More On Myofascial Trigger Points (TrP’s)

Back in May of this year, I posted an article titled Trigger Points (TrP’s) In Detail and thought I would take it a step further by describing additional TrP’s that I learned about via the Precision Neural Mobilization seminar I attended. Before I list them however, please allow me to give you some other details.

1) TrP’s may be caused by several factors, including acute or chronic muscle overload, activation by other TrP’s, disease, psychological distress, homeostatic imbalances, direct trauma to the region, accident trauma, radiculopathy, and infections/health issues.

2) TrP’s form only in muscles—as a local contraction in a small number of muscle fibers located within in a larger muscle or muscle bundle. They can pull on tendons and ligaments associated with the muscle, which in turn, can cause pain deep within a joint where there are no muscles. They can also cause muscle weakness.

3) TrP referral patterns follow specific nerve pathways and have been readily mapped—thanks to Travell & Simons—to aid in the identification of pain. Many TrP’s have pain patterns that overlap, and some create reciprocal cyclic relationships.

4) A taut band in muscles containing TrP’s can feel like hard nodules. Upon palpation, a twitch response can often be felt; activateing the “all or nothing” response in a muscle that causes it to contract. Pressing on an affected muscle can often refer pain, and clusters of TrP’s are not uncommon in some in larger muscles (i.e. the gluteus group).

As promised, here is a list of TrP’s above and beyond what I gave you the last time; the first three being what was listed in my previous post…

  • Active – A TrP that causes a clinical pain complaint. It is always tender; prevents full lengthening of a muscle; weakens a muscle; activates a local twitch response when stimulated; direct compression refers patient-recognized pain that is generally in it’s pain reference zone. (Click here for a website that lists reference zones and pain referral patterns.)
  • Latent – A TrP that is clinically inactive with respect to spontaneous pain; painful only when palpated. It may have all other characteristics of an active TrP and always has a taut band that increases muscle tension and restricts range of motion (ROM).
  • Satellite – A TrP that is influenced neurogenically or mechanically by the activity of a key TrP.
  • Associated – A TrP in one muscle that develops in response to compensatory overload, a shortened position, or referred phenomena cause by TrP activity in another muscle. Satellite and secondary TrP’s are types of associated TrP’s.
  • Attachement – A TrP at the musculotendinous junction and/or at the osseous attachment of a muscle that identifies the enthesopathy caused by unrelieved tension, characteristic of the taut band that is produced by a central TrP.
  • Central – A TrP that is closely associated with dysfunctional end-plates and is located near the center of muscle fibers.
  • Key – A TrP responsible for activating one or more TrP’s.
  • Primary – A central TrP that is activated by acute or chronic overload, or repetitive overuse of a muscle in which it occurs, and was not activated as a result of TrP activity in another muscle.

The misdiagnosis of pain is the most important issue taken up by Travell and Simons. Referred pain from trigger points mimics the symptoms of a very long list of common maladies, but physicians, in weighing all the possible causes for a given condition, rarely consider a myofascial source. The study of trigger points has not historically been part of medical education. Travell and Simons hold that most of the common everyday pain is caused by myofascial trigger points and that ignorance of that basic concept could inevitably lead to false diagnoses and the ultimate failure to deal effectively with pain.

The above quote comes from a workbook titled The Trigger Point Therapy Workbook. With this book, you will learn about TrP’s and how to treat them; however, it is important for you to keep in mind that if your muscular-skeletal system is misaligned, other muscles are affected, which in my opinion, makes it hard to self-treat in a way that is more than just temporary. Every little bit helps though!

As always, I hope you find this information informative!

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“Neutral balance alignment is key to becoming pain free!”™ ~ Me

The QL: Another Player In Back Pain

In a previous post, I went over the psoas major and how it is a major player in back pain, so today I thought I would go over the QL—the quadratus lumborum, which is a common source of low back pain. Before I go on though, let’s go over the anatomy…

THE ANATOMY (per Tortora & Derrickson, 11th edition)
Origin: Iliac crest and iliolumbar ligament.
Insertion: Inferior border of 12th rib and first four lumbar vertebrae.
Action: Acting together, pull 12th ribs inferiorly during forced exhalation, fix 12th ribs to prevent their elevation during deep inhalation, and help extend lumbar portion of vertebral column; acting singly, laterally flex vertebral column, especially lumbar portion.
Innervation: Thoracic spinal nerve T12 and lumbar spinal nerves L1-L3 or L1-L4.

The QL is a very strong lateral flexor and lateral stabilizer of the trunk; working synergistically with the psoas—on the same side—in lateral stabilization. It also assists the multifidi, erector spinae, and serratus posterior inferior in extension.

So, how do you know when the QL could be influencing back pain? Well, here are a few indicators for treatment…

  • Persistent pain, even at rest
  • Back pain after a violent sneeze or cough
  • Great pain when turning from one side of the body to the other while in bed
  • Excruciating pain when laterally bending or during forward flexion
  • Pain when standing; however, putting bilateral pressure above both iliac crests lessens the pain
  • Hyperlordosis is present.

If you experience one or more of the aforementioned, there is a good chance the QL is a player in your back pain—low back, specifically.

As always, I hope you find this information to be informative!

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“Neutral balance alignment is key to becoming pain free!”™ ~ Me

Headaches And Pain… Oh, My!

For me, the pain associated with headaches could be debilitating at times. So much so, I would sometimes just want to crawl in bed and cry like a baby until I fell asleep; however, when I first experienced PNMT, I quickly realized that there were other options out there aside from mainstream treatments. More on that later!

Before I go over the different types of headaches though, I feel it’s important that I share some RED FLAGS that I learned through becoming certified in PNMT:

  • See a physician to have other possible causes ruled out if the headaches are a new occurrence—the number of serious problems that have headaches as a side-effect is numerous.
  • See if physician immediately if you have any other global health declines.
  • See a physician if you’ve had headaches in the past but they are different in frequency, intensity, and/or location.
  • See a physician if you’ve had headaches for a long time but now they are daily; accompanied by GI symptoms, restlessness, anxiety, irritability, memory problems, difficulty in intellectual concentration, and depression. This could be considered analgesic rebound; analgesic overuse being very common.

Now, onward with different types of headaches. I will include some bullet points and reference the clinical studies, which happens to be where I got most of my information from…

TENSION HEADACHES – In the U.S., these account for 1-4% of all emergency room visits and is the 9th most common reason for doctor visits; being the most common type of chronic recurring head pain. All ages are susceptible, but most are young adults. — Michelle Blanda, MD; Tension Headache Clinical Presentation

  • These are usually associated with a stressful event, poor posture, or depression; and are not aggravated by physical activity.
  • They are of moderate intensity but can have a throbbing quality, are bilateral, and usually present in the occipitofrontal region.
  • They typically last 30-minutes up to 7-days.
  • Muscular tightness or stiffness in the neck, occipital, and frontal regions is common.
  • Cervical muscles, when palpated, may be very tender.
  • Nausea or vomiting is not present.
  • Insomnia is present.
  • Often present upon rising or shortly thereafter.

MIGRAINE HEADACHES – This disorder is one of the most common complaints in medicine. In the U.S., more than 30 million people have one or more migraines per year. — Jasvinder Chawla, MD; Migraine Headache

  • They typically throb or pulsate.
  • The pain is initially unilateral (on one side) and localized to the Temporalis and Frontalis muscles, or over the eye, but can be felt anywhere around the head or neck.
  • The pain typically builds up over a 1- to 2-hour period and then slowly diffuses towards the back of the head.
  • They typically last 4-72 hours; usually subsiding gradually within a day, and after a period of sleep.
  • Intensity is moderate to severe and intensifies with movement or physical activity.
  • Light and sound sensitivity are very common.
  • Nausea occurs in about 80% of migraines; vomiting in about 50%.
  • Other interesting symptoms include:
    – About 60% of people reported prodrome (preheadache) symptoms hours to days prior to the migraine. Postdrome symptoms may persist for 24-hours after the headache.
    – Auras—which can be visual, sensory, motor, or any combination of these—usually develop over 5-20 minutes and lasts less than 60 minutes.

CLUSTER HEADACHES – In the U.S., it is estimated that 2-9% of migraine sufferers experience these, making it relatively uncommon compared to the classic migraine. This condition is more common in males than in females. — Lori K Sargeant, MD; Headache, Cluster

  • No aura exists like they do in migraines.
  • Sudden onset peaks in 10- to 15-minutes; duration lasts 10-minutes to 3-hours per episode; frequency may occur several times a day for 1- to 4-months.
  • Typically, 1-2 cluster periods are experienced per year; each lasting 2- to 3- months.
  • The pain associated with is described as severe; as if the eye is being pushed out.
  • They are often nocturnal—active at night.
  • Triggers in some patients include stress, allergens, and seasonal changes.
  • Alcohol and smoking induce attacks during a cluster but not during remission.
  • Risk factors include: male sex; older than 30-years; small amounts of alcohol; previous head trauma or surgery (occasionally).

CERVICOGENIC HEADACHES – The presence of these headaches in the general population is estimated to be between 0.4% and 2.5%; however, the prevalence is as high as 20% in pain management clinics. This condition is four times more common in women than in men. — David Biondi, DO; Cervicogenic Headache: A Review of Diagnostic and Treatment Strategies

  • This condition is a relatively common cause of chronic headaches that is often misdiagnosed or unrecognized; clinical features may mimic those commonly associated with other headache disorders, making this headache hard to distinguish.
  • They involve head pain that is referred from bony structures or soft-tissues of the neck; TrP’s are usually found in the suboccipital, cervical, and shoulder musculature.
  • These often develop after a head or neck injury, but may also occur in the absence of trauma.
  • They are typically described as a deep—or dull—pain that radiates from the occipital to parietal, temporal, frontal, and periorbital regions.
  • Sufferers will often have restricted cervical range of motion and altered neck posture.
  • Head pain can be triggered or reproduced by active neck movement.
  • Paresthesia and numbness over the occipital scalp are usually present.
  • Many sufferers overuse or become dependent on analgesics; medication, when used alone, does not generally provide substantial pain relief.

As stated earlier in this post, I have suffered from headaches for many years, but not so much over the past five years due to the powerful effects of PNMT. In fact, many of my clients have suffered from them as well—that is until I got my hands on them. 🙂

Believe it or not, muscle involvement—which is stated in some of the above mentioned headache descriptions—can be a huge contributing factor that is definitely worth looking in to. In fact, the SCM, Longus Colli, Trapezius, and the Suboccipital muscles are just a few examples that can mimic or refer headache-related pain. Also note that muscular-skeletal alignment is a key factor as rubbing where it hurts won’t solve the problem.

If this post strikes a cord with you, consider looking for a massage therapist as an alternative option for headache related pain-relief!

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“Neutral balance alignment is key to becoming pain free!”™ ~ Me

Self-Care (For Massage Therapists And Clients)

Copyright © 2009, by Doug Alexander

In my opinion, treating our own TrP’s is pretty difficult; however, it can offer some short-term relief until the issue of pain and dysfunction—caused by muscular-imbalances—is addressed as a whole, by a trained professional. I say this because I have my own issues and find it hard to help myself most of the time—and this is what I do for a living.

There are so many options out there on the World Wide Web… From stretching techniques to tools galore. But what works and what doesn’t? Unfortunately, I can not really answer that question, but I can offer up the following information based on my own experiences, and those of my clients after hearing their experience with the suggestions I have expressed over the years.

With that said, I would like to bring to your attention an Electronic Self Care Manual that was created by Doug Alexander and his team at TouchU, located in Ontario, Canada. I had the pleasure of somewhat-meeting Doug via e-mail a couple of years ago, and through corresponding with him, I luckily ended up with this awesome manual (the above image is just one page out of 73) at my finger tips; handing out particular portions to my clients as a professional courtesy. This manual happens to be full of great advice; including information on types of injuries, stretching exercises (yes, with pictures), breathing techniques, postural improvements, etc. This .pdf is available to both therapists and non-therapists. If you are not a client of mine, please contact TouchU directly for a copy. If you are a client of mine, there is no need to contact them directly as I have it readily available for you.

In regards to tools for self-care, one I highly recommend is the Original Backnobber II, made by The Pressure Positive Co. My husband, and every client I have recommended this to, loves it. I have several clients that even take it with them during business trips because it breaks down into two pieces, making it easy to put in their carry-on luggage. Another great tool from this company is the Knobble II. I have actually laid right on top of this as a way to address TrP’s that I have had in my back, shoulder blades, etc.

Well, folks… That’s all for now. This was a pretty short post, but I hope you still found the information informative!

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“Neutral balance alignment is key to becoming pain free!”™ ~ Me

Trigger Points (TrP’s) In Detail

You’ve heard the term “trigger point” or “knot”, but do you really know what it is? I find in my practice that many people do not have a full know-how, which is why I feel it’s important to go into detail with it here.

First and foremost, the term “myofascial trigger point” was coined by Dr. Janet Travell in 1942. If it wasn’t for her hard-work and dedication on the subject—followed by others as well (here is a brief history)—we may not have the awareness today regarding how TrP’s can cause referred musculoskeletal pain. Kudos to her and those who followed!

TrP’s are those highly sensitive areas within our muscles that hurt when touched; giving rise to specific sensations or symptoms. Technically speaking, they are hyperirritable spots in skeletal muscle that are associated with palpable nodules in taut bands of muscle fibers. At a cellular level, the individual “knot” is made up of sarcomeres that are extremely contracted, which produces heat and a local energy crisis for the tissue. Symptoms of this crisis can include referred sensations (i.e. pain, numbness, tingling, pins-and-needles, hot/cold, etc.), a local twitch response, decreased range of motion (ROM), pain on contraction against resistance, and weakness.

There are three types of TrP’s; active, latent, and satellite. How do we know which is which though? When a TrP is compressed, or pressure is applied to, certain characteristics will follow…

Active TrP’s actively refer pain locally or to another location in the body along nerve pathways. At rest, they are commonly known to radiate pain that is familiar to the original pain complaint.

Latent TrP’s may be tender when pressure is applied, but they do not cause pain at rest, and do not yet refer pain actively. They produce shortening of length and increased muscle tension.

Satellite TrP’s are active TrP’s that rely on another “key” TrP for their existence. Treating the “key” TrP will often resolve the satellite TrP by either changing it from active to latent, or get rid of it all together.

I find TrP’s to be fascinating and I wish more people were aware of them and how their referral patterns can be related to—or actually be the direct cause of—pain and dysfunction within our muscular-skeletal system. Because I have found that so many people are unaware of TrP referral patterns, I decided to include one example of more than 620 potential possibilities in human muscles. And considering so many people suffer from pain in and around the shoulder girdle, I thought I would show just one of the four TrP’s found in the Infraspinatus.


Infraspinatus - Thorax & Arm
Image copyright of Primal Pictures

NOTE: I personally added the TrP and referral pattern to this image. It is just an approximation. The “X” is where the actual TrP is and the black area is where it could hurt when pressed upon.

If you are interested in the image you see in this post, please visit Primal Pictures to check out their Award Winning software. I own the 3D Human Anatomy: Regional Version and it is awesome.

If you are interested in learning about TrP and their referral patterns, I highly recommend that you check out this flip-chart. I also own this and refer to it quite frequently in my practice.

In closing, the number of people that get misdiagnosed and/or undergo unnecessary, invasive, and expensive treatments and procedures for pain-relief—with less than stellar results—honestly amazes me. I’m not disregarding other medical professionals and treatment options out there by any means, just hoping that some day in the near future, certified Precision Neuromuscular Therapists will be one of the first lines of defense when it comes to pain and dysfunction caused by muscular-imbalances; TrP’s do play a huge role and that’s what we treat.

UPDATE as of 9/20/12: Here is another post with additional information related to TrP’s.

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“Neutral balance alignment is key to becoming pain free!”™ ~ Me