Myofascial Pain FAQ

	I have tried to work my trigger point but I can 't seem to get any real relief? All serious pain should first be evaluated by a physician to exclude and underlying treatable medical / surgical cause. The number one reason that there is ineffective pain relief is the pertinent trigger point is not being treated. Locating trigger points is not easy and it took me months to become effective after reading both references including several anatomy books... and I am an MD. Initially, working with someone who is experienced with trigger points will convince you they are the problem and will show you how to effectively find and treat them. You can do it on your own if you are doggedly persistent. Many times more than one trigger point / muscle is involved. All must be inactivated for lasting complete relief. The pain will return until the trigger point is inactivated. The time is variably and is usually related to the duration of the pain. The longer you have had the pain, the longer to completely rid yourself of it.
	My physician wants to put me on rest and non-steroidal pain medication. Is that sufficient? This might work but it will be extremely slow relief with extended incapacitation and will do nothing to prevent a recurrence. Supplemental pain medication along with some sort of physical therapy is the best route. Physical therapy is wonderful and should eventually provide relief but directly confronting the trigger point is much, much quicker. I sprained my sacroiliac joint and underwent 8 weeks of PT. It did work which for me was a miracle as I was flat on my back at the beginning. However, knowing what I know now about trigger points, I would recover now in under a week with trigger point treatment.
	How do other methods of myofascial pain control stack up against trigger point therapy? Narcotics - very ineffective. Myofascial pain responds much better to nonsteroidal anti-inflammatory medication such as ibuprofen. Pain medication should be supplemental only, and not the primary treatment. Rest - Muscle immobility does nothing to treat trigger points. If may, in fact, induce trigger point formation. Rest is useful if it corrects some ergonomic problem or stops some irritating, repetitive activity. Rather than rest and immobility, correct the ergonomic problem and stop or change the irritating activity. Physical Therapy - very good as it promotes ergonomic behavior and includes stretching. As a preventative, it can't be beat. However, active trigger points cannot be stretched and PT alone hits a dead end with some trigger point pain. Also, pain relief is achieved much more slowly. Chiropractic - very good tool for immediate help with myofascial pain but not good for fine tuning or long term relief. Most people can effectively treat their own pain over the long term. My analogy would be a chiropractor has one tool - a sledge hammer. He/She is very good with it, but that is the only tool available and many times you need something smaller and more focused. Therapeutic Massage - particulary useful if focused on trigger points. Direct trigger point treatment is better. Generic massage has little value in pain relief.
	How do trigger points cause pain and other problems? Trigger points cause pain, restricted range of motion, and/or weakness in the involved muscle. The muscle cannot fully expand/stretch or contract and thus inhibits other muscles. The constant tension strains other muscles and joints with occasional misalignment. There may be nerve or blood vessel entrapment by the swollen, contracted muscle. A classic example is sciatic nerve compression by the pyriformis muscle. The autonomic nervous system can also be affected and cause peculiar symptoms. Proprioreceptors are present in muscles and may be affected. An example is dizziness and vertigo caused by trigger points in the sternocleidomastoid muscle. Two lists of unusual trigger point symptoms are listed here with their corresponding links.
	What causes a trigger point to develope? Trigger points are usually associated with some degree of mechanical abuse of the a muscle in the form of muscle overload. The overload may be acute, sustained, and /or repetitive. Leaving the muscle in the shortened position can convert a latent trigger point to an active trigger point particularly if the muscle is contracted in the shortened position.
	What is the difference between an "active" trigger point and a "latent" trigger point? An active trigger point produces a clinical complaint, usually pain, that the patient recognizes when the trigger point is compressed. Latent trigger points produce other characteristic effects including increased muscle tension and muscle shortening but no spontaneous pain. Both can cause significant motor dysfunction.
	Please describe the typical trigger point pain? Poorly localized, regional, aching pain in subcutaneous tissue, including muscles and joints. The pain is often referred to a distance from the trigger point in a pattern that is characteristic for each muscle eg. gluteus minimus Sometimes numbness or paresthesia rather than pain
	How do I use the body site pain diagrams on this website? There are diagrams of a body regions broken down with areas marked as pain sites. Find the area that best fits the location of your pain. There is a corresponding page with these pain sites listed followed by a list of muscles. The muscles are ones that can cause pain within the area. The muscles are listed in order of decreasing frequency of causing pain in this area. A diagram of the trigger points of some of the individual muscles is also available (not many now) which will further help localize the pain and probable involved muscles. In the pdf files there are summaries of all the muscles with brief information on all aspects including pain location. The summaries are from Travell and Simons. The books have an entire chapter devoted to each muscle with a summary page at the beginning.
	Do you follow the books step by step each time or do you have a quicker approach? The more examples of people you see with similar pain patterns, the more likely you know the primary muscles involved. Although several muscles are listed as causing pain in a specific area, the exact location, type of pain, mitigating factors - all help eliminate some possibilites and point to the most likely culprit. When in doubt, go by the books if your initial guesses were not confirmed. I hope to add my own laundry list of muscles for certain pain patterns to this website. Though all of the treatment modalities for trigger points do work, in my hands, some work better than others and it varies from muscle to muscle.
	Are there any specific tools that are useful for trigger point therapy? Everyone has their own personal favorites. I will mention a few of mine and include photos and more information on a tools webpage (yet to be created). A theracane is probably the single most useful tool other than a tennis ball / hard rubber ball. The theracane enables one to reach almost any point on their own body and apply pressure to a trigger point. A device similar to the theracane is a Backnobber II which is very portable as it breaks down into two pieces which would fit into a briefcase. Balls of various sizes are extremely useful for deep trigger point beneath or within thick muscles. The ball is placed on a hard surface such as a wall or the floor and the body is pushed into the ball with a very effective stripping massage. Varying the ball size and hardness will work on all of these deep trigger points. I have bought a few specialty tools which looked good but don't seem to work as well. I also made a few small simple homemade tools which also work well.
	What do you think of the spray and stretch technique or trigger point injection for use by the average person? My luck with trigger point injection has been poor. I use needles every week in my profession sticking lumps in bumps in patients who are referred to me for a diagnosis. These lumps are much bigger and more discreet than the average trigger point. Trigger points are often rubbery and very mobile. It it just plain hard to skewer them with a needle. Spray and Stretch does work but it is more cumbersome and really takes two people. It is hard to correctly spray yourself. A cold pack judiciously applied or a heat wrap also works. You have to be careful with the spray so as to not frostbite the skin. I would recommend heat or cold to aid in stretching trigger points sometimes but each person will have to determine for themselves the best ancillary tool to use.
	Can trigger points really be cured or is it a lifelong project to manage your trigger points? This is one of those trick questions as the answer is both yes and no. Acute injuries with a short history can be cured and really do go away for good. More chronic injuries, many of which are due to years of poor ergonomics, may never completely go away. The pain can be controlled and the disability minimized but lifelong stretching may be needed along with occasional trigger point work for acute flareups. Completely correcting poor ergonomics is needed but seems impossible in many cases. I now have bifocals and much poorer vision than when I was younger. When using a computer screen (as I am doing right now), it is work to keep everything in sharp focus (despite a 24 in lcd monitor) without tensing my neck and shoulder muscles. When I use my computer a lot , my neck and shoulder muscles / trigger points get irritated. I stretch and manipulate my trigger points, but I don't give up my computer.
	What are common misconceptions about trigger points? Simply treating the trigger point should be sufficient. ANSWER - If the causing stress is not recurrent and if there are no perpetuating factors, that may be true. After the trigger points have persisted for some time, the muscle must be retrained to normal function and full-stretch range of motion. The pain cannot be as severe as the patient says and must be largely psychogenic. ANSWER - Believe the patient. Patients have rated their pain as severe as or more severe than pharyngitis, cystitis, angina, herpes zoster, and rheumatoid arthritis. Myofascial pain syndromes are self-limited and will cure themselves. ANSWER - An acute uncomplicated trigger point may spontaneously convert to a latent trigger point within a week or two if the muscle is not overstressed and if there are no perpetuating factors. Otherwise it might evolve into a chronic myofascial pain syndrome. Relief of pain by treatment of skeletal muscles for myofascial trigger points rules out serious visceral disease. ANSWER - Visceral pain may be referred and a vapocoolant spray or local anesthetic injection into the the somatic reference zone can temporarily relieve the pain of myocardial infarction, angina, or acute abdominal disease with no effect on the visceral pathology.
	What are the minimum criteria for identification of a trigger point? The table below from Travell and Simons nicely lists the criteria.