TRIGGER POINTS • Katerina Moustaka

TRIGGER POINTS

Muscle is an orphan organ. No medical speciality claims it

David Simons

The sum total of our muscles (640 in all, representing 36-42% of our weight) can be considered the largest organ of the human body. Highly complicated, vulnerable to dysfunction, and the main target of wear and tear due to everyday activities. However, it is often only the bones, joints and nerves that Medicine focuses its attention on.

And yet, 75-85% of musculoskeletal symptoms is caused, mainly or to a great extend, by the muscles themselves. Or, to be more specific, by discrete, irritable points in skeletal muscle producing palpable sensitive nodules (the familiar muscle "knots") and caused when our soft tissues are injured, strained or over stressed.

In medical script, they are called myofascial trigger points. And they are the “best kept secret” in the pathogenesis of many symptoms, musculoskeletal and otherwise. These include headaches (trigger points play a role in migraines and tension headaches), pack pain, and neck pain.

How they are created

The formation of trigger points can be attributed to :

• One-time or recurrent muscle strain, e.g. lifting of heavy objects or lifting with improper ergonomics, repetitive movements at work or in sports, sudden movements, mechanical straining of the area due to joint dysfunction.

• Direct muscle injury or impact injury, e.g. due to slip and fall or MVA, causing a sudden stretching or tearing of the muscle.

• Maximal and sub-maximal loading, eccentric loading in weight lifting

• Prolonged inactivity, e.g. Prolonged sitting due to office work or bed confinement due to illness.

• Psychological stress.

• Improper body posture.

Inactivity, decontitioning syndrome

Dietary deficiency ;Vitamins (B1,B6,B12,D,C) /or magnesium and zinc deficiency

Common cold.

Radiculitis.

• Inflammation.

• Secondary activation by other trigger points.

Characteristics of trigger points

Their basic characteristic, to which they owe their name, is that once they are created, they can radiate or produce referred symptoms to an area greater than their own size, and sometimes to distant parts of the body which have been mapped out for every muscle.

Symptoms include pain, numbness or a “burning” sensation, plus muscle tightening, stiffness, decreased range of motion and weakness, both locally and at the respective referral areas. This happens when trigger points are “active”.

If we manage to convert them into a “dormant state” through avoidance of physical activity, rest, pain-killers or other medication, massage, physiotherapy, etc., then the clinical picture changes. Pain recedes. However, muscle tightening and weakness remain, changing the fundamental movement patterns, usually without us realizing it, and at the first strain (exposure to cold, weight lifting, intense work out, tiredness, psychological stress), symptoms reappear, sometimes in a more severe form...

Why it is important to diagnose and treat them

The clinical importance of trigger points is vast due to two separate facts. First, they are extremely common. We all have trigger points. And secondly, they can

:

Create symptoms by themselves.

Participate and exacerbate the symptoms of other myoskeletal disorders.

Mimic other conditions.

Symptoms that are caused by trigger points

Everyday muscle pain and discomfort Headache Back pain Sciatica (pain in the buttock that also extends to the leg) Neck pain
1They can also mimic:

Tendonitis

Meniscus tear

“Frozen shoulder” syndrome

Carpal tunnel syndrome

Periarthritis (shoulder)

Plantar fasciitis

Arthritis

Temporomandibular joint syndrome

Trigeminal neuralgia

Epicondylitis

 

More rarely they can cause:

Toothache

Earache

Tinnitus

Vertigo

Insistent dry, nonproductive cough

Dysphagia

Pain behind the eye

Angina pain

Bellyache

Menstruation pain

What usually happens:

Even though the first scientific research and development of treatment protocols started in 1942 from the field of Medicine (by Janet G. Travell, personal physician of JFK, and later followed him to the White House), and although the frequency and variety of symptoms caused by trigger points makes them one of the most important players in musculoskeletal Dis-ease, neither their diagnosis nor their treatment methods are included in the curriculum of most Medical Schools. This means that the majority of people seeking relief from pain are still treated with the conventional (and usually ineffective) approach: medication, physiotherapy, and strengthening exercises.

1However...

Classical physical therapy modalities or simple massaging cannot eliminate trigger points -actually the whole fibrosis or nodules needing to be "dissolved' approach is wrong. Stretching and strengthening exersices not only are ineffective, in active trigger points, but could potentially exacerbate symptom intensity.

Oral nonsteroidal anti-inflammatory drugs (NSAIDs) as well as muscle relaxants, while offering temporary relief turning active trigger points into dormant ones, do not eliminate them either. In persistent cases, the big guns are brought out: antidepressants. Which may achieve to relax the body as a whole, but under no circumstances do they affect trigger points specifically. And when oral medication proves ineffective, we use the ultimate weapon: administration of NSAIDs /or corticosteroids combined with local anesthetic injections on the trigger point. However, this solution requires a high degree of specialization, vast experience, and deep knowledge of trigger point referral patterns. Something that very few health professionals have, with the exception of anesthesiologists in Pain Clinics.

Furthermore, none of the above will eliminate the cause that perpetuates trigger points. Joint dysfunction...

What we do:

Most trigger points can be dealt with in a fast and effective way on two basic conditions. Correction of joint dysfunction (see chiropractic), and local spasm- nodule relaxation.

The simplest method of permanently dissolving tension at a trigger point is by ischemic compression. That is, applying a steady pressure at a specific angle on the muscle, in order to temporarily (for 30-60 seconds approximately) limit the blood supply to that spot and "force" it to relax. If you are wondering if this procedure is painful, I will be honest. Yes, it is. Trigger points have the ability to “become activated” by pressure, and we usually have reproduction of the symptoms at the referral area... However, when the practitioner is experienced and the patient cooperates, we can have the best results in the less painful manner possible, adjusting pressure intensity so that it is well tolerated by the recipient.

What we are trying to do is eliminate the trigger point without wiping out the poor suffering patient at the same time. Let us not forget that with this particular type of muscle work, we attempt a dialogue with the nervous system, and sometimes this is a first for the patient. So the dialogue has to have the proper tone. It has to be friendly and supportive, not rude and aggressive.