Myofascial Trigger Points – Inservice by Bridget Lavaveshkul, SPT – March 4, 2013
Introduction
Musculoskeletal disorders are the main cause of disability in the working-age population of the
United States affecting 10% of the population.
Dr. Janet Travell
Coined the term “Trigger Point” in 1942
Considered foremost expert on Trigger points; co-authored Myofascial Pain and Dysfunction:
The Trigger Point Manual with Dr. David Simmons
Definition of a trigger point: a hyperirritability in a taut band of muscle associated with a twitch
response and tenderness or referred pain upon manual examination
Active – TPs that cause pain at rest or with activity of the muscle
Latent – TPs that do not cause pain, but instead restrict ROM and weaken the muscle
Central TP – those occurring in the center/midpoint/belly of the muscle
Attachment TP – at or near where muscle attaches to bone
Referred pain is characterized as deep, aching, steady, rarely as burning
Problems with Movement
TPs can maintain muscle spasms, cause muscles to tire quickly, decrease coordination, distort
your perception when gauging the weight of objects, make muscles reluctant to stretch or
contract
Causes: trauma to muscle fibers, overuse, mechanical overload, postural faults, immobilization after
surgery, psychological stress, prolonged ischemia can cause muscle cell damage and initiate latent
TPs
Differential Diagnosis
Myofascial TPs
Peripheral muscular origin
Female to male ratio 1:1
Local or regional pain
Focal tenderness
Muscle feels tense (taut bands)
Restricted stretch ROM
Examination for MTrPs anywhere
Immediate response to MTrP injection
Fibromyalgia
CNS origin
Female to male ratio 4-9:1
Widespread, general pain
Widespread tenderness throughout
Muscle feels soft and doughy
Commonly hypermobile
Examination for prescribed tender points
Delayed response to MTrP injection
Myofascial pain syndrome is a chronic pain disorder defined as sensory, motor, and autonomic
symptoms that are caused by myofascial trigger points. Sensory disturbances include: dysesthesias,
hyperalgesia, and referred pain. Autonomic manifestations: coryza, lacrimation, salivation, changes in
skin temperature, sweating, proprioceptive disturbances, and erythema of the overlying skin.
How to Confirm TPs?
No laboratory test or imaging techniques are established for diagnosing TPs.
Research dealing with ultrasound, EMG, thermography, and muscle biopsy has been used.
Common Referral Diagnoses given when Trigger Points are Overlooked
Initial Dx
Likely TP source
Appendicitis
Migraine
Mid back pain
LPB
Frozen Shoulder
Lower rectus abdominus
Sternocleidomastoid, temporalis, posterior cervical
Upper rectus abdominis, thoracic paraspinals
Lower rectus abdominis, thoracolumbar paraspinals
Subscapularis
Subacromial Bursitis
Radiculopathy C6
Middle Deltoid
Pectoralis minor, scalene
Treatment Techniques
Trigger point injection
Local anesthetic which may or may not include a corticosteroid is injected at site of TP
Indicated for those who have symptomatic active TPs that produce a twitch response to
pressure and create pattern of referred pain.
Dry Needling
Same as trigger point injection, but without medication
Found to be just as effective as trigger point injection, however most often increased
soreness
Spray and Stretch
Helps to inactivate TPs, relieve muscle spasm, reduce referred pain
Passive stretch of target muscle while spraying Fluori-Methan or ethyl chloride topically
Drop in skin temp provides temporary anesthesia blocking spinal stretch reflex on pain
sensation, thus able to passively stretch muscle through normal ROM
Kostopoulos, D. Effect of topical aerosol skin refrigerant (Spray and Stretch technique) on
passive and active stretching.
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30 participants, found to be effective; able to achieve significant increase in AROM/PROM hip flexion,
also females achieved greater pre/post AROM than males
MANUAL TECHNIQUES
Trigger Point Release
Gentle persistent pressure against the palpable tissue barrier in the TP. The first increase in
tissue resistance felt is the “barrier.” This point is usually perceived as tender but not
painful. Pressure is maintained until clinician feels a release in muscle tension.
Effective for acute TPs (before pathologic changes) c goal to train patient to self-manage
pain and dysfunction
Hanten, W. et al. Effectiveness of a home program of ischemic pressure followed by
sustained stretch for treatment of myofascial trigger points.
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40 patients c TPs in upper back and neck utilized HEP of theracane and stretches vs active ROM
(control)
A home program, consisting of ischemic pressure and sustained stretching, was shown to be effective
in reducing TP sensitivity and pain intensity in individuals with neck and upper back pain.
Hidalgo-Lozano, A. et al. Changes in pain and pressure pain sensitivity after manual
treatment of active trigger points in patients with unilateral shoulder impingement: A case
series
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12 patients c unilateral shoulder impingent attended 4 sessions for 2 weeks. TP release and
neuromuscular intervention (longitudinal stroke c slow and painfree pressure)
Outcome measures: VAS, Pain pressure threshold levator scapulae, supraspinatus, infraspinatus, pec
major
This case series has shown that manual treatment of active muscle TrPs can help to reduce shoulder
pain and pressure sensitivity in shoulder impingement.
Limitations: small sample size, no control group
Strain/Counterstrain (SCS) [Positional Release Technique (PRT)]
Dr. Lawrence Jones, D.O., an osteopathic physician, first developed SCS/PRT in the 1950's
Muscles are passively placed in greatest comfort position. The resultant relaxation of tissue
leads to an improvement in vascular circulation and removal of the chemical mediators of
inflammation. It improves the function, relieves the tension and eases the musculoskeletal
pain
Therapist applies gradually increasing pressure to the MTrP until the sensation of pressure
becomes one of pressure and pain. Then moves pt into new position with less tension
resulting in a subjective reduction of pain of up to 75%
Kelencz, C. et al. Trapezius upper portion trigger points treatment purpose in positional
release therapy with electromyographic analysis
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6 patients aged 44-63 c upper trap tension
10 session 30 minutes each
Outcome measures: Mcgill pain questionnaire, EMG
The results demonstrated a progressive decrease of pain in each session. The tension was evaluated
by the EMG analysis; Tension decreased 31.86% on the right side and 43.38% on the left side
Okhovatian, F. Comparison between the immediate effect of manual pressure release and
strain/counterstrain techniques on latent trigger point of upper trapezius muscle
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66 participants c TPs in upper trap, outcomes: pain pressure threshold, VAS. Three groups: TP, SCS,
control (ultrasound)
TP release and SCS techniques are superior to sham ultrasound in immediately reducing pain in
patients with non-specific neck pain and upper trapezius, but manual TP technique is better than SCS
technique.
Several studies reported us of SCS in combination with other interventions for cervicothoracic
pain, lateral epicondylitis; chronic and acute conditions. Most research dealing c tender points.
Differences between
Local Tenderness
Location
Tender Points
Yes
somatic tissues: muscles,
ligaments, tendon, bone
Evoked Referred pain
No
Presence of taut band
No
Presence of autonomic
No
phenomena (jump sign or twitch response)
vs
Trigger Points
Yes
Muscle and/or its fascia
Yes
Yes
Yes
Active Release Technique (ART)
During active release therapy, the clinician applies a combination of deep digital tension at
the area of tenderness and the patient actively moves the tissue through the adhesion site
from a shortened to a lengthened position. Michael Leahy, DC, CCSP
The goal is to improve tissue function by reducing tissue stiffness, fibrosis, and/or adhesion
James W. George. The effects of active release technique on hamstring flexibility: a pilot
study
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20 healthy males
ART on origins and insertions of hamstrings and dorsal sacral ligament
Outcome Measure: sit and reach
Results: Mean score increased 8.3 cm
Limitations: small sample size included only young, healthy males; Measurements taken immediately
following the ART treatment; thus, how long the increased flexibility might last is unknown. no
comparative interventions included such as PNF or massage.
Scott D Howitt .Lateral epicondylosis: a case study of conservative care utilizing ART® and
rehabilitation
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51 year old, recreational tennis player
Treatment: 6x over 2 weeks with ART at common origin of extensor carpi radialis brevis/longus, and
supinator. 20 minutes IFC, 10 minutes ice
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A combination of soft tissue therapy, rehabilitation, and therapeutic allowed for the athletic patient to
return to play
Scott Howitt DC. The conservative treatment of Trigger Thumb using Graston Techniques
and Active Release Techniques
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Case study 42 y.o. 8 rx over 4 weeks of ART and Graston technique followed by ice and self-mobs to
thenar eminence and 1st digit.
Outcome measures: subjective pain rating, ROM
End of treatment, no pain and only slight irritation in capsule in forced full flexion
F/U 14 months after D/C no further complications, complete resolution, pre-injury status
Appears ART has a higher success rate with lateral epicondylitis, carpal tunnel, and overuse
syndromes.
I’ve worked the trigger points out, now what?
Long term goal of returning muscle to normal length and motor function
Warm up
Manual
Once trigger points are inactivated, utilize strengthening therex and stretching to help
increase ROM in pain free range
If the muscles are not returned to normal length, there is a greater likelihood the TPs will
reoccur.
Conclusion
Manual techniques such as traditional TP release, SCS/PRT, and ART have all been shown
to be safe and effective at treating TPs.
Used as an adjunct c other interventions can benefit our patients
Referral Pain Patterns and Trigger Point Diagrams
http://www.triggerpoints.net/
References
Davies, C., Simons, G., Davies, A. The Trigger Point Therapy Workbook: Your Self-Treatment Guide for
Pain Relief. New Harbingers Publications. 2004. 32-38.
George, J., Tunstall, A., Tepe, R., Skagg, C. The effects of active release technique on hamstring flexibility:
a pilot study. Journal of Manipulative and Physiological Therapeutics. 2006; 29: 224-227.
Hanten, W., Olson, S., Butts, N., Nowicki, A. Effectiveness of a home program of ischemic pressure
followed by sustained stretch for treatment of myofascial trigger points. Physical Therapy. 2000; 80:
997-1003.
Hidalgo-Lozano, A., Fernandez-de-las-Penas, C., Diaz-Rodriguez, L., Gonzalez-Iglesias, G., Palacios-Cena,
D., Arroyo-Morales, M. Changes in pain and pressure pain sensitivity after manual treatment of active
trigger points in patients with unilateral shoulder impingement: a case series. Journal of Bodywork and
Movement Therapies. 2011; 15: 399-404.
Hong, CZ. Lidocaine injection versus dry needling to myofascial trigger points. The importance of the
local twitch response. Am J Phys Med Rehabil. 1994; 73: 256-63.
Howitt, S. Lateral epicondylosis: a case study of conservative care utilizing ART and rehabilitation. J Can
Chiropr Assoc 2006; 50(3). 182-189.
Howitt, S., Wong, J., Zabukovec, S. The conservative treatment of trigger thumb using Graston
Techniques and active release technique. J Can Chiropr Assoc 2006; 50(4). 249-254.
Huguenin, L. Myofascial trigger points: the current evidence. Physical Therapy in Sport. 2004; 5: 2-12.
Kelencz, C., Tarini, V., Amorim, C. Trapezius upper portion trigger points treatment purpose in
positional release therapy with electromyographic analysis.
Kostopoulos, D., Rizopoulos, K. Effect of topical aerosol skin refrigerant (spray and stretch technique)
on passive and active stretching. Journal of Bodywork and Movement Therapies. 2008. 12;2: 96-104.
Okhovatian, F., Mehdikhani R., Naimi, S. Comparison between the immediate effect of manual pressure
release and strain/conunterstrain techniques on latent trigger point of upper trapezius muscle. Clinical
Chiropractic. 2012. 15;2: 55-61.
Simons, D., Travell, J., Simons, L. Myosfasical Pain and Dysfunction 1: The Trigger Point Manual. Upper
Half of Body. Williams and Wilkin 1999. 17, 21-23, 31-44.