounds displeasingly violent for a massage
tool, whereas most people seem to think of the Thumper of cute animated-character fame. (Still others imagine summoning
enormous sand worms.) BACK TO TEXT
Trials are scanty even for the most popular modalities in musculoskeletal medicine, and vibration for trigger points is almost
certainly too obscure to have ever been studied, and even if it was it would probably just some junky little trial with low
power and a risk of confirmation bias off the charts. BACK TO TEXT
Issurin VB, Liebermann DG, Tenenbaum G. Effect of vibratory stimulation training on maximal force and flexibility. J Sports
Sci. 1994 Dec;12(6):561–6. PubMed #7853452.
In this 1994 experiment, as described by Sands et al , gymnasts “used a vibrating ring suspended by a cable, in which the foot
of the subject was placed while they stretched forward over the raised leg, targeting the hamstrings. The resulting increase in
ROM was astonishing. These researchers demonstrated that vibration could enhance flexibility.” The results were replicated
by Sands et al in 2006, and Kinser et al in 2008.
BACK TO TEXT
Sands WA, McNeal JR, Stone MH, Russell EM, Jemni M. Flexibility enhancement with vibration: Acute and long-term. Med Sci
Sports Exerc. 2006 Apr;38(4):720–5. PubMed #16679989.
This experiment replicated the results of an intriguing 1994 experiment by Issurin et al . Ten highly trained gymnasts did
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
forward splits with or without vibration. They stretched to the point of discomfort for 4 minutes, alternating between each
leg, 10 seconds of stretching at a time. Flexibility immediately after stretching with vibration was dramatically greater; the
long-term results were less striking.
BACK TO TEXT
Kinser AM, Ramsey MW, O'Bryant HS, et al. Vibration and stretching effects on flexibility and explosive strength in young
gymnasts. Med Sci Sports Exerc. 2008 Jan;40(1):133–40. PubMed #18091012.
Replicates the findings of both Issurin and Sands — “simultaneous vibration and stretching may greatly increase flexibility,
while not altering explosive strength.”
BACK TO TEXT
When I pointed out to Cohen by email how silly this claim is, he replied, “In no way am I saying that the act of stretching itself
causes weight loss.” That’s technically true, but his book clearly suggests that stretching leads to weight loss — an indirect
cause instead of a direct one. Cohen insists, “When you stretch before you eat 2 things happen: (1) you release emotional
stress which may cause you to overeat; (2) you become more connected with your body and can sense it’s [sic] impending
fullness better therefore it’s harder to overeat.” What utter nonsense, in so many ways! I would estimate that those proposed
mechanisms could account for, on a good day with exactly the right person, maybe 5% of what’s involved in weight loss (as if
Cohen even knows! — weight loss science is mind-bogglingly complicated). It’s like claiming that cell phone usage leads to
weight loss because convenient communicating with your friends and family is stress relieving. Good grief. BACK TO TEXT
The KONG® toys are actually not particularly cheap. In fact, they are about the same price as the two expensive massage balls
that I negatively reviewed in the previous section — so what gives? For me, the difference is clear: first, I actually find
KONGs more useful; and, second, I would far rather buy a dog toy than give my money to companies who provide such poor
quality health care information. BACK TO TEXT
Mense S, Simons DG, Russell IJ. Muscle pain: understanding its nature, diagnosis and treatment. 1st hardcover ed. Lippincott
Williams & Wilkins; 2000. p213. “Clinically, it is often observed that with gentle, normal activity and in the absence of
perpetuating factors, an acute active trigger point may revert spontaneously to a latent state. BACK TO TEXT
Smeets RJ, Wade D, Hidding A, et al. The association of physical deconditioning and chronic low back pain: a hypothesisoriented systematic review. Disabil Rehabil. 2006 Jun;28(11):673–693. PubMed #16809211. BACK TO TEXT
Michaelson P, Holmberg D, Aasa B, Aasa U. High load lifting exercise and low load motor control exercises as interventions for
patients with mechanical low back pain: A randomized controlled trial with 24-month follow-up. J Rehabil Med. 2016
Apr;48(5):456–63. PubMed #27097785.
This study compared two therapeutic exercise strategies for back pain: high load lifting versus low load motor control
exercises. Each group of 35 subjects did a dozen sessions over eight weeks. Although 50-80% of subjects reported reduced
pain, there was no difference between the groups.
BACK TO TEXT
Schoenfeld BJ, Grgic J, Ogborn D, Krieger JW. Strength and hypertrophy adaptations between low- versus high-load resistance
training: A systematic review and meta-analysis. J Strength Cond Res. 2017 Aug. PubMed #28834797. PainSci #52976. BACK TO
TEXT
Lima LV, Abner TS, Sluka KA. Does exercise increase or decrease pain? Central mechanisms underlying these two phenomena.
J Physiol. 2017 Mar. PubMed #28369946. “Regular physical activity is recommended for treatment of chronic pain and its
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
effectiveness has been established in clinical trials for people with a variety of pain conditions. However, exercise can also
increase pain making participation in rehabilitation challenging for the person with pain.” BACK TO TEXT
Nikander R, Mälkiä E, Parkkari J, et al. Dose-Response Relationship of Specific Training to Reduce Chronic Neck Pain and
Disability. Med Sci Sports Exerc. 2006 Dec;38(12):2068–2074. PubMed #17146312.
Similar to Ylinen, researchers divided 180 female office workers with chronic neck pain into three groups: one group did
strength training, another did endurance training, and a third did nothing. They found that “both strength and endurance
training decreased perceived neck pain and disability.”
BACK TO TEXT
Ylinen J, Häkkinen A, Nykänen M, Kautiainen H, Takala EP. Neck muscle training in the treatment of chronic neck pain: a
three-year follow-up study. Europa Medicophysica. 2007 Jun;43(2):161–9. PubMed #17525699. BACK TO TEXT
Hubal MJ, Gordish-Dressman H, Thompson PD, et al. Variability in muscle size and strength gain after unilateral resistance
training. Med Sci Sports Exerc. 2005 Jun;37(6):964–972. PubMed #15947721.
This 2005 paper presents good evidence that there may be genetic differences between people that account for a surprisingly
wide range of responses to strength training. In a fascinating radio interview about the paper, co-author Dr. Eric Hoffman
says, “If we take two friends and enter them into a resistance training program, you could find that the one friend would trip
all their muscle strength, whereas we have cases in the study of the other friend who either gains no strength, and we have
some subjects that even lose a little strength.”
BACK TO TEXT
Most massage probably doesn’t increase circulation significantly! The right kind of massage can probably increase it a little, but
it’s still nothing compared to what exercise will do. See Does Massage Increase Circulation?. BACK TO TEXT
Wong B, McKeen J. The new manual for life. PD Publishing; 1998. BACK TO TEXT
One of the primary effects of fast deep breathing when you’re not exercising is reduced blood acidity (AKA increased alkalinity).
Respiration is largely driven by carbon dioxide production, which increases blood acidity. CO2 in the blood is directly
proportionate to plasma acidity: more CO, more acidity. Exhalation removes CO2 from the blood, and therefore reduces its
acidity. When we exercise, the reason we breathe hard is to get rid of an excess of CO2 and control our blood acidity (as well
as to get O2). If we’re producing excess CO2/acid when we’re exercising, breathing merely controls it and keeps acidity
comfortably within the normal range. But what happens when we breathe hard in the absence of excess CO2 production?
Blood acid levels actually drop quite low, to the edge of normal range or a bit beyond, because you are aggressively purging
CO2 when there wasn’t an excess to begin with. This is acute respiratory alkalosis. It’s not a big change on the pH scale, but
we are quite sensitive to changes in pH! Which is why it’s so tightly controlled in the first place. BACK TO TEXT
Yes, that’s right: hyperventilation is actually involved, and that’s okay. Hyperventilation is perfectly safe in small doses, and it
may even have therapeutic biochemical effects in this context. If you get too light-headed, just back off and slow down and
you’ll be fine again quickly. More detail about this is provided in the full bioenergetic breathing article. BACK TO TEXT
Travell J, Simons D, Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Lippincott, Williams &
Wilkins; 1999. p147. “Available nonsteroidal anti-inflammatory drugs given orally afford little relief from pain originating in
central trigger points. However, they can be very helpful for alleviating the postinjection soreness that is likely to peak a day
or two after injection … . This alleviation reflects the fact that the tissue injury of needling induces an inflammatory reaction
that is fundamentally different from the pathophysiology within the trigger point itself.” BACK TO TEXT
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Primarily because many people are taking more acetaminophen than they realize, and because combining it with alcohol
greatly increases the risk — and a lot of people drink. For more information about the safety of acetaminophen, see
“Acetaminophen and Liver Injury: Q & A for Consumers” from the FDA. BACK TO TEXT
Such as Tylenol 2s and 3s, and several other brand names. Read your labels! BACK TO TEXT
Oral diclofenac is nasty stuff: it is associated with horrible cardiovascular risks and should probably be banned
(McGettigan et al ). But the dosage from topical use is much smaller and safer (How risky are NSAIDS?). BACK TO TEXT
Frost A. Diclofenac versus lidocaine as injection therapy in myofascial pain. Scand J Rheumatol. 1986;15(2):153–6.
PubMed #3749828. These researchers found that injecting an anti-inflammatory drug (dicloflenac, the very same stuff that’s in
Voltaren® Gel) into trigger points actually worked better than lidocaine, which is pretty neat when you consider that lidocaine
is an anaesthetic. Summarizing this study, Travell et al (p147) wrote, “When a nonsteroidal anti-inflammatory drug was
injected in high concentrations at the trigger point, its prostaglandin-suppressing action seemed to help relieve pain
originating from trigger points.” This is a great demonstration of that fact that trigger points probably have at least something
in common with inflammatory biochemistry, justifying the value of experimentation. BACK TO TEXT
CDC.gov [Internet]. Centers for Disease Control and Prevention. CDC Guideline for Prescribing Opioids for Chronic Pain; 2016
Apr [cited 16 Jun 22]. “Plainly stated, the risks of opioids are addiction and death, and the benefits for chronic pain are often
transient and generally unproven.” (CDC Director Tom Frieden, from March 2016 press briefing about the new guidelines).
The FDA quickly responded with “enhanced warnings” about the “risks of misuse, abuse, addiction, overdose and death.”
BACK TO TEXT
PSMag.com [Internet]. Gershon L. Five Studies: Understanding America’s Opioid Crisis; 2016 July 27 [cited 16 Jul 29]. BACK TO
TEXT
Tennant F. Why oral opioids may not be effective in a subset of chronic pain patients. Postgrad Med. 2016 Jan;128(1):18–22.
PubMed #26635137.
We tend to think of opioids as potent drugs that are going to make pretty much anyone high, and therefore probably provide
some pain relief … but there’s an incredible range of responses to drugs, even strong ones. This paper presents some specific
reasons why some people just aren’t much affected by (oral) opioids: “there is a group of intractable pain patients who do not
effectively metabolize oral opioids,” mainly because of gastrointestinal disorders and an inherited metabolic problem
(cytochrome P450 enzymatic defects).
BACK TO TEXT
The muscle relaxant properties of diazepam are produced via inhibition of polysynaptic pathways in the spinal cord. BACK TO
TEXT
There are two kinds of skeletal muscle relaxants: (1) the antispastic variety, for conditions such as cerebral palsy and multiple
sclerosis; and (2) the antispasmodic variety, for musculoskeletal conditions. Antispastic agents are not discussed here, as there
is no particular reason to think that they are helpful for musculoskeletal problems. BACK TO TEXT
Travell J, Simons D, Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Lippincott, Williams &
Wilkins; 1999. p147.
The rationale for the use of muscle relaxants has been based largely on the erroneous concept that muscle pain
causes spasm of the same muscle, which in turn causes more muscle pain. This pain-spasm-pain concept has
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
failed the test of experimental investigation, we see no rationale for muscle relaxants in the treatment of
myofascial pain caused by trigger points.
Often the increased muscle tension that is identified as “spasm” related to musculoskeletal pain is actually caused
by taut bands of trigger points. Muscle relaxants have no effect on muscle fibers that are in contracture because of
dysfunctional endplates.
BACK TO TEXT
I know a pharmacologist who asserts that there’s simply not enough methocarbamol to be significant in any of the popular
preparations (Robaxacet and Robax Platinum and all the other all that “Roba-this” and “Roba-that” drugs). In other words,
even if methocarbamol works, you’d need more of it that you can easily get — and more than you’d really want to take. As
the dosage increases, so do the side effects, and so does the extra and unwelcome acetaminophen in some preparations. So
don’t just take more. BACK TO TEXT
Khwaja SM, Minnerop M, Singer AJ. Comparison of ibuprofen, cyclobenzaprine or both in patients with acute cervical strain: a
randomized controlled trial. Canadian Journal of Emergency Medical Care. 2010 Jan;12(1):39–44. PubMed #20078917.
A new study in the Canadian Journal of Emergency Medical Care compared ibuprofen and a muscle relaxant (cyclobenzaprine or
Flexeril) for patients with serious soft-tissue injury in the neck. Groups of about 20 patients received one, the other, or both.
Results were statistically identical for all patients. This test showed no benefit to using or adding a muscle relaxant for acute
muscle strain in the neck. The study is too small to be powerful, but it certainly shows that there’s no strong advantage to
muscle relaxants in a situation where they are often assumed to be an important medication, and the results are consistent
with other research results.
BACK TO TEXT
See S, Ginzburg R. Choosing a skeletal muscle relaxant. Am Fam Physician. 2008 Aug;78(3):365–70. PubMed #18711953.
PainSci #55418.
ABSTRACT
Skeletal muscle relaxants are widely used in treating musculoskeletal conditions. However, evidence of their effectiveness consists
mainly of studies with poor methodologic design. In addition, these drugs have not been proven to be superior to acetaminophen or
nonsteroidal anti-inflammatory drugs for low back pain. Systematic reviews and meta-analyses support using skeletal muscle
relaxants for short-term relief of acute low back pain when nonsteroidal anti-inflammatory drugs or acetaminophen are not effective
or tolerated. Comparison studies have not shown one skeletal muscle relaxant to be superior to another. Cyclobenzaprine is the
most heavily studied and has been shown to be effective for various musculoskeletal conditions. The sedative properties of
tizanidine and cyclobenzaprine may benefit patients with insomnia caused by severe muscle spasms. Methocarbamol and
metaxalone are less sedating, although effectiveness evidence is limited. Adverse effects, particularly dizziness and drowsiness, are
consistently reported with all skeletal muscle relaxants. The potential adverse effects should be communicated clearly to the patient.
Because of limited comparable effectiveness data, choice of agent should be based on side-effect profile, patient preference, abuse
potential, and possible drug interactions.
BACK TO TEXT
Flaten MA, Simonsen T, Olsen H. Drug-related information generates placebo and nocebo responses that modify the drug
response. Psychosom Med. 1999;61(2):250–5. PubMed #10204979. BACK TO TEXT
It is a myth that muscles are paralyzed by anaesthesia and that surgeons have to be extremely careful not to dislocate joints.
There is still normal muscle tone with standard anasthesia, and in fact, “There is a constant battle to relax the muscles during
some procedures,” explains Dr. Steven Levin [in private correspondence]. “Maybe the newer anesthetics have more curarelike effects, but if they do, they would have to intubate every patient. If the patient is breathing on their own, they have
muscle tone! Sometimes, when fixing a fracture or repairing a ligament, the patient must be curarized.”
The curare poison is the only way to truly paralyze muscle for surgery, but it’s used sparingly and specifically: it’s not part of
normal anaesthesia, which only stops protective reflexes. “You have to be awfully insensitive not to know when you are
exceeding tissue limits,” Dr. Levin says.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Even a supposedly relaxed muscle shrinks about 20% when cut. The tone is mediated by the brain and spinal cord, which is
not affected by anaesthesia. Some believe there is some intrinsic regulation of tone — that is, the muscle sets its own tone —
but Dr. Levin directly refutes this with some pretty sound logic: “Curare works at the neuro-muscular synapse, so it is the
CNS that maintains the muscle tone, including the resting muscle tone (RMT). In my many years of doing surgery, I have
never cut a muscle that did not retract unless it was curare-ized (and even then there is some contraction), so the tone has to
be a primitive function, maybe some of it spinal, present even in deeply anesthetized creatures.” That’s from this page, a bit
hard on the eyes and heavy reading, but neat stuff.
BACK TO TEXT
Finnerup NB, Attal N, Haroutounian S, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and metaanalysis. Lancet Neurol. 2015 Feb;14(2):162–73. PubMed #25575710. PainSci #53440. “ … a weak recommendation for use and
proposal as second line for lidocaine patches.” BACK TO TEXT
Affaitati G, Fabrizio A, Savini A, et al. A randomized, controlled study comparing a lidocaine patch, a placebo patch, and
anesthetic injection for treatment of trigger points in patients with myofascial pain syndrome: evaluation of pain and somatic
pain thresholds. Clin Ther. 2009 Apr;31(4):705–20. PubMed #19446144. BACK TO TEXT
Lin YC, Kuan TS, Hsieh PC, et al. Therapeutic effects of lidocaine patch on myofascial pain syndrome of the upper trapezius: a
randomized, double-blind, placebo-controlled study. Am J Phys Med Rehabil. 2012 Oct;91(10):871–82. PubMed #22854911. BACK
TO TEXT
Firmani M, Miralles R, Casassus R. Effect of lidocaine patches on upper trapezius EMG activity and pain intensity in patients
with myofascial trigger points: A randomized clinical study. Acta Odontol Scand. 2015 Apr;73(3):210–8. PubMed #25428627.
BACK TO TEXT
See the section, Pain in three flavours: the good, the bad, and the ugly. And see the article, Massage Therapy Side Effects: What
could possibly go wrong with massage? The risks and side effects of massage therapy are usually mild, but “deep tissue”
massage can cause trouble. And see below — quite an interesting example is coming up. BACK TO TEXT
Lai MY, Yang SP, Chao Y, Lee PC, Lee SD. Fever with acute renal failure due to body massage-induced rhabdomyolysis.
Journal of Nephrology, Dialysis and Transplantation. 2006 Jan;21(1):233–4. PubMed #16204282. PainSci #54301.
Interesting, short, and readable story of an elderly man who collapsed after an unusually strong massage.
BACK TO TEXT
Sadly, there are numerous disastrous examples of alternative health care “professionals” misinterpreting and minimizing
serious symptoms as a “healing crisis,” as in the recent British case in which a “detox” diet caused a woman serious brain
damage. BACK TO TEXT
The closer the new (aggravated) trigger point is to the old (relieved) trigger point, the more likely it is to seem like nothing has
really changed. This is hardly an unusual situation, because trigger points are often clustered together quite closely in a
region. It’s routine procedure for me to note the exact location of a patient’s primary trigger point, because the next time I see
that patient, there’s a pretty good chance that they are going to identify a new spot, very close by, as the new primary trigger
point — which they may or may not be able to tell apart from the old one! It’s important for me to be able to tell my patients
confidently, “This is not the same trigger point as last time. The one from last time isn’t very sensitive today. This new one
right next to it is now our top priority — which means progress!” BACK TO TEXT
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Trigger point therapy can be a trigger for vasovagal-syncope (fainting), with its associated prodrome of symptoms such as light
headedness, nausea, sweating, ringing in the ears, uncomfortable feeling in the heart, weakness and visual disturbances. For
instance, someone with a tendency to faint may be more likely to do so when getting blood drawn … or when they get a
strong massage. Such cases are usually fairly obvious. The patient often knows that they have a vasovagal-syncope
syndrome, and that pain, stress or fear are triggers: an unpleasant reaction to challenging therapy comes as no surprise at all.
If a patient isn’t clear why they fainted, then it’s still easy to discriminate it from a more serious problem, though a doctor
should become involved. Vasovagal syncope can seem dramatic, but it generally is milder than other reactions. These include
really nasty cases of dizziness, nausea and vomiting that might result from upper cervical instability or vertebral artery
“dissection” (VAD) — life-threatening complications of neck manipulations (as in chiropractic adjustments). BACK TO TEXT
Even people with upper cervical instability, patients who vomit or could even die if you move their neck incorrectly, can be
treated safely by a skilled therapist. BACK TO TEXT
It seems that way. People tend to feel stuck with whatever furniture their workplace provides. Sometimes they petition their
bosses for a better chair, and then give up when the answer is “No.” I even know of a case of an office where the boss refused
to replace a chair because the office chairs were fancy and fashionable and more functional chairs would have “ruined the
look of the office” for their design-conscious clientele. But the truth is, in most such circumstances, it’s possible and
worthwhile for employees to buy their own chairs! BACK TO TEXT
That may sound like a long time before you can earn your adhesion badge, but consider that a trigger point may well have
existed in stealth mode (latent) long before you knew about it — by the time it starts to bother you, it may well have been
around for several years already. BACK TO TEXT
People keep writing to me, “Tch tch, Paul, yoga is totally mainstream!” But I disagree. If you live in downtown Vancouver, it’s
certainly mainstream. Yes, you can buy yoga mats at Walmart. But I grew up in a small blue-collar town, and I can assure
you, yoga still seems veeeeery weird to a lot of folks who aren’t living in the throbbing urban centres of our civilization. And
there’s plenty of them who moved here not that long ago. Big Macs are mainstream. Yoga is not. BACK TO TEXT
Kundermann B, Spernal J, Huber MT, Krieg JC, Lautenbacher S. Sleep deprivation affects thermal pain thresholds but not
somatosensory thresholds in healthy volunteers. Psychosom Med. 2004;66(6):932–937. PubMed #15564360. BACK TO TEXT
Bennett RM, Jones J, Turk DC, Russell IJ, Matallana L. An internet survey of 2,596 people with fibromyalgia. BMC Musculoskelet
Disord. 2007;8:27. BACK TO TEXT
Alstadhaug K, Salvesen R, Bekkelund S. Insomnia and circadian variation of attacks in episodic migraine. Headache. 2007
Sep;47(8):1184–8. PubMed #17883523. BACK TO TEXT
Tang NK, Wright KJ, Salkovskis PM. Prevalence and correlates of clinical insomnia co-occurring with chronic back pain. J Sleep
Res. 2007;16(1):85–95. Although of course it may be low back pain that is keeping these people awake, in fact my clinical
experience suggests that this is by no means the case: chronic low back pain patients are often poor sleepers, and insomnia
may routinely precede episodes of pain! BACK TO TEXT
Moldofsky et al ’s sleep deprived subjects “reported more musculoskeletal symptoms” and “a significant increase in muscle
tenderness.” The same researchers repeated those results in a second study. In 1999 Lentz et al found in their sleep-deprived
subjects a whopping “24% decrease in musculoskeletal pain threshold.” Another sleep-deprivation study of nine men by
Onen et al showed that pain sensitivity increased 8% with a “sleep debt” of 40 hours (40 hours of lost sleep with no
opportunity to recover). BACK TO TEXT
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Onen SH, Alloui A, Gross A, Eschallier A, Dubray C. The effects of total sleep deprivation, selective sleep interruption and
sleep recovery on pain tolerance thresholds in healthy subjects. J Sleep Res. 2001;10(1):35–42. PubMed #11285053. BACK TO TEXT
Coren S. Sleep thieves: an eye-opening exploration into the science and mysteries of sleep. Simon & Schuster; 1997. UBC
scientist Stanley Coren takes the reader on an entertaining tour of the weird world of sleep ... and then sets about proving that
almost all of us are sleep-deprived, and paying for it with our health. Because of this book, I believe that sleep-deprivation is
probably a factor in most cases of chronic pain. Stanley Coren is an entertaining writer, a skilled science popularizer from my
own stomping grounds (Vancouver). Although he is better known for his books about the intelligence of dogs, this book
about sleep is just as much fun, and of particular interest to anyone who has ever suffered from insomnia or other sleep
disorders. It’s definitely not a self-help guide for insomniacs (see The Insomnia Guide for that), just a really interesting tour of
sleep science in general. BACK TO TEXT
Grundy PF, Roberts CJ. Does unequal leg length cause back pain? A case-control study. Lancet. 1984 Aug 4;2(8397):256–8.
PubMed #6146810.
This classic, elegant experiment found no connection between leg length and back pain. Like most of the really good science
experiments, it has that MythBusters attitude: “why don’t we just check that assumption?” Researchers measured leg lengths,
looking for differences in “lower limb length and other disproportion at or around the sacroiliac joints” and found no
association with low back pain. “Chronic back pain is thus unlikely to be part of the short-leg syndrome.” Other studies since
have backed this up, but this simple old paper remains a favourite.
BACK TO TEXT
Cooperstein R, Lucente M. Comparison of supine and prone methods of leg length inequality assessment. J Chiropr Med. 2017
Jun;16(2):103–110. PubMed #28559750. PainSci #52779.
Assessments of leg length are common, both with the patient lying down or standing. Either could be reliable, but in this test
they did not agree with each other. Two chiropractors with more than 30 years experience each assessed the same few dozen
patients, and agreement between their results when they felt confident in them was “perfectly nil.“ Despite the widespread
and confident use of each method, this test clearly suggests that at least one of them is unreliable, but it’s also entirely possible
that both of them are.
BACK TO TEXT
Grob D, Frauenfelder H, Mannion AF. The association between cervical spine curvature and neck pain. Eur Spine J.
2007;16(5):669–678. PubMed #17115202. PainSci #56033. BACK TO TEXT
Wolfe F, Clauw DJ, Fitzcharles MA, et al. Fibromyalgia criteria and severity scales for clinical and epidemiological studies: a
modification of the ACR Preliminary Diagnostic Criteria for Fibromyalgia. J Rheumatol. 2011 Jun;38(6):1113–22.
PubMed #21285161.
BACK TO TEXT
O'Connell NE, Wand BM, McAuley J, Marston L, Moseley GL. Interventions for treating pain and disability in adults with
complex regional pain syndrome. Cochrane Database Syst Rev. 2013;4:CD009416. PubMed #23633371. PainSci #54535. BACK TO
TEXT
Waring RH. Report on Absorption of magnesium sulfate (Epsom salts) across the skin. Unpublished. 2006. PainSci #56301.
Magnesium and sulfates in the blood were measured and found to be higher after people had Epsom salts baths. No
therapeutic effects were studied or claimed. The results seem straightforward. However, this study was never peer-reviewed
and published in a scientific journal or repeated by other scientists — it has only ever been available as a PDF from the
website of the Epsom Salt Council, an industry lobby group that is “Eager to let everyone know the benefits of our product …
to help spread the word about the wonder that is Epsom salt. You see, we're wild about this pure, time-tested mineral
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
compound and its dozens of uses.”
Despite the obvious potential for bias here, Waring told me in personal correspondence that her experiment was
straightforward and conducted independently.
BACK TO TEXT
I explain exactly why in detail in Why Drink Water After Massage? The idea of “toxins” is used to scare people into buying
“detoxification” snake oil — they are vague, profitable buzzwords. Exactly which toxins we’re talking about, or how they are
disposed of, is a perfect mystery to the people selling detox treatments. BACK TO TEXT
Schwellnus MP, Drew N, Collins M. Increased running speed and previous cramps rather than dehydration or serum sodium
changes predict exercise-associated muscle cramping: a prospective cohort study in 210 Ironman triathletes. Br J Sports Med.
2011 Jun;45(8):650–6. PubMed #21148567.
Blood samples from 210 Ironman triathletes were checked for electrolytes and other signs of hydration status. 43 had suffered
cramps. There was no significant differences between the crampers and the non-crampers in any of the pre-testing or posttesting. The shocking conclusion? Dehydration and electrolyte shortage don’t cause cramps — intense effort does. “The
results from this study add to the evidence that dehydration and altered serum electrolyte balance are not causes for EAMC.”
A nice myth-mangler of a study!
So, cramps are not trigger points, but it’s certainly possible that they have some biology in common. Trigger points do seem
an awful lot like tiny cramps! I would be surprised if trigger points were sensitive to hydration when cramps are not. BACK TO
TEXT
News.BBC.co.uk [Internet]. Jones M. Malaria advice ‘risks lives’: Some high street homeopaths claim they can prevent malaria, a
Newsnight investigation has found; 2006 [cited 12 Feb 19].
Secret filming revealed homeopaths were claiming their preparations could be used instead of anti-malarial drugs to protect
travellers in high risk areas such as sub-saharan Africa.
BACK TO TEXT
PS Ingraham. Homeopathy Schmomeopathy: Homeopathy is not a natural or herbal remedy: it’s a magical idea with no
possible basis in reality. PainScience.com. 1580 words. BACK TO TEXT
Note from Paul: as you will discover in the stretching section of this book, I am not confident that stretching is an important
treatment method. BACK TO TEXT
Di Stasi SL, Macleod TD, Winters JD, Binder-Macleod SA. Effects of Statins on Skeletal Muscle: A Perspective for Physical
Therapists. Phys Ther. 2010 Aug. PubMed #20688875. BACK TO TEXT
“Rhabdo” is a nasty but also very interesting condition. I discuss it in detail in Poisoned by Massage. BACK TO TEXT
Mammen AL. Statin-Associated Autoimmune Myopathy. N Engl J Med. 2016 Feb;374(7):664–9. PubMed #26886523.
BACK TO TEXT
Regarding classification, professionals should take a look at a great 2004 interview with Eliot A. Brinton, MD: “There are 4
interrelated terms for muscle problems that can occur with statins. Unfortunately, they are often confused even by healthcare
professionals … .” (Technical note: this document is freely available, but direct linking will hit a paywall. Medscape only
reveals the whole thing to people arriving from a Google search. Simply search for do a Google search for it to get around the
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
paywall.) BACK TO TEXT
Ganga HV, Slim HB, Thompson PD. A systematic review of statin-induced muscle problems in clinical trials. Am Heart J. 2014
Jul;168(1):6–15. PubMed #24952854.
In this review of several statin trials, only slightly more patients had pain on statins than without (placebo): just 12.7%,
compared to 12.4%. You could conclude from this data that there actually is no such thing as statin mylagia! But it probably
probably is a real phenomenon, which is highly plausible based on the existence of rarer but very severe side effects on
muscle (see Mammen or Statin Therapy). We don’t have very good data about it, it’s mostly not severe, and it’s hard to
distinguish from the “background noise” of many other common causes of musculoskeletal pain.
BACK TO TEXT
Gupta A, Thompson D, Whitehouse A, et al. Adverse events associated with unblinded, but not with blinded, statin therapy in
the Anglo-Scandinavian Cardiac Outcomes Trial-Lipid-Lowering Arm (ASCOT-LLA): a randomised double-blind placebocontrolled trial and its non-randomised non-blind extension phase. Lancet. 2017 Jun;389(10088):2473–2481. PubMed #28476288.
This study was designed to test the existence of the phenomenon of statin myalgia. Taking statins did not increase pain in
patients when they were unaware that they were taking them. This suggests that statin myalgia is something people get because
they are afraid of it, not because it’s a real side effect. As the authors concluded:
These analyses illustrate the so-called nocebo effect, with an excess rate of muscle-related AE reports only when
patients and their doctors were aware that statin therapy was being used and not when its use was blinded. These
results will help assure both physicians and patients that most AEs associated with statins are not causally related
to use of the drug and should help counter the adverse effect on public health of exaggerated claims about statinrelated side-effects .
BACK TO TEXT
Michalska-Kasiczak M, Sahebkar A, Mikhailidis DP, et al. Analysis of vitamin D levels in patients with and without statinassociated myalgia - a systematic review and meta-analysis of 7 studies with 2420 patients. Int J Cardiol. 2015 Jan;178:111–6.
PubMed #25464233.
BACK TO TEXT
Fda.gov [Internet]. U.S. Food and Drug Administration. Information on Bisphosphonates; 2008 Jan 7 [cited 10 Dec 13]. BACK TO
TEXT
Although a 2016 New England Journal of Medicine article made headlines debunking hype about a vitamin D deficiency
“pandemic,” even their estimates are “of concern”: 6% of the population, more than 1 in 20 people (see 2016). Walk down a
busy street in Canada — there’s more deficiency in the north — and you’ll pass someone vitamin D deficiency every few
seconds. And that’s the low estimate: other experts have declared that there is a pandemic of vitamin D deficiency (or at least
that it’s extremely common) even in otherwise completely healthy people. See 2007 and 2008. BACK TO TEXT
Tangpricha V, Khazai N. Vitamin D Deficiency and Related Disorders. eMedicine. 2009 Oct. PainSci #55038.
BACK TO TEXT
McCabe PS, Pye SR, Mc Beth J, et al. Low vitamin D and the risk of developing chronic widespread pain: results from the
European male ageing study. BMC Musculoskelet Disord. 2016 Jan;17:32. PubMed #26774507. PainSci #53693.
This study measured vitamin D levels in more than 2300 older European men in good health and then checked up on them a
few years later. If they had low vitamin D at the beginning, they were more likely to have chronic widespread pain later.
However, that connection got much weaker when they eliminated obese and depressed patients from consideration. Obesity
and depression are known, confirmed risk factors for chronic pain. The study concluded: “Low vitamin D is linked with the
new occurrence of chronic widespread pain, although this may be explained by underlying adverse health factors,
particularly obesity and depression.”
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
This study is one about a dozen others investigating a link between chronic pain and vitamin D deficiency, reviewed by
Hsiao et al . Notably, in most studies the link is clear even after adjusting for other factors.
BACK TO TEXT
McBeth J, Pye SR, O'Neill TW, et al. Musculoskeletal pain is associated with very low levels of vitamin D in men: results from
the European Male Ageing Study. Ann Rheum Dis. 2010 Aug;69(8):1448–52. PubMed #20498201.
This study found a modest but clear link between vitamin D deficiency and chronic pain. Researchers look at 3000 older men.
About 250 (8%) of them were suffering from chronic, widespread pain, and they had at least a 20% greater chance of having
low vitamin D, less than 15ng/ml — the low end of “enough” Vitamin D. A weaker connection was also found in men with
less pain. As with all studies like this, all it can tell us is that there is a connection, not what kind of connection: D deficiency
might cause pain, or it might just be another side effect of the real causes of pain. Nevertheless, this is one of the best studies
of its kind ever done, and the authors concluded: “These findings have implications at a population level for the long-term
health of individuals with musculoskeletal pain.”
BACK TO TEXT
Holick MF. Vitamin D deficiency: what a pain it is. Mayo Clin Proc. 2003 Dec;78(12):1457–9. PubMed #14661673.
PainSci #55029.
In this editorial for Mayo Clinic Proceedings, Holick explains that “Vitamin D deficiency causes muscle weakness and muscle
aches and pains in both children and adults.” In reference to Plotnikoff et al , who studied the relationship between D and pain
directly and produced quite dramatic data, “The association between nonspecific musculoskeletal pain and vitamin D
deficiency was suspected because of a higher prevalence of these symptoms during winter than summer. The study patients
ranged in age from 10 to 65 years, and all had symptoms of vitamin D deficiency. Of the more than 90% of patients who were
medically evaluated for persistent musculoskeletal pain 1 year or more before screening, none had been tested previously for
vitamin D deficiency.”
BACK TO TEXT
Plotnikoff GA, Quigley JM. Prevalence of severe hypovitaminosis D in patients with persistent, nonspecific musculoskeletal
pain. Mayo Clin Proc. 2003 Dec;78(12):1463–70. PubMed #14661675. PainSci #55011.
What is the prevalence of hypovitaminosis D in patients with nonspecific musculoskeletal pain syndrome? It’s quite striking,
according to this important 2003 paper. Researchers did a cross-sectional study of 150 patients to find out and concluded
(rather dramatically, emphasis mine) that “all patients with persistent, nonspecific musculoskeletal pain are at high risk for the
consequences of unrecognized and untreated severe hypovitaminosis D. This risk extends to those considered at low risk for
vitamin D deficiency: nonelderly, nonhousebound, or nonimmigrant persons of either sex.”
Even watered down, these results would be of considerable interest to pain patients.
BACK TO TEXT
Zittermann A. Vitamin D in preventive medicine: are we ignoring the evidence? Br J Nutr. 2003 May;89(5):552–72.
PubMed #12720576. “ … vitamin D insufficiency can lead to a disturbed muscle function.” BACK TO TEXT
Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, et al. Fall prevention with supplemental and active forms of vitamin D: a
meta-analysis of randomised controlled trials. BMJ. 2009;339:b3692. PubMed #19797342. PainSci #55598.
Can taking vitamin D prevent falls? Apparently so: these researchers set out to “test the efficacy of supplemental vitamin D …
in preventing falls among older individuals” and found that a “high dose” (700-1000 IU a day) actually reduced falling by a
whopping 19%. That’s quite a substantial effect! It’s also a rare example of research actually confirming that vitamin
supplementation does something helpful — most similar research in the last decade has come up quite empty-handed.
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
More to the point for PainScience.com: how does vitamin D reduce falls? The authors explain: “Vitamin D has direct effects on
muscle strength modulated by specific vitamin D receptors present in human muscle tissue.” Muscles like vitamin D, and “these
benefits translated into a reduction in falls.”
Fascinating.
BACK TO TEXT
Schreuder F, Bernsen RM, van der Wouden JC. Vitamin D supplementation for nonspecific musculoskeletal pain in nonWestern immigrants: a randomized controlled trial. Ann Fam Med. 2012;10(6):547–55. PubMed #23149532. PainSci #54533.
This test of the effect of Vitamin D supplementation on nonspecific chronic musculoskeletal pain showed that pain modestly
improved within 6 weeks. Musculoskeletal strength (stair climbing ability) also improved somewhat. See a thorough analysis
of this study by Dr. Steven Leavitt for Pain-Topics.org [defunct but preserved by archive.org]: “a most remarkable aspect of
this study is that, even though patients probably received fundamentally inadequate vitamin D supplementation and for a
relatively brief period of time, there were still strongly beneficial outcomes … significant enough to realize meaningful
differences in everyday clinical practice.”
BACK TO TEXT
Hathcock JN, Shao A, Vieth R, Heaney R. Risk assessment for vitamin D. Am J Clin Nutr. 2007 Jan;85(1):6–18.
PubMed #17209171.
PainSci #54804.
“A prevailing concern exists … regarding the potential for toxicity related to excessive vitamin D intakes.” However,
“Collectively, the absence of toxicity in trials conducted in healthy adults that used vitamin D dose > or = 250 microg/d (10,000
IU vitamin D3) supports the confident selection of this value as the UL.”
BACK TO TEXT
Heaney RP. Vitamin D: criteria for safety and efficacy. Nutr Rev. 2008 Oct;66(10 Suppl 2):S178–81. PubMed #18844846.
PainSci #54803.
How much Vitamin D supplementation is enough? How much is too much? “The input needed for efficacy, in addition to
typical food and cutaneous inputs, will usually be 1000-2000 IU/day” and “toxicity is associated only with excessive
supplemental intake (usually well above 20,000 IU/day).” This paragraph from the article on toxicity and safety is particularly
relevant:
Both the intoxication literature and the recent controlled dosing studies have been reanalyzed by Hathcock et al .
These authors show that essentially no cases of confirmed intoxication have been reported at serum 25(OH)D
levels below 500 nmol/L. Correspondingly, the oral intakes needed to produce such levels are in excess of 20,000
IU/day in otherwise healthy adults and, more usually, above 50,000 IU/day. These findings led Hathcock et al to
select 10,000 IU/day as the tolerable upper intake level (TUIL, or UL), with considerable confidence. It is likely
that a higher intake could be defended, but little good would be served by doing so, as 10,000 IU/day is
substantially more than is apparently needed for any recognized efficacy endpoint.
BACK TO TEXT
Vieth et al : “Reports about vitamin D inadequacies are presented straightforwardly, but, when it comes to discussing the intake
of vitamin D needed to correct the situation, outdated official recommendations for vitamin D are propagated by the public
media. This probably occurs because of restrictive editorial policies driven by concern about possible litigation if media were
to advise a ‘toxic’ intake greater than the UL. The unfortunate result is that there is minimal motivation for policy makers to
implement the relatively simple steps that could correct this nutrient deficiency.” BACK TO TEXT
Zittermann A. Vitamin D in preventive medicine: are we ignoring the evidence? Br J Nutr. 2003 May;89(5):552–72.
PubMed #12720576. “The oral dose necessary to achieve adequate serum 25(OH)D levels is probably much higher than the
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
current recommendations of 5-15 microg/d.” BACK TO TEXT
Heaney RP. Vitamin D in health and disease. Clin J Am Soc Nephrol. 2008 Sep;3(5):1535–41. PubMed #18525006.
PainSci #54800.
“The safest and most economical way to ensure adequate vitamin D status is to use oral dosing of native vitamin D,” and “the
safe upper intake level for vitamin D(3) is 10,000 IU/day.” More detail from the paper:
Vitamin D, particularly its active hormonal form, calcitriol, is a highly potent molecule, capable of producing
serious toxic effects, including death, at milligram intake levels. There is thus a healthy fear of the compound
relating in part to cases of sporadic poisoning (49) as well as to medical misadventure 70 yr ago, involving
administration of millions of units per day of the vitamin. Nevertheless, despite these appropriate concerns, there
is, in fact, a comfortable margin of safety between the intakes required for optimization of vitamin D status and
those associated with toxicity.
BACK TO TEXT
There is no question that excessive vitamin D can be dangerous, but it would take a lot to kill. Indeed, megadoses of 50,000
IU/day have failed to produce any sign of toxicity, and when supplement baron Gary Null overdosed on vitamin D in his
own contaminated product — talk about poetic justice — he was taking upwards of two million IU per day. That nearly killed
him, but it didn’t, and we’re talking about accidental dosing five hundred times higher than the Institute of Medicine’s upper
limit. BACK TO TEXT
Dommerholt J, Huijbregts P,Gerwin R. Nutritional and Metabolic Perpetuating Factors in Myofascial Pain; Ch. 3, pp 51-61, in
Myofascial Trigger Points: Pathophysiology and Evidence-Informed Diagnosis and Management. Sudbury, Massachusetts;
Jones and Bartlett; 2011. BACK TO TEXT
Lowe, JC. Thyroid status of 38 fibromyalgia patients: Implications for the etiology of fibromyalgia. Clinical Bulletin of
Myofascial Therapy 1996:2(1):36-40. BACK TO TEXT
Baskin HJ, Cobin RH, Duick DS, Gharib H, Guttler RB, Kaplan MM, Segal RL; American Association of Clinical
Endocrinologists medical guidelines for clinical practice for the evaluation and treatment of hyperthyroidism and
hypothyroidism. Endocr Pract 2002 Nov-Dec;8(6):457-69. BACK TO TEXT
Ortancil A, Sanli A, Eryuksel R, Basaran A, Ankarali H. Association between serum ferritin level and fibromyalgia syndrome.
European Journal of Clinical Nutrition 64, 308-12 (March 2010) | doi:10.1038/ejcn.2009.149 BACK TO TEXT
Conrad E MD, Iron Deficiency Anemia, eMedicine. Updated: Aug 4, 2009. BACK TO TEXT
Spanierman, C. Toxicity, Iron. emedicine.medscape.com. Accessed 8/23/10. ” BACK TO TEXT
Gerwin, R. A review of myofascial pain and fibromyalgia- factors that promote their persistence. Acupuncture in Medicine
2005;23(3):121-134. BACK TO TEXT
Mauro, GI et al. Vitamin B12 in low back pain: a randomized, double-blind, placebo-controlled study. European Review of
Medical Pharmacological Sciences 2000;(4):53-58. BACK TO TEXT
Ohl D, Quallich S. Clinical Hypogonadism and Androgen Replacement Therapy: An Overview: Testosterone Deficiency:
Hypogonadism. Urol Nurs. 2006;26(4):253-259,269. BACK TO TEXT
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Most likely as a consequence of the neurological symptoms of insomnia, depression and anxiety. BACK TO TEXT
Ogrinc K, Ruzik-Saljic e, Strle F. Clinical assessment of patients with suspected Lyme borreliosis. International Journal of
Medical Microbiology 2008;298(supplement 1):156-260. BACK TO TEXT
And in the (beautifully titled) post Fake disease, fake compassion, Dr. Peter Lipson writes:
In the area of chronic Lyme disease, there are all manner of Lyme “specialists” who dispense unproven and
dangerous treatments, the most common of which is long-term antibiotic therapy. This treatment can be very
lucrative, and quacks have encouraged their pigeons to form advocacy groups–cults, really–that reinforce their
false beliefs, encourage a sense of persecution, and continue to feed the coffers of crooked and misguided
practitioners.
So you have to dial up your “buyer beware” instincts to the maximum in this area. While there are clearly patients who suffer
long after a primary Lyme disease infection is over, I don’t think we know why, and it’s not clear that they are still actually
suffering from Lyme disease per se, or (more pertinently) that they can be treated by treating them as if they still have Lyme
disease. The attempt to do so certainly involves some guessing, and may well be futile, or even opportunistic (“fake
compassion,” as Dr. Lipson calls it). For more cogent and detailed skepticism on this topic, please click this link to Google for
Lyme disease on ScienceBasedMedicine.org. BACK TO TEXT
Choi CJ, Knutsen R, Oda K, Fraser GE, Knutsen SF. The association between incident self-reported fibromyalgia and
nonpsychiatric factors: 25-years follow-up of the Adventist Health Study. J Pain. 2010 Oct;11(10):994–1003. PubMed #20400378.
More smokers have fibromyalgia than non-smokers. The difference was statistically significant in a survey of more than 3000
women. BACK TO TEXT
Behrend C, Prasarn M, Coyne E, et al. Smoking Cessation Related to Improved Patient-Reported Pain Scores Following Spinal
Care. J Bone Joint Surg Am. 2012 Dec 5;94(23):2161–6. PubMed #23095839.
This study added to the pile of evidence that smoking is “associated with low back pain, intervertebral disc disease” along
with many other medical complications. Their conclusion, after studying the records of more than 5000 patients with “axial or
radicular pain from a spinal disorder,” was that there is a “need for smoking cessation programs for patients with a painful
spinal disorder.” Very likely both neck and back, of course.
BACK TO TEXT
Petre B, Torbey S, Griffith JW, et al. Smoking increases risk of pain chronification through shared corticostriatal circuitry.
Human brain mapping. 2014 Oct. PubMed #25307796.
The science here is a bit more complex than I usually deal with, but the punchline is simple enough: “We conclude that
smoking increases risk of transitioning to chronic back pain.”
BACK TO TEXT
Note from Paul: depends on the surgery! But, yes, basically I agree with that — it's disturbing how much back surgery is not
just unproven, but proven to be useless and dangerous. BACK TO TEXT
Berrueta L, Muskaj I, Olenich S, et al. Stretching Impacts Inflammation Resolution in Connective Tissue. J Cell Physiol. 2016
Jul;231(7):1621–7. PubMed #26588184. PainSci #52915. BACK TO TEXT
https://www.painscience.com/tutorials/trigger-points.php?id=3003958#sec_definition[07/10/2019 6:25:00 PM]
The Complete Guide to Trigger Points & Myofascial Pain (2019)
Langevin HM, Stevens-Tuttle D, Fox JR, et al. Ultrasound evidence of altered lumbar connective tissue structure in human
subjects with chronic low back pain. BMC Musculoskelet Disord. 2009 Dec;10:151. PubMed #19958536. PainSci #53554.
Researchers measured the thickness of lumbar connective tissues with ultrasound in 60 chronic low back pain patients and 47
health people. The fascia was about 25% thicker in people with back pain, which is quite a bit, and a surprising finding with
potentially major — but unknown — clinical significance. The authors suggest that it could be related to “genetic factors,
abnormal movement patterns and chronic inflammation.”
This observation has not been reproduced by other researchers, but a follow-up study in 2011 examined the flexibility of the
same tissue, and found it was about 20% less in back pain patients: see Langevin for more commentary on the implications of
both studies.
BACK TO TEXT
Mense S, Simons DG, Russell IJ. Muscle pain: understanding its nature, diagnosis and treatment. 1st hardcover ed. Lippincott
Williams & Wilkins; 2000. p. 253. BACK TO TEXT
All of this is still from Muscle Pain, on page 265. BACK TO TEXT
Mense S, Simons DG, Russell IJ. Muscle pain: understanding its nature, diagnosis and treatment. 1st hardcover ed. Lippincott
Williams & Wilkins; 2000. p. 265. BACK TO TEXT
You may have trouble believing this one, so here are the details: the traditional quadriceps stretch, which people often call the
“runner’s stretch,” does not actually stretch much muscle. It stretches only the small rectus femoris portion of the quadriceps,
because that’s the only part of the quadriceps that crosses the hip. Yep, that’s right: one of the most familiar of all stretches is
affecting only about 10% of the quadriceps muscle mass! The big underlying trio of vastus muscles is anatomically impossible
to stretch, because they only cross the knee, and it is impossible to bend the knee enough to elongate them significantly (the
hamstrings are in the way). The rectus femoris can only be stretched because hip extension can elongate it more than the rest
of the group. BACK TO TEXT
This is called the sensory theory of muscle extensibility, and it’s pretty recent scientific history that it’s become the “last theory
standing” to explain why stretching increases flexibility. For the science, see Weppler CH, Magnusson SP. Increasing muscle
extensibility: a matter of increasing length or modifying sensation? Phys Ther. 2010 Mar;90(3):438–49. PubMed #20075147.
PainSci #55283. . For a detailed discussion, see Quite a Stretch. BACK TO TEXT
Depending on where you live, your massage therapist may have had as much as 3000 hours (3 years full-time) of somewhat
scientific training (as we do here in my part of Canada), or as little as none at all — there are places where no training
whatsoever is necessary to hang out a shingle and call yourself a massage therapist! Even in places where the profession is
heavily regulated, there may be a thriving industry of less-trained therapi