Trigger Point 101
Training hard comes with a price. That price is usually some sort of nagging pain or injury that we typically just assume will be with us for the rest of our lives.
“Oh yea, it’s just my bad shoulder. It always aches after I bench.” “You know how that knee is. There is usually a dull pain in there all the time.”
Oftentimes, these injuries can be alleviated by some soft tissue work and stretching. There are a variety of different types of soft tissue work including active release techniques (ART), myofasical release (MFR), and neuromuscular therapy (NMT). And the list goes on and on. I believe that all types of soft tissue work have their place, and what may be more important than seeking out a specific type of soft tissue work is just getting something done by a skilled therapist.
“Trigger point” is a term that gets thrown around by massage therapists, physical therapists, and chiropractors and has recently been making its way into the strength and conditioning world. Because people seem to be talking about trigger points more and more, I decided to give you a run down of exactly what a trigger point is, why we should care about them, and what we can do about them.
What is a trigger point?
While some may tell you that trigger points are tender areas in the muscle, this isn’t entirely true. One key characteristic of trigger points is that they are tender to touch. However, every tender area isn’t a trigger point. If an area of a muscle is just tender but doesn’t have the other characteristics of trigger points, the area is just a “tender point.” These tender points are areas of congestion where tissue may be ischemic (lacking blood flow) or fibrotic, or there may be a lot of scar tissue matted down in the particular area of stress.
Trigger points are areas of taunt, hypercontracted bands or nodules within a muscle. They’re tender to touch and have a predicted pain referral pattern. These hypercontracted nodules within the muscle are palpable and will often feel like little peas or semi-cooked spaghetti. For a visual example, take a look at this picture of some trigger points inside the sterocleidomastoid.
As you can see, there are a few small contracted nodules within the fibers that are at normal resting length. The trigger points can be either active or latent.
A latent trigger point means that it only sends its pain referral pattern when you touch it. For example, if you take a tennis ball and place it between your scapula and your spine, you may push into a trigger point in the rhomboids, which will give you this radiating or dull ache all over the upper back area. If you didn’t push into that area with the trigger point, you wouldn’t know it was there. This is a latent trigger point. It only refers when you press into it.
An active trigger point is one that is currently referring its myofasical pain response. A good example of this is if you’ve ever had a headache and pinched your upper traps. In doing so, you were able to produce your symptoms (i.e. the headache or that ache through the top of your head and behind your eyes). Congratulations! You found an active trigger point!
Trigger points usually can be found in clusters. So if you deactivate one (I’ll tell you how later), you have to search out and try to deactivate the others within that muscle. This may take some time and may be very intense, so you might want to do it over a few sessions.
Another thing to consider is that trigger points aren’t just located within the belly of the muscle. They can also be located in the tendonus attachment of the muscle, and some trigger point referral patterns have even been documented in the ligaments. A good example of this is the pain referral pattern for the sacrotuberous ligament, which refers a pain pattern down the back of the leg and into the calf (similar to what people may diagnose as or call sciatica). Another one is the pain referral pattern for the iliolumbar ligament, which can be felt in the groin or pain on the outside of the hip (what some may diagnose as or refer to as trochanteric bursitis).
What muscles can develop trigger points?
No man is safe! Any muscle can develop a trigger point, and there are several books documenting where these trigger point referral patterns are. Travell and Simons’ Myofasical Pain and Dysfunction: The Trigger Point Manual, Volume 1 (the upper extremity)and Myofasical Pain and Dysfunction: The Trigger Point Manual, Volume 2 (the lower extremity) are the most comprehensive and widely accepted books on the topic of trigger points.
Many times trigger points can be found in muscles that are antagonistic to muscles that are constantly contracted. An example of this is the infraspinatus. It’s always trying to exert an eccentric force on someone’s shoulder who sits at a desk all day, typing away in a chronically internally rotated position. After awhile, the infraspinatus gets tired and lengthens. However there are bands of that muscle that stay contracted (trigger points) to try and counteract the internal rotation force. Over time, these bands can present their pain referral pattern.
One of the pain referral patterns for the infraspinatus is the front of the shoulder where people will often say they received a diagnosis of bicipital tendonitis or impingement. It isn’t uncommon for someone to come to see me with pain in the front of his shoulder (near or around the biciptal groove) and say that they think they have impingement. Upon inspecting their infraspinatus, I can find the trigger points. When I push into them and ask how it feels and if he feels pain or sensation anywhere else, the person comments that he feels the pain in the front of his shoulders. It is the same pain that he feels throughout the day. On more than one occasion, I’ve deactivated trigger points in someone’s infraspinatus and he or she left totally pain free.
Trigger points can also be found in muscles that are under chronic contraction. A good example of this is the upper traps or the suboccipital muscles (or even the pectoralis major from the above example). Another common example is the psoas. People with this trigger point are always in an anterior pelvic tilt. The upper traps or suboccipitals may develop trigger points from being over contracted all day as individuals sit at their desks with poor posture. Both of these muscles have pain referral patterns that go up into the head and behind or just above the eyes. It is no wonder that people who work desk jobs get such frequent headaches! So basically, any muscle can develop a trigger point for any number of reasons (3).
Primary activating factors:
- Persistent muscular contraction, strain or overuse (emotional or physical cause)
- Trauma (local inflammatory reaction)
- Adverse environmental conditions (cold, heat, damp)
- Prolonged immobility
- Febrile illness
- Systemic biochemical imbalance (hormonal, nutritional)
Secondary activating factors:
- Compensating synergist and antagonist muscles to those housing triggers may also develop triggers
- Satellite triggers evolve in referral zone (from key triggers or visceral disease referral, e.g., myocardial infarct)
- Allergies (food and other)
- Nutritional deficiency (especially C, B-complex and iron)
- Hormonal imbalance (thyroid, in particular)
- Low oxygenation of tissues
The key is to know where to look and what to do when you find a trigger point!
Why should we care about trigger points?
The first and obvious reason to care about trigger points is because they hurt! Anything that hurts is going to alter the way we move. In turn, this leads to other dysfunctions and problems and potentially more trigger point development. Aside from altering the way we move, we psychologically don’t feel good when we’re in pain. No one likes to be in pain or miss time playing their sport or training because they hurt.
Some common clinical characteristics of trigger points are:
- Pain upon contraction: Again, no one likes to hurt. If it hurts to contract, we don’t want to contract.
- Pain during stretching of the muscle in certain ranges of motion: If it hurts to take a muscle through a certain range of motion, we stop doing it or we limit that range of motion, which leads to more problems.
- Muscle weakness: This is a big one! If muscles are weak, they can’t optimally do their job. An example of this is trigger points in the psoas or the glute medius. If these muscles are weak, they can cause other problems down the chain. Often times, we think of weak muscles as muscles that need to be strengthened. However, what happens when you try to strengthen a muscle (causing it to contract more) with taunt bands that are already hypercontracted? Not a whole lot, that’s what! You may end up just chasing your tail trying to help that person.
In short, we should care about trigger points because they can negatively affect our performance.
What can we do about trigger points?
So now that we know what trigger points are, how they develop, and why we should care about them, most people are probably wondering, “How do I get rid of them?”
The method of getting rid of trigger points isn’t that difficult. You just have to know what muscles to check, how to access the muscle (not just how to find it, but knowing which direction the fibers run can be very helpful), and how to release the trigger point.
If you’re rolling on a foam roller or tennis ball or if you’re performing trigger point therapy on someone else, look for trigger points that refer to the area of the body the person is complaining about. A great book that I recommend often is The Trigger Point Therapy Workbook: Your Self-Treatment Guide for Pain Relief by Clair Davies. It is basically a “how to” book for finding trigger points and where their pain referral patterns are. Each chapter deals with a region of the body. The first page of each chapter has various places that people may feel pain (i.e. anterior shoulder pain) along with the names of the muscles and the page numbers where the reader can learn about which muscles could be referring pain to that area (e.g. the muscles that can refer to the anterior shoulder are infraspinatus, anterior deltoid, scalenes, supraspinatus, pectoralis major, pectoralis minor, biceps, latissimus doris, and coracobrachialis). It then tells you exactly how to work those muscles! It may be the best $20 you ever spent (assuming you already purchased a foam roller).
Once you have found and confirmed your trigger point, you need to set up a barrier, which breaks apart the actin and myosin (the contractile proteins within the sarcomere). Actin and myosin are bound together due to the chronic contraction in the specific band of the muscle.
This barrier can be created with your fingers (as in the picture) or with any one of the self-care tools available today (e.g. foam roll, the stick, thera-cane, trigger point ball, tennis ball). Many people like to take the foam roller and roll back and forth on it. This is okay because it helps to address the fascia, improves circulation to the tissue, and breaks up adhesions. However, if you want to deactivate the trigger point, you need to stop on the tender area that is referring pain and hold your pressure until it begins to release and the pain starts to dissipate.
The amount of time that you hold the trigger point has been debated over the years, but approximately 8–12 seconds is the accepted amount of time. It’s important to note that if you’re pushing and it isn’t releasing, you may be giving it to much pressure and just blasting through superficial tissue and/or more superficial trigger points. Also, if the trigger point doesn’t release after a short period of time, you may want to mark the area (with a pen or something that will wash off), work other areas of the muscle, and come back to it, as trigger point therapy can get very intense. This intensity may not allow the trigger point to release right away. The real key is to give the trigger point just enough pressure that you start to feel it release (and confirm that with a slight dissipation of the referral symptoms) and go deeper and work through the next barrier.
How much pressure is enough? A little bit goes a long way with this. In the past, it was suggested that you hold pressure on the trigger point at the individual’s pain tolerance of 7–8/10 (10 being excruciating pain). It is now accepted that even a 7–8/10 may be too high to get a proper release, so authors and researchers suggest holding the trigger point at a level of 5/10 until the individual experiences a decrease in symptoms. At this point, you can either go deeper into the tissue (look for trigger points that are in deeper muscles) or move to another location and search for trigger points (the trigger point clusters that I referred to above).
It is important to know that this sustained compression is what will help to alleviate the trigger point. If you only hold for a short period of time and don’t continue with the treatment, the shortened nodule within the muscle will return to its previous state and very little therapeutic benefit will be gained.
So to review:
- Find the trigger point.
- Hold pressure at 5/10.
- Wait for the tissue to release (you can feel it soften under your skin or you’ll begin to feel a decrease in the pain referral pattern).
- Once the tissue releases and the referral starts to dissipate, either go deeper into the tissue or move on and look for other trigger points in the cluster.
Once the trigger points have been deactivated and “order has been restored to the muscle,” you can go ahead and roll the muscle out to promote some blood flow to the area, stretch the tissue (if it’s a muscle that needs stretching), and strengthen the tissue.
Things to consider
Remember, not all tender areas are trigger points. They may be tender points where tissue is ischemic, scarred up, or fibrotic. This may require other forms of soft tissue therapy.
- Trigger points are not (usually not) the only problem. They are usually part of a bigger problem that has to do with other soft tissue dysfunctions. You should seek out a therapist who can work with you to determine what the underlying problems are.
- Self care is important. Make sure you’re foam rolling and working on your soft tissue. Make sure your training program is developed properly to limit tissue stress and overuse.
- Soft tissue work, foam rolling, and proper strength exercises are essential in making sure that your tissue stays healthy and that you stay pain free.
- Be aware of your activities of daily living and your posture so that you aren’t putting unnecessary stress on structures that don’t need it. So much of our pain and dysfunction comes back to how we operate on a daily basis. Altering activities of daily living, while difficult, is crucial in making lasting changes in your soft tissue.
- Just because you deactivate a trigger point doesn’t mean that it can’t return.
- Always seek medical attention if you feel there’s something more serious going on.
- Simons D (2002) Understanding Effective Treatments of Myofasical Trigger Points. Journal of Bodywork and Movement Therapies 6(2):81–88.
- Chaitow L, Walker-DeLany J (2000) Clinical Application of Neuromuscular Techniques, Vol. 1: The Upper Body. Elsevier Limited.
- Chaitow L, Walker-DeLany J (2002) Clinical Application of Neuromuscular Techniques, Vol. 2: The Lower Body. Elsevier Limited.
- Davies C (2004) The Trigger Point Therapy Workbook: Your Self-Treatment Guide for Pain Relief. Second edition. Oakland, CA: New Harbinger Publications, Inc.
- Archer P (2007) Therapeutic Massage in Athletics. Philadelphia: Lippincott, Williams & Wilkins.
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