Not if you have it! Her pain was permanently relieved in three appointments. She was quite pleased, I can tell you! Just wanted to give you a quick update … my back has been absolutely fine.
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 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. 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 decent trigger point therapist has a pack of treatment successes like this.
Not that therapists are great judges of their own efficacy, 54 but where there is this much smoke… 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 about it. So much unnecessary suffering! Can a good enough massage therapist remove all trigger points in a session?
Or even less. The skill of a therapist is actually only one relatively minor factor among many that affect the success of massage therapy for trigger points — or any therapy, for any pain problem. Even the best therapists can be defeated by a no-win situation and factors beyond their control. For comparison, can a good enough dog trainer train any dog in a hour?
It depends on the situation. It depends, it depends, it depends. There are several common kinds of muscle pain, or pains that can seem like it: arthritis, medication side effects, exercise soreness, muscle tears, and the profound body aching caused by an infection like COVID Thanks to their medical obscurity and the half-baked science, trigger points are often the last thing to be considered.
There are some clues you can look for that will help you to feel more confident that, yes, this kind of muscle pain is the problem instead of something else, maybe something scarier. Almost everyone more or less knows what it feels like to have a muscle knot, so almost everyone has a head start in self-diagnosing trigger points. Continue reading this page immediately after purchase. See a complete table of contents below.
Most content on PainScience. This page is only one of a few big ones that have a price tag. There are also hundreds of free articles, including several about trigger points.
Book sales — over 69, since ? This is a tough number for anyone to audit, because my customer database is completely private and highly secure. This count is automatically updated once every day or two, and rounded down to the nearest It includes all individual and bundled books for sale on PainScience.
Paying in your own non-USD currency is always cheaper! My prices are set slightly lower than current exchange rates, but most cards charge extra for conversion.
Why so different? So I offer my customers prices converted at slightly better than the current rate. Payment unlocks access to more chapters of what is basically a huge webpage. There is no paper book — I only sell book-length online tutorials.
The design and technology of the book is ideal for reading on tablets and smart phones. You can also print the book on a home printer. Feel free to lend your tutorial: I do not impose silly lending limits like with most other ebooks. No complicated policies or rules, just the honour system!
You buy it, you can share it. You can also give it as a gift. Literally safer than a bank machine. Card info never touches my servers. To prevent fraud and help with order lookups. No legalese, just plain English. The e-boxed set is a bundle of all 10 book-length tutorials for sale on PainScience. Headache coming soon, fall of Most patients only need one book, because most patients have only one problem.
But the set is ideal for professionals, and some keen patients do want all of them, for the education, and for lending to friends and family. And, of course, you do get a substantial discount for the bulk purchase. But no rush—complete the set later, minus the price of any books already bought. More information and purchase options.
You can also keep reading more without buying. Here are some other free samples from the book, and other closely related articles on PainScience. But charts tend to put the focus on the wrong thing, and people need principles way more than they need diagrams. Probably not, but maybe! This is a very short version of my full review. I used to wonder why I even bothered to create this tutorial! Why not just recommend the Workbook? Delving into the nature of the beast — the science — is the strength of this tutorial.
But the Workbook has fallen behind the times on that score. The current edition still promises too much and neglects important new knowledge. This topic is too important for such neglect.
This tutorials offers a more realistic and balanced view of trigger point therapy, meets the challenge of difficult cases head on, and hard-nosed reviews of every possible treatment option. Which is quite a bit less than even a single appointment with someone who claims to do trigger point therapy. Every one of those points is the tip of an iceberg. But this summary should help give you a better sense of whether or not you want to learn more from this source.
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 remain nameless :. 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.
But certification of trigger point therapists is generally an amateurish and fragmented mess, with many businesses and organizations competing to be the standard. 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.
For instance, although professional associations are rarely of much interest to patients, they may provide directories of professionals to help patients find practitioners.
NAMTPT provides resources for both patients and professionals, such as a trigger point therapist directory just over therapists and a symptom checker.
The International Myopain Society IMS [PRO] — A nonprofit health professionals organization dedicated to the promotion of information about soft-tissue pain disorders like myofascial pain. A CPE educates clinical peers, patients, families, and caregivers on ways to relieve pain by the safest means possible.
ASPE training is not focused on muscle pain. They provide a directory of members and listings of pain clinics. 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. David G. Simons co-authored the famous big 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 although they seem to be primarily serving Europe. They maintain a decent bibliography of trigger point research. I have a friendly occasional correspondence with founder Dr. Testimonials on health care websites reek of quackery, so publishing them has always made me a bit queasy.
These are all genuine testimonials, mostly received by email. In many cases I withold or change names and identifying details. Just read his stuff. Your evidence based approach to pain is to be applauded. You have consolidated and correlated many things that I have previously read as a chaotic patchwork quilt in diverse places and provided valuable additional information and insight that I have not previously found.
I really appreciate all of the time and effort you have put into your work. I have had arthritis and a hip replacement, with all of the attending issues. My goal has been to seek the proper information to rationally and practically address this. Your work has given me better direction and clarity in understanding some of the body dynamics from an honest perspectice. Many thanks for your work with this. First of all thank you for what you do. I stumbled onto your site about six months ago and it has radically changed my perspective on myofascial pain and how I approach and treat patients.
In the 16 years I have been a licensed acupuncturist and the 20 before that as a certified massage therapist this is far and away the most useful and eye opening information I have ever come across. Thank you for your website, it is really a great resource. I have purchased 2 tutorials trigger points and PF. I also love the concept that you permanently update them and that we have permanent access.
I have never seen this concept anywhere else but I find it is really worth the money and better than a book, in the long run. That attests to your ability to write in a very engaging and easy-to-follow tone. Thank you for delivering information about trigger points and resulting pain in a manner that is understandable to the general public. Myofascial trigger points are considered to represent a pathogenic model of pain from diverse etiologies [ 23 ].
MTrPs, or muscle knots, are a type of electrically active, hyperirritable areas of muscle associated with contractile nodules and dysfunctional motor endplates [ 5 ]. Theoretically, a sensitive spot may be found anywhere in the skeletal muscle but is usually found near the motor endplates [ 3 , 5 , 17 , 18 , 24 ]. MTrP can be either active, causing painful disorders, or latent, causing pain only when stimulated [ 2 , 5 , 7 ]. Clinical identification is the most commonly used technique to locate MTrP, and both needle and surface electromyography have been described for research purposes [ 4 , 15 , 17 ].
Knowledge of the anatomical location of these structures is essential not only to provide a correct diagnosis but also for the sake of many therapeutic modalities including a direct approach of the affected area [ 1 , 3 , 5 , 6 , 9 , 17 , 21 , 25 , 26 ].
Several painful cervical and thoracic disorders are related to trigger points in the trapezius muscle, and misdiagnosis of these conditions is common when the putative responsible MTrPs are not adequately evaluated [ 6 ]. The trapezius muscle covers the posterior aspect of the neck and the superior part of the thorax and attaches the upper limb to the skull and vertebrae.
Its fibers are divided according to their orientation into superior, intermediate, and inferior fibers, each of which exhibits a different action. The superior fibers have their origin in the superior nuchal line and external occipital protuberance and reach the lateral portion of the clavicle. The intermediate fibers retract the scapula and originate from the spinous processes from the 7th cervical to the 3rd thoracic vertebrae and are inserted on the acromion.
These fibers represent the strongest portion of the muscle. The last portion, represented by the inferior fibers, depresses the scapula and lowers the shoulder. Its fibers have their origin in most thoracic spinous processes and are inserted along the spine of the scapula [ 27 , 28 ]. Seven MTrPs are related to the trapezius muscle [ 5 ]. Four points are located in the muscle belly of the trapezius: 1 the mid-portion of the superior margin, extending into the vertical fibers that reach the clavicle; 2 found caudally and laterally to the location of the first point, in the transverse fibers of the muscle; 3 the medial fibers near the inferior margin of the muscle; and 4 the central part of the muscle belly between the C7-T3 levels.
Two additional MTrPs are found on the tendinous insertion: 1 over the medial part of the spine on the scapula and 2 on the acromial insertion of the trapezius muscle. There is another MTrP superficially located on the posterior aspect of the middle part of the clavicle [ 9 ]. According to our findings, which coincides with what was published by Simons et al.
MTrP3 and MTrP5 were easier to identify in our cadavers; MTrP3 was located near the inferior border of the muscle in its inferior fibers of the muscle, showing two insertional points Figures 1 and 2 and MTrP5, as expected from its clinical pattern, was found in several different areas, but with three insertional points Figures 1 and 2 rather than only one insertional point as observed clinically, all belonging to the intermediate portion of the muscle. Despite the variations observed in points 3 and 5, it is possible that the clinical localization of the MTrP to a single area is due to the anatomical proximity of these different nervous entry points, thus resulting in somewhat overlapping electromyographic identification.
This anatomical study was, in accordance with our hypothesis, based on the dissection of adult cadavers to observe where branches of the spinal accessory nerve entered the muscle belly and whether there was a positive correlation with MTrP. The trapezius muscle has two additional MTrPs corresponding to its tendinous insertion and they can also be responsible for painful disorders, although there is no relation to the end motor plates. MTrP4 was found on the medial aspect of the spine of the scapula and MTrP6 on the acromion, both of which are sites of tendinous insertion of the trapezius muscle Figure 1.
The findings from this study reveal that the locations where the accessory nerve enters the belly and tendons of the trapezius muscle are the same locations of the MTrP that can be identified in this muscle. This might have a strong relation to the pathophysiology of the MPS and could also be useful when treating the condition. We believe that knowledge of the anatomical basis of MTrP is a cornerstone that will help provide a precise map for clinical applications related to certain painful disorders and that further investigation of trigger points in other muscles is needed.
The authors have no conflict of interests in the authorship or publication of this contribution with this paper. Bernardo Rodrigues Ayres contributed in bibliographical review, translating, and writing. Samir Omar Saleh contributed in dissection.
Mauro Andrade contributed in review and translation. Wu Tu Hsing contributed in conception and review. Alfredo Luiz Jacomo contributed in conception and review. All authors have read and approved the final version of the paper. This is an open access article distributed under the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Article of the Year Award: Outstanding research contributions of , as selected by our Chief Editors. Read the winning articles. Journal overview. Special Issues. Academic Editor: Li-Wei Chou. Received 10 Nov Accepted 25 Jan Published 24 Feb Abstract This study aimed to bring the trapezius muscle knowledge of the locations where the accessory nerve branches enter the muscle belly to reach the motor endplates and find myofascial trigger points MTrPs.
Introduction Myofascial pain syndrome MPS is the most frequent cause of chronic musculoskeletal pain [ 1 — 6 ], with estimates of world-wide prevalence ranging from 0.
Methods Twelve human adult cadavers 6 males and 6 females were dissected to expose the dorsal primary rami that innervate the trapezius muscle after branching off the spinal nerve. Results We observed in all of the cadavers that the nerve fibers reached the muscle and tendon in areas coincident with the clinical locations of MTrPs described by Simons [ 5 , 11 , 18 , 20 ]. Table 1. Figure 1. Observe on the left side that points 5 and 3 are regions that correspond to nerve insertional points.
The spots are painful on compression and can produce referred pain, referred tenderness, motor dysfunction, and autonomic phenomena. Trigger points are classified as being active or latent, depending on their clinical characteristics.
It is tender to palpation with a referred pain pattern that is similar to the patient's pain complaint. The pain is often described as spreading or radiating. It differentiates a trigger point from a tender point, which is associated with pain at the site of palpation only Table 1. Do not cause referred pain, but often cause a total body increase in pain sensitivity. A latent trigger point does not cause spontaneous pain, but may restrict movement or cause muscle weakness.
This response is elicited by a sudden change of pressure on the trigger point by needle penetration into the trigger point or by transverse snapping palpation of the trigger point across the direction of the taut band of muscle fibers. Thus, a classic trigger point is defined as the presence of discrete focal tenderness located in a palpable taut band of skeletal muscle, which produces both referred regional pain zone of reference and a local twitch response.
Trigger points help define myofascial pain syndromes. Tender points, by comparison, are associated with pain at the site of palpation only, are not associated with referred pain, and occur in the insertion zone of muscles, not in taut bands in the muscle belly.
Concomitantly, patients may also have trigger points with myofascial pain syndrome. Thus, these two pain syndromes may overlap in symptoms and be difficult to differentiate without a thorough examination by a skilled physician. There are several proposed histopathologic mechanisms to account for the development of trigger points and subsequent pain patterns, but scientific evidence is lacking.
Many researchers agree that acute trauma or repetitive microtrauma may lead to the development of a trigger point. Lack of exercise, prolonged poor posture, vitamin deficiencies, sleep disturbances, and joint problems may all predispose to the development of micro-trauma.
Examples of predisposing activities include holding a telephone receiver between the ear and shoulder to free arms; prolonged bending over a table; sitting in chairs with poor back support, improper height of arm rests or none at all; and moving boxes using improper body mechanics. Acute sports injuries caused by acute sprain or repetitive stress e.
Patients who have trigger points often report regional, persistent pain that usually results in a decreased range of motion of the muscle in question. Often, the muscles used to maintain body posture are affected, namely the muscles in the neck, shoulders, and pelvic girdle, including the upper trapezius, scalene, sternocleidomastoid, levator scapulae, and quadratus lumborum. It is reproducible and does not follow a dermatomal or nerve root distribution.
Patients report few systemic symptoms, and associated signs such as joint swelling and neurologic deficits are generally absent on physical examination. In the head and neck region, myofascial pain syndrome with trigger points can manifest as tension headache, tinnitus, temporomandibular joint pain, eye symptoms, and torticollis.
Trigger-point hypersensitivity in the gluteus maximus and gluteus medius often produces intense pain in the low back region. Palpation of a hypersensitive bundle or nodule of muscle fiber of harder than normal consistency is the physical finding most often associated with a trigger point. The commonly encountered locations of trigger points and their pain reference zones are consistent. Examples of the three directions in which trigger points Xs may refer pain red.
A Peripheral projection of pain from suboccipital and infraspinatus trigger points. B Mostly central projection of pain from biceps brachii trigger points with some pain in the region of the distal tendinous attachment of the muscle.
C Local pain from a trigger point in the serratus posterior inferior muscle. No laboratory test or imaging technique has been established for diagnosing trigger points.
Predisposing and perpetuating factors in chronic overuse or stress injury on muscles must be eliminated, if possible. Pharmacologic treatment of patients with chronic musculoskeletal pain includes analgesics and medications to induce sleep and relax muscles. Antidepressants, neuroleptics, or nonsteroidal anti-inflammatory drugs are often prescribed for these patients. Nonpharmacologic treatment modalities include acupuncture, osteopathic manual medicine techniques, massage, acupressure, ultrasonography, application of heat or ice, diathermy, transcutaneous electrical nerve stimulation, ethyl chloride Spray and Stretch technique, dry needling, and trigger-point injections with local anesthetic, saline, or steroid.
The long-term clinical efficacy of various therapies is not clear, because data that incorporate pre- and post-treatment assessments with control groups are not available. The Spray and Stretch technique involves passively stretching the target muscle while simultaneously applying dichlorodifluoromethane-trichloromonofluoromethane Fluori-Methane or ethyl chloride spray topically. Dichlorodifluoromethane-trichloromono-fluoromethane is a nontoxic, nonflammable vapor coolant spray that does not irritate the skin but is no longer commercially available for other purposes because of its effect in reducing the ozone layer.
However, its use is safer for both patient and physician than the original volatile vapor coolant, ethyl chloride. Ethyl chloride is a rapid-acting general anesthetic that becomes flammable and explosive when 4 to 15 percent of the vapor is mixed with air. The decision to treat trigger points by manual methods or by injection depends strongly on the training and skill of the physician as well as the nature of the trigger point itself. Furthermore, manual methods are indicated for patients who have an extreme fear of needles or when the trigger point is in the middle of a muscle belly not easily accessible by injection i.
However, manual methods are more likely to require several treatments and the benefits may not be as fully apparent for a day or two when compared with injection. While relatively few controlled studies on trigger-point injection have been conducted, trigger-point injection and dry needling of trigger points have become widely accepted. This therapeutic approach is one of the most effective treatment options available and is cited repeatedly as a way to achieve the best results.
Trigger-point injection is indicated for patients who have symptomatic active trigger points that produce a twitch response to pressure and create a pattern of referred pain. In comparative studies, 17 dry needling was found to be as effective as injecting an anesthetic solution such as procaine Novocain or lidocaine Xylocaine. Both dry needling and injection with 0. Postinjection soreness, a different entity than myofascial pain, often developed, especially after use of the dry needling technique.
Trigger-point injection can effectively inactivate trigger points and provide prompt, symptomatic relief. Table 2 10 , 18 outlines the necessary equipment for trigger-point injection. Contraindications to trigger-point injection are listed in Table 3 10 , 18 and possible complications are outlined in Table 4.
Lidocaine Xylocaine, 1 percent, without epinephrine or procaine Novocain, 1 percent. Information from references 10 and Pneumothorax; avoid pneumothorax complications by never aiming a needle at an intercostal space.
Hematoma formation; avoid by applying direct pressure for at least two minutes after injection. Increased bleeding tendencies should be explored before injection. Capillary hemorrhage augments postinjection soreness and leads to unsightly ecchymosis.
The patient should be placed in a comfortable or recumbent position to produce muscle relaxation. This is best achieved by positioning the patient in the prone or supine position. This positioning may also help the patient to avoid injury if he or she has a vasovagal reaction.
The choice of needle size depends on the location of the muscle being injected. The needle must be long enough to reach the contraction knots in the trigger point to disrupt them. A gauge, 1. For thick subcutaneous muscles such as the gluteus maximus or paraspinal muscles in persons who are not obese, a gauge, 2.
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