Trigger Points and Referred Pain
A Quick Technical Overview
According to Doctors Janet Travell and David Simons in their widely acclaimed medical textbook, Myofascial Pain and Dysfunction: The Trigger Point Manual, myofascial trigger points are tiny contraction knots that develop in a muscle when it is injured or overworked.
The Physiology of a Trigger Point
The part of a muscle fiber that actually does the contracting is a microscopic unit called a sarcomere. Contraction occurs in a sarcomere when its two parts come together and interlock like fingers.
Millions of sarcomeres have to contract in your muscles to make even the smallest movement. A trigger point exists when over stimulated sarcomeres are chemically prevented from releasing from their interlocked state.
A Microscopic View
The drawing is a representation of several muscle fibers within a trigger point. It’s based on a microscopic photograph of an actual trigger point.
This particular trigger point would cause a headache over your left eye and sometimes at the very top of your head.
Letter A is a muscle fiber in a normal resting state, neither stretched nor contracted. The distance between the short crossways lines (Z bands) within the fiber defines the length of the individual sarcomeres. The sarcomeres run lengthwise in the fiber, perpendicular to the Z bands.
Letter B is a knot in a muscle fiber consisting of a mass of sarcomeres in the state of maximum continuous contraction that characterizes a trigger point. The bulbous appearance of the contraction knot indicates how that segment of the muscle fiber has drawn up and become shorter and wider. The Z bands have been drawn much closer together.
Letter C is the part of the muscle fiber that extends from the contraction knot to the muscle’s attachment (to the breastbone in this case). Note the greater distance between the Z bands, which displays how the muscle fiber is being stretched by tension within the contraction knot. These overstretched segments of muscle fiber are what cause shortness and tightness in a muscle.
Normally, when a muscle is working, its sarcomeres act like tiny pumps, contracting and relaxing to circulate blood through the capillaries that supply their metabolic needs. When sarcomeres in a trigger point hold their contraction, blood flow essentially stops in the immediate area.
The resulting oxygen starvation and accumulation of the waste products of metabolism irritates the trigger point. The trigger point responds to this emergency by sending out pain signals.
Taken from Clair Davies Book
The Trigger Point Therapy Workbook.
The defining symptom of a trigger point is referred pain; that is, trigger points usually send their pain to some other site. This is an extremely misleading phenomenon and is the reason conventional treatments for pain so often fail. It’s a mistake to assume that the problem is at the place that hurts!
Travell and Simons’s research has shown that trigger points are the primary cause of pain 75% of the time and are at least a part of nearly every pain problem.
Trigger points cause headaches, neck and jaw pain, low back pain, tennis elbow, and carpal tunnel syndrome. They are the source of the pain in such joints as the shoulder, wrist, hip, knee, and ankle that is so often mistaken for arthritis, tendinitis, bursitis, or ligament injury.
Trigger points also cause symptoms as diverse as dizziness, earaches, sinusitis, nausea, heartburn, false heart pain, heart arrhythmia, genital pain, and numbness in the hands and feet. Even fibromyalgia may have its beginnings with myofascial trigger point.
Taken From Clair Davies Book.
The Trigger Point Therapy Workbook.
Millions of Canadians suffer from chronic pain. Surveys indicate over 18% of Canadians suffer from severe chronic pain. At any given moment, half of all Canadians will have experienced some kind of pain. A majority of Canadians experience head pain at least monthly.
People suffering from chronic pain do not receive adequate treatment. While over 70% of cancer patients experience moderate to severe pain during their illness, fewer than half receive adequate pain relief. A study at one large medical centre found that the majority of patients who were in moderate to severe pain were not even asked by their Doctors or nurses if they were having pain.
Pain is devastating to individuals and families. When pain persists at these levels, a person’s entire life becomes impacted. It becomes difficult to concentrate, to remember things, to perform routine tasks, to think about anything except the pain. Lost wages and medical costs are often financially devastating to many people. One of the most common reasons that people buy books on suicide and physician assisted suicide is the fear of living in severe intractable pain.
Pain is costly to society. The annual cost of chronic pain, including medical expenses, lost income, and lost productivity, but not the social costs, is estimated to exceed $10 billion.
Most pain is treatable. According to many experts, 90% of cancer pain can be relieved through relatively simple means. The truth is that fewer than half of cancer patients get adequate treatment for pain. A recent survey in the Medical Post indicated that 55% of physicians in Canada felt their peers were not doing enough to treat cancer pain.
Most pain is under treated. One recent study of chronic pain patients involved in litigation concluded that the overall rate of inaccurate or incomplete diagnosis at time of referral was 40% to 67 %. In a large survey of oncologists, 86% of respondents felt that the majority of patients with pain were under treated. Another study indicated that only 30% of practicing neurologists felt adequately trained to treat the entire spectrum of pain disorders. In general, the lack of medical training in pain management and the uneasiness of both healthcare providers and patients to deals with pain leads to widespread under treatment of both acute and chronic pain.
Most pain sufferers are under medicated. Although 91% of respondents in a recent survey believe prescription medication is effective in relieving pain, 2 out of 3 said that when they are in “fairly serious “pain they avoid taking pain medication until they really cannot bear the pain. Research clearly indicates this only serves to worsen the pain.
Pain is stigmatized by society. Patients and healthcare professionals are embarrassed about pain, reluctant to acknowledge and talk about it.
What is Fibromyalgia Syndrome?
Fibromyalgia Syndrome (FMS) means pain in the fibrous tissues of the body, such as muscles, tendons, and ligaments that last 3 months or more.
To receive the FMS diagnosis an individual must have undergone a tender point test and have at least 11 of 18 tender points that are found in the upper, lower, right and left sides, front and back.
Primary Fibromyalgia syndrome (FMS) is a form of Fibromyalgia where pain occurs in muscles, tendons, and ligaments throughout the body. The cause is not known. It is most common in young and middle-aged women, but can also be found in men, children, adolescents, and older adults.
Secondary Fibromyalgia is a form of Fibromyalgia that is caused by another disorder. It may also be associated with overuse or trauma to the muscles, such as that experienced following a motor vehicle accident. In secondary Fibromyalgia, the pain is often localized (it occurs in a specific area of the body). Men are more likely to have secondary Fibromyalgia than primary Fibromyalgia.
Concomitant Fibromyalgia is a form of Fibromyalgia that co-exists with another condition that causes muscle pain, such as arthritis, lupus or other diseases of the connective tissues
Recent Functional MRI studies have demonstrated objective findings that this is a neurological disorder of unknown cause. Many have speculated that FMS is a form of anxiety, depressive disorder or mental illness. None of these theories have been confirmed.
Anxiety and depression can occur as a result of the daily struggle. Trigger Point, can help those that sufferer FMS
From The Book Fibromyalgia & Chronic Myofascial Pain Syndrome. A Survival Manual.
Dr Devin Starlanyl and Mary Ellen Copeland M.S.,M,A.
FMS(fibromyalgia syndrome) Article.
Symptoms from fibromyalgia (FM) and myofascial trigger points (TrPs) are often the source of diagnostic confusion. This is compounded since many FM research articles have failed to take into account co-existing TrPs that may be contributing to or causing described symptoms. The sensitization of the central nervous system (CNS) that is part of FM can be initiated by many different things, such as infections, trauma, or a multitude of other stressors. There may be a genetic component that gives some of us a more easily rattled CNS. In others, the stressors are just too strong or last too long for their CNS to endure without sensitization. Pain from several TrPs or other peripheral sources, such as arthritis, can do this. Once central sensitization occurs, sleep, posture and dietary and exercise patterns are disrupted. Multiple biochemical responses may begin, leading to further imbalances in the body.
Localized pain is NOT part of FM. Trigger points are NOT part of FM. Myofascial pain is NOT part of FM. Some people have tried to “simplify” by lumping these conditions together, resulting in mass confusion. Perpetuating factors and many good treatment options have been missed, and needless testing and even surgical procedures have been performed. You have what you have, and you need to understand what that is so that you can get those things under control.
Many doctors and patients have mentioned difficulty discerning whether symptoms are due to FM or TrPs. Some symptoms may have components of both, or may be due to other causes, such as medication side-effects. Other chronic illness often has TrP and/or FM components. For example, many cases of arthritis may include treatable pain from TrPs, and even many symptoms of old age, such as stiffness and decreased range of motion, may be aggravated or even caused by TrPs and can be treated successfully.
TrPs are most commonly associated with specific referred pain patterns, and familiarity with the complete pain patterns is required for efficient diagnosis and treatment. While multiple muscle TrPs may cause or contribute to a symptom, the specific pain pattern helps to distinguish which TrPs are involved. There may be multiple TrPs, with overlapping pain and other symptom patterns. TrPs can cause many more symptoms besides (or instead of) pain. They can cause muscle dysfunction such as weakness and restriction of range of motion even before pain is noticed. In addition, they may be accompanied by autonomic symptoms such as sweating, goosebumps or blanching of the skin, by or proprioception symptoms such as inability to judge the weight of an object in the hand, or dizziness. Your teeth may bite the inside of your cheek or the tongue because one part of the body can’t tell where the others are in relation to it. The buccinator muscle (cheek and tongue biting) and genioglossus (tongue biting) TrPs can be especially associated with this. This can add insult to injury, or just add more injury. We stumble and fall over our feet, and we spill things and wind up wearing our food. We’re not clumsy. We are proprioceptively impaired. Here is a listing of some symptoms that can be caused by TrPs. It is not comprehensive, but will give you an idea of the trouble TrPs can cause and of the misery that could be relieved if they were adequately diagnosed and treated. If you already have multiple TrPs, check for more if a symptom occurs and the cause cannot be found. Always be sure that there are no organic causes. If a symptom recurs after treatment, either there are uncontrolled perpetuating factors, or the treatment is not properly done or adequate to the task. The same symptoms should not be treated again and again with the same therapy endlessly. This is a sign that there are perpetuating factors (including other TrPs) that must be discovered and brought under control if possible. TrPs can occur in any part of any muscle and in many layers of each muscle. Perpetuating factors often have their own perpetuating factors. For example, throat and nasopharyngeal TrPs may be aggravated by rhinitis and post nasal drip, which may be aggravated by allergies and TrPs in the pterygoid, etc. Each myofascial TrP has its own distinct referral pattern, but TrPs can occur in any place in any layer of any muscle, and also can occur in other tissues.
List of some confusing and often missed symptoms associated with TrPs:
Muscle contracture: sustained intrinsic muscle shortening (tension, tight muscle) in the absence of motor unit action potentials. This is different than shortening due to spasm or fibrosis. It is the type caused by TrPs.
Some trapezius TrPs can cause steady burning or superficial burning feeling in their specific TrP patterns along the shoulder blade.
Burning, prickling or lightning-like jabbing pain can come from TrPs in scar tissue. The scars may be internal, such as those from surgery.
Difficulty breathing can be due to activation of any respiratory muscle TrPs, including TrPs in the diaphragm. These TrPs can cause air hunger, shortness of breath and/or panting respiration.
Sinus congestion may be caused by sternocleidomastoid TrPs.
Impotence can be caused by TrPs, especially those entrapping blood vessels and nerves.
Nausea may be due to abdominal TrPs and some back TrPs along the spine.
Dizziness can be caused by several TrPs, including sternocleidomastoid.
Heartburn/abdominal fullness/bloating/indigestion can be associated with upper abdominal external oblique and upper rectus abdominus paraxphoid TrPs.
Nasopharyngitis can be part of multiple head, neck and throat TrPs.
Vomiting can be caused by several abdominal TrPs.
Urinary incontinence/frequency/retention may be part of abdominal and pelvic TrPs. Suspect them in cases of bedwetting in older children, especially of the child has TrPs or “growing pains.”
Urinary frequency can belong to TrPs along upper rim of the pubis.
Ringing in the ears can be due to lateral pterygoid TrPs and/or deep masseter TrPs.
Restricted rotation of thoracic spine may be from intercostal TrPs.
Blurred vision and/or visual disturbance may stem from eye muscle TrPs, sternocleidomastoid TrPs; upper trapezius TrPs, and/or orbicularis oculi TrPs.
Deep “bone” pain can be due to deep paraspinal muscles.
“Visceral” abdominal pain can be caused by TrPs along the spinal column in the upper lumbar area.
Difficulty climbing stairs may be part of longissimus TrPs.
Diarrhea may be caused by TrPs in the lower abdominal area.
Diffuse abdominal/gynecological pain can come from TrPs in the right lower rectus abdominus or high adductor magnus.
Prostatitis-type pain may be due to intrapelvic or high adductor magnus TrPs.
Urinary sphincter muscle spasm/ bladder sensitivity may be associated with TrPs directly above pubis.
Cystitis-type pain may be due to TrPs in the low rectus abdominus.
Dyspepsia and abdominal pain can be caused by TrPs in abdominal muscles.
Feeling drunk: “a swimmin’ in the head,” and unintentional veering may be part of sternocleidomastoid TrPs, as may loss of coordination; balance disorder.
Gait disturbances, so that you cannot walk normally, may be part of gluteus minimus TrPs. Abnormal gait coordination and spatial disorientation may also be part of sternocleidomastoid TrPs. Loss of positional sense in walking may be due to TrPs in the piriformis and other short lateral rotators.
Inability to sit still due to pain is often part of gluteus maximus TrPs symptoms.
Stuffiness of ear: medial pterygoid TrPs.
Abdominal cramping/colic may be caused by TrPs in the lateral periumbilical area.
Dysmenorrhea may be caused by TrPs in the lower rectus abdominus halfway between umbilicus and symphysis pubis.
Cardiac arrhythmia can be associated with a pectoralis major TrP, between 5th and 6th ribs midway between nipple and sternum right side.
Heart attack type pain (can include pain referral down left arm) may be due to TrPs in the pectoralis major and/or sternalis.
Edema of breast may be caused by lymphatic entrapment by pectoralis major TrPs.
Nipple hypersensitivity/ intolerance to clothing may be due to TrPs in the pectoralis major.
Restriction of jaw opening may be due to many TrPs. The zygomaticus major alone may cause restriction of the opening by 10-20 mm.
Pharynx and throat pain may be caused by multiple facial and neck TrPs
Mouth pain, including tongue, pharynx and hard palate, may be caused by medial pterygoid TrPs.
Eye redness or swelling may be caused by sternocleidomastoid TrPs.
Gallbladder-type pain may be caused by TrPs in the oblique abdominals/lateral border rectus abdominus.
Appendicitis-like pain may be caused by TrPs in the iliopsoas, iliocostalis thoracis, and right rectus abdominus McBurney point TrP, rectus abdominus directly above umbilicus, or costal external oblique.
A lax, pendulous abdomen with gas is associated with TrPs in abdominal muscles.
Hyperasthesia/dysthesia/hypoesthesia in the cutaneous back may be due to paraspinal TrP nerve entrapment.
Renal colic-like referred pain to the loin, inguinal and scrotal regions may be caused by erector spinae TrPs.
Retraction of testicle may be due to TrPs in the erector spinae.
Testicle pain may be due to lower lateral abdominal wall TrPs.
Toothache pain may be due to sternocleidomastoid, trapezius, masseter, or temporalis TrPs. This may include tooth cold and pressure sensitivity.
Sore throat and/or painful swallowing may be due to TrPs in the medial pterygoid, digastric, mylohyoid, stylohyoid or crico-arytenoid muscles.
TMJ pain may be caused by TrPs in the lateral pterygoid or deep masseter.
Stitch in the side may be due to TrPs in the serratus anterior and/or external oblique.
Elevated first rib may be caused by TrPs in the anterior scalene. This can cause or contribute to costoclavicular syndrome.
Carpal tunnel pain may be caused by TrPs in the subscapularis.
Illegible handwriting and clumsy fingers; inability to button buttons, sew, paint or anything that can require a steady grip, weeder’s thumb” may be due to TrPs in the adductor and opponens pollicis or interosseous.
Foot slap gait irregularity may be caused by the long extensors of toes.
Difficulty raising arms above head may be caused by many TrPs including supraspinatus, biceps brachii and subscapularis.
Locked kneecap may be caused by TrPs in the vastus lateralis.
Buckling hip may be caused by a combination of TrPs in the rectus femoris and high vastus intermedius.
Buckling knee may be due to vastus medialis TrPs.
Buckling ankle may be due to peroneus TrPs.
Remember, if you already have TrPs and one or more of these symptoms develop, look for the pattern. TrPs can cause or contribute to so many symptoms — not just pain. If you have localized pain in specific patterns or a number of these symptoms, think about TrPs. Try to find someone who can assess you for myofascial pain. Please help to teach others about this common but often misdiagnosed condition.
Taken from artical by Dr Devin.J.Starlanyl.
from The Trigger Point Therapy Workbook
Janet G. Travell, MD (1901-1997)
Among those who recognize the reality and importance of myofascial pain, Janet Travell is generally recognized as the leading pioneer in its diagnosis and treatment. Few would deny that she single-handedly created this branch of medicine. Many would contend that it's the world’s great loss that her amazing career was not crowned with the recognition that would have come with a Nobel Prize.
At the time the first volume of her book went to press in 1983, she had been studying and treating trigger points and referred pain for over forty years. She had already published more than forty articles about her research in medical journals, the first appearing in 1942. Her revolutionary concepts about pain have improved the lives of millions of people.
Trigger point massage, the most effective modality used by massage therapists for the relief of pain, is based almost entirely on Dr. Travell’s insights. The innovative clinical techniques for the treatment of pain that are beginning to be used by physicians and physical therapists all over the world wouldn’t have existed without Dr. Travell’s dedicated energy and intelligence.
Dr. Travell’s personal success with one particular patient had a far-reaching effect on history. Not many people remember that Janet Travell was the White House Physician during the Kennedy and Johnson administrations. President Kennedy honored her with that position in gratitude for her treatment of the debilitating myofascial pain and certain other ailments that in 1955 had threatened to prematurely end his political career. It’s a stunning example of how trigger point therapy can change someone’s life and destiny.
Although in her sixties at the end of her duties at the White House, Dr. Travell had no intention of retiring or even slowing down. She went on developing and teaching her methods with vigor and enthusiasm for the next thirty years. She was past eighty when the first volume of her grand opus, Myofascial Pain & Dysfunction: The Trigger Point Manual was published, and past ninety when the second volume appeared. She refused to rush into print: she wanted to get it right.
David G. Simons, MD (1922- 2010)
David Simons lends authority to the study of myofascial pain with his long experience as a research scientist. In his early career, Dr. Simons worked as an aerospace physician, developing improved methods of measuring physiological responses to the stress of weightlessness.
A fascinating sidelight to Dr. Simons’s career is the world altitude record for manned balloon flight he set in 1957 as a young Air Force Flight Surgeon. In point of fact, he beat Sputnik into space. He was featured on the cover of Life magazine that year and subsequently wrote a book, Man High, about his adventure.
Drs. Travell and Simons first met when she lectured about trigger points and myofascial pain at the Air Force’s School of Aerospace Medicine. Simons was so intrigued by Travell’s work that he eventually retired from the Air Force and began a long informal apprenticeship under her wing. An intense synergy developed between the two over the next twenty years, culminating at last in the production of The Trigger Point Manual, an inspiring testament to the transcendent power generated when two minds of uncommon intelligence work together.
Dr. Simons’s strict attention to detail and adherence to scientific method helped him bring rigorous objectivity to the documentation of myofascial pain. He was the driving force in getting the Travell and Simons books written, doing most of the actual writing himself, with Dr. Travell’s vast knowledge and experience as his primary resource. One day, when ordinary people know about trigger points and the diagnosis and treatment of myofascial pain is taught widely in medical schools, physicians everywhere will honor Doctor Simons, along with his mentor, Dr. Travell, as true medical pioneers.
Into his eighties now, David Simons is still hard at work promoting further research concerning trigger points. His latest book, Muscle Pain: Understanding its Nature, Diagnosis, and Treatment, with coauthor Doctor Siegfried Mense, seeks to impart a better understanding of the neurophysiology of muscles.