Trigger Point Therapy
by Christine Craggs-Hinton
Most people with fibromyalgia will have heard about trigger points, but are not sure what to do about them – this is where I come in, I hope. Trigger points are tiny nodules in muscle fibres that send out ‘referred’ pain to different areas of the body. They can be caused by injury, muscle overuse, emotional stress, poor posture and poor general health. An individual with fibromyalgia will have numerous trigger points. In fact, trigger points are known to be a component of all pain syndromes, people with osteoarthritis, rheumatoid arthritis, spondylitis, spinal stenosis, sciatica and so on having them. People with ‘common back pain’, migraines, tennis elbow, frozen shoulder and carpal tunnel syndrome also have trigger points – in fact, trigger points are often the cause of this type of problem.
Once a trigger point is fixed into a muscle, it is fiercely unwilling to give up its hold. Indeed, trigger points are more likely to spread from one muscle to another, giving rise to a chronic pain situation. To the fingertips, trigger points may feel as small as a pinhead or, in rare cases, as large as a thumb knuckle. If your fingertips are not particularly sensitive and you are now wondering whether you will be able to locate your trigger points, don’t worry – you will know when you have hit one because it will hurt!
All trigger points are tender to light finger pressure, but ones that are active cause an involuntary twitch or jerk from the pain (Vecchiet, 1990). From a doctor’s perspective, the more intense the pain and the greater the twitch, the more likelihood there is of referred pain being present (Hong, 1997). A person experiencing referred pain from one or more trigger points has ‘myofascial pain syndrome’, from which many more people suffer than doctors are aware.
How trigger points arise
When sarcomeres, the microscopic components that pump blood through muscle fibres, become over-stimulated for reasons of stress, overuse and so on, they can stop being able to relax. As a consequence, blood flow in that region is greatly reduced and oxygen depravation and waste build-up occur. The affected muscle fibre sends out panic signals to the brain, and the brain responds by telling the individual to rest the muscle. However, the unfortunate result of rest in this instance is that the muscle shortens and become taut. Full lengthening of the muscle is soon impossible, causing restricted mobility. Muscle fatigue and decreased strength will naturally ensue.
The muscles that have been shortened and made taut by trigger points often pinch neighbouring nerves – and when a nerve is pinched, the electrical impulses carried along that nerve cause numbness, tingling or stabbing in the areas served by the nerve. A pinched nerve in the upper back or neck will cause numbness, tingling or stabbing in the arms and hands, whereas a pinched nerve in the lower back will cause the same sensations in the legs and feet.
Trigger points are capable of cascading from one muscle to another. For instance, if a woman felt pain from a trigger point in her shoulder, satellite trigger points could set up in the muscles in her arm and before long she would be aware of discomfort in her arm as well. In this way, a widespread chronic pain situation can arise.
On pressing a trigger point there will be pain, but trigger points also send out pain or discomfort to some other site, often quite far away. For example, a headache may not be the result of a problem in the head, but have been sent to the head by a trigger point in a muscle in the neck. Likewise, pain down one leg is likely to be caused by a trigger point in the lower back or buttocks. The trigger point is the pain generator, but the majority of the pain is felt somewhere else.
Referred trigger point pain is often a deep oppressive ache that occurs at rest or on movement, or both. In some cases, especially when nerve pain is present, the pain can be excruciating, often described as searing or stabbing. There may also be tingling and numbness. It’s unfortunate that many hours are often spent rubbing areas that are painful. If you are very lucky, you can make the pain abate for a short while, but rubbing referred pain sites will never stop the pain in its tracks. The only way to stop referred pain is to tackle the source – the trigger point.
Misdiagnosis of trigger points
Trigger points and the referred pain they cause are not discussed in medical school, as a result of which wrong diagnoses are often made. Mistaken diagnoses include tendonitis, bursitis, a ligament injury, disk problems and even arthritis. For as long as some doctors fail to recognize and treat trigger points, misdiagnoses will occur. Many GPs and orthopoedic surgeons know nothing of trigger points, and as trigger points don’t show up on X-rays or scans, the patient may be told there is nothing wrong with them and that nothing can be done.
The Deep Stroking Massage
While I feel bound to recommend professional trigger point massage first and foremost (from a physiotherapist trained in that skill), I have to say that combining it with self-treatment can improve its efficacy enormously. However, some of you may be unable to find a trained therapist and will have no choice but to self-treat. Others of you will prefer to try out self-treatment first of all.
Does trigger point massage hurt?
Because the trigger point is, in most people, very painful in itself, working it is bound to cause pain. However, many people say it’s a pleasant kind of pain, not at a level that would cause you to tense up. The electrical impulses you may feel as you massage a trigger point are neurological messages that are disrupting the feedback loop perpetuating the trigger point. Healing begins as a result of this disruption. Don’t be alarmed if you don’t feel electrical impulses, though. If you are carrying out the massage properly, the trigger point will begin to heal.
It is important that you don’t massage too heartily and too frequently, or you are likely to cause yourself more pain. Being too eager can not only bruise the skin, it can also bruise the deeper tissues. It’s understandable that you are tempted to start a little over-zealously, however. After all you can see a possible end to your pain. It often takes trial and error to discover how much pressure is required.
I would strongly advise that at first you tackle one trigger point at once, then you can monitor the results. Also, it is best to work on your worst trigger points first and gradually come to the less painful ones.
How long will it take to get rid of my pain?
It’s an unfortunate fact that trigger points that have been active for a number of years will have made pathways into the nervous system that reinforce and perpetuate the pain. It can, therefore, take a few months to resolve a long-standing problem. Even then, it is not reasonable to expect that the trigger points will never come back. Your knowledge of how to get rid of them should keep you on top of the problem, however.
When pain is still fairly new, trigger point massage can get rid of it very quickly – usually in two or three days. It is often the same with pain that is localized – in the jaw for example. Exactly how long a pain problem will take to resolve is up to you and your body. In the end, much depends on your ability to determine which is referred pain and which is the trigger point.
The massage technique
The best way to encourage a trigger point to relax is to give a brief massage across the trigger point nodule – or if you can’t feel the nodule, across that area of extreme tenderness – lasting no more than 15-20 seconds. The massage should be in the form of short one to one and a half inch (3-4 cm) strokes in one direction only, done at the rate of approximately one stroke per second. This action enables you to push out blood and lymph fluid, the latter containing accumulated waste products. It is important, also, to slide with the skin, rather than over the skin.
With a thin piece of cloth over your skin, try to make the strokes gradually deeper and deeper, pressing the nodule against the underlying bone. When you release your fingers (or knuckle, thumb or tool) after each stroke, fresh blood will flood into the area, carrying with it the revitalizing oxygen and nutrients of which it was starved. There is no particular direction in which you should stroke.
The amount of pressure you use will depend on the area you are treating. For example, the muscles of the back require more pressure than the muscles of the forearm. The pressure should be midway between painful and pleasurable – it ‘hurts so good’. If the sensations decrease, press harder. If that fails to bring the desired effect, you are likely to have slipped off the nodule and should try to relocate it.
If you have one or more trigger points that are more painful than pleasurable to work, don’t avoid doing so. You now have the knowledge to get rid of your pain. It would be a shame not to use it. Brave the pain for an initial deep stroke, then wait for ten seconds before continuing. This gives the endorphins, your body’s natural painkillers, time to start flowing, enabling the remaining strokes to be rather less painful. Being overly gentle is no good either. The stroke must be deep to release the knotted tissues. In other words, you have to cause yourself a certain amount of pain to be pain-free in the end.
When the technique is performed six to twelve times a day, the trigger point should release, upon which the referred pain will disappear. If the treatment fails, you are either being too aggressive or working on the wrong spot.
For areas in which you wish to use your fingertips, it is essential that fingernails are kept cut to the quick for the duration of the regime. If you use the pads of your fingers you will reap little reward as insufficient energy can be applied. You will also tire far more quickly.
Using a tool for massage is probably best, but there are areas in which tools are not appropriate. In order that your hands are safeguarded from injury, they should be supported in the following ways:
Using a massage tool