From my Trigger Point of view

This paper is written simply to try and stimulate you as a practitioner to think about what you are doing when addressing Myofascial Pain and Dysfunction disorders, especially when addressing such problems from a Trigger Point of view. I hope that practitioners and others interested in Myofascial Trigger Points and soft tissue disorders in general, will find the paper useful. I am not trying to disrespect any practitioner or others concerning their approach, work or belief. I am just trying to share my clinical experiences and present the findings made as a clinician. I know many practitioners acknowledge the findings and the reasoning being presented in this paper. Let us see where it goes…

frontpicman

Tissue injury/change

Hypoxia (lack of oxygen) and accumulation of waste products (due to lack of circulation/exchange deficiency) can cause pain symptoms of various degrees in the tissue involved. Hypoxia happens either by overworked structures (Cumulative Injury Disorder – CID) and/or after an injury. Hypoxia over time results in adhesions and “hardening” in, or between fibers in soft tissue structure (1, 2, 3, 4).

cid

When investigated closer, we find that all of our soft tissue is connected and blends together where they meet, cross, penetrates and/or inserts. When movement is made, our soft tissue “melts” and slides together or from each other (depending on movement and function of structures) (5, 6).

adhesion

When the tissue is in the healing phase after an injury or when overworked for too long too many times, the body lays down new tissue to replace the original damaged fibers. This type of new tissue will be formed by much less elastic and passive fibers (adhesions or “Fuzz”). These newly laid down fibers will eventually connect and “grow” into the surrounding layers. The Cumulative Injury Cycle demonstrates the cycle of an injured tissue and points out the importance of breaking out of the ongoing cycle (2, 3, 4, 5, 6, 7, 8).

muscleinjury_diagram

We can compare an injury inside the body (beneath the skin) and what happens in the healing phase, to a cut to our skin. The injured area becomes hard and less stretchable after some months. At some point, the tissue thickens and blends in with the surrounding layers from other soft tissues such as; muscles, fascia, tendons, ligament, nerves, capsules. If you have a scar from an operation, try to pick up the skin and feel what happens underneath. Compare to the other healthy side on your body. What did you discover?  (3, 4).

scartissue

 

It makes NO sense at all that these local “muscle spots” by themselves should radiate/refers neurological symptoms in the distribution area of a specific peripheral nerve. It is obvious that the peripheral nerve itself plays an important role in the total symptom pattern. The changes in the soft tissue surrounding the nerve after an injury or when overworked, causes the nerve to respond locally and in the distribution area (pressure, friction lack of blood supply etc.) (3, 4, 5, 6, 9).

For some reason, Trigger Point is one of the most accepted terminologies among practitioners dealing with soft tissue treatment, when it comes to describing/treating pain spots that preferably radiate to other specific areas. And, it has become some sort of acceptance how to address such problems. Many tools and many possibilities, all based on vague theories. Well, is it not about time we work on a theory that makes sense, and explains the referred symptoms  without concluding, quote; “With certain muscles, the reality of referred pain can often be demonstrated by simply pressing on a trigger point that is bad enough to reproduce part of its referred pain pattern. It’s a little harder to explain why pain is referred at all”(10, 11).

Tissue layers and structural tunnels in our body

 As mentioned earlier, our soft tissue is interconnected, but its structures are also “separated” by fascia. These “separations” makes it possible for the different structures to glide, stretch and contract respectively to, from and for each other when movement is made (lifting your arm or walking). If we follow the neurovascular structures from where they leave the center of the body and enters the limbs throughout to our fingers and toes (Peripheral nerves from the Spinal cord through a bony tunnel made out of two vertebras, and the arteries and vein where they branch out), we will find that our soft tissue structures such as muscles, tendons, ligaments and fascia, creates natural pathways (tunnels) throughout our musculoskeletal system. These tunnels are found between our layers of soft tissue structures, and they are easily accessible to palpation and certainly compression (5, 11, 12).

Tunnels are not fixed, and will move and adapt as we move our bodies. As we move our limbs, our nerves and vascular structures glides back and forward in each tunnel respectively to which movement is made. When you extend your wrist the Median nerve will glide distally in the Carpal Tunnel, and when you flex the wrist the nerve glides superiorly (5, 6, 13).

anatomy

 

Sensitive structures like nerves, veins and arteries should not be met by force or violence. Personally, I would never in my mind find it reasonable to compress and/or twitch a nerve with direct force (risk of damaging the myelin sheet/nerve). Practitioners “tend” to have an idea that the more it hurt, the better it is. In cases, where we are talking about sensitive structures like nerves and vascular structures, it is definitively not the case. Nerves they branch, penetrates structures and glides among the tissues through our entire musculoskeletal systems (5, 6, 9, 12).

Examples of some natural nerve tunnels (often also vascular) in the body:

  • Between the muscles Psoas and Iliacus (Femoral nerve)
  • Coracopectoral tunnel (Brachial Chord)
  • Between the Median and Anterior Scalene muscles (Plexus)
  • Arch of the Soleus (Tibial nerve)
  • Through the muscle Pronator Teres (Median nerve)
  • Between the muscles Trapezius and Levator scapulae (Spinal Accessory nerve)
  • Between the muscles Extensor Carpi Radialis longus and brevis (Superficial Radial nerve)
  • Trough and/or by the hip rotators in the hip like the muscle Piriformis (Sciatic nerve)
  • Between the two heads of the muscle Flexor Carpi Ulnaris (Ulnaris nerve)
  • At the Superior Oblique (Suboccipital nerve)

Soft tissue palpation and Hands On work

To palpate and differentiate soft tissue as they move and/or in passive position is an ART. It is as simple as playing the piano and just as difficult. It takes a practitioner a great deal of training and experience to be able to actually feel different structures, and to differentiate them from one and the other. The deeper the structures are, the more difficult it is to palpate and differentiate.

palpation

 

It is particularly difficult to feel a nerve. The deeper the nerve the more difficult it is to palpate and differentiate it from the other surrounding structures. Peripheral nerves vary in size and length. Some nerves are thick and easy to palpate for a trained hand, while others are thin and more difficult to feel (13).

It takes a great deal of training and experience for a practitioner to develop good palpation skills. A trained practitioner will be able to feel the body’s different structures and layers. He or she can feel the different depths of tissues and if abnormalities are present in, or between the tissues involved.

When treating a tender “spot” in the soft tissue, the practitioner must be sure not to compress any neurovascular structures. It is not the nerve tissue itself you want to influence, but the surrounding structures causing the nerve to respond (13).

If the practitioner uses force to create compression with the thumb or wrist, he or she will not be able to feel or differentiate the tissues underneath the contact point. The Trapezius muscle is quite thin. Think about how you treat the Trigger Point just superior to the medial boarder of the Spina Scapulae (preferably radiates/refers  neurological symptoms either distally along the medial boarder of the Scapulae, and/or up the medial/lateral side of the neck all the way to the head). How deep and how hard do you go with your contact or tool? (14, 15).

copression

 

Wikipedia 2014 (10):

“Practitioners claim to have identified reliable referred pain patterns which associate pain in one location with trigger points elsewhere. There is variation in the methodology for diagnosis of trigger points and a dearth of theory to explain how they arise and why they produce specific patterns of referred pain.

Compression of a trigger point may elicit local tenderness, referred pain, or local twitch response. The local twitch response is not the same as a muscle spasm. This is because a muscle spasm refers to the entire muscle contracting whereas the local twitch response also refers to the entire muscle but only involves a small twitch, no contraction.

Among physicians, many specialists are well versed in trigger point diagnosis and therapy. These include physiatrists (physicians specializing in physical medicine and rehabilitation), family medicine, and orthopedics. Osteopathic as well as chiropractic schools also include trigger points in their training. Other health professionals, such as athletic trainers, occupational therapists, physiotherapists, acupuncturists, massage therapists and structural integrators are also aware of these ideas and many of them make use of trigger points in their clinical work as well.“

Are you a soft tissue practitioner?

If you are a practitioner and you work with soft tissue diagnosis and treatment, you probably have treated such tender “spots” that radiates/refers neurological symptoms many times. A lot of our treatment modalities these days are focused on some sort of high direct compressive force, with or without twitching (tools, machines or fingers, hands, elbows etc.). Sometimes we penetrate the skin with a needle and twitch it around deep in to the tissues where it hurts and also “preferably” radiates/refers to other parts of the body. We might even use machines which produces waves of direct blows to the actual area.

More tissue injury = better recovery?

Say you are a pretty much up to date practitioner dealing with these issues on a regular basis. You have a good anatomical, physiological and neurological base knowledge, and many “treatment tools” available. You have worked for a long time and built up lot of experience in dealing with such complaints. You know where to find and palpate muscles, nerves, tendons, blood vessels, ligaments etc. And, you know how the nervous system functions and how the peripheral nervous system is built up. What would your initiative reasoning be for solving these “Trigger Points”?

What is your choice of approach? Are you thinking of compressing the nerve and/or surrounding tissue? Or, are you thinking of reducing/releasing compression on the nerve from its surrounding tissues? These two examples of starting points addressing soft tissue symptoms such as “Trigger Points”, will definitely determine the approach of the practitioner.

Some common misunderstandings amongst practitioners when it comes to treating “Trigger Points” (and other Myofascial Pain and Dysfunctions):

  • “It should hurt when I treat”.
  • “The more pain the better the results”.
  •  “I need to go hard to solve the problem; I even might use my elbow to create more compression force in the tissue”.
  • “If my thumb or elbow does not do the trick, then a needle deep in to the tissues might work”.
  • Etc. etc. etc.

Example: Median nerve entrapment at the m. Pronator Teres

 

median nerve biomechanics

The Median nerve penetrates through one of the heads or between both of the muscle Pronator Teres in the forearm, just below the elbow. The depth (from the skin and to the nerve) may vary due to the size of the muscles and other structures or tissues.

- Pain in the forearm and in the distribution area is present. Symptoms can be loss of strength, tingling sensations, electrical firings, numbness etc. all the way to the palm of the hand and fingers.

The patient’s symptom dscriptions and history together with your tests (palpation) will indicate how the nerve is involved and for how long the problem has been present/developed. Symptom onset and the description of symptoms will tell you something about how the nerve is involved and at what stage. If the problem has been present for a long time, with gradually increase of symptoms, you should ask yourself why those structures in that particular area behaves the way they do? Has it something to do with how that particular patient is using his/her body and/or is it because of adhesions and other alternations in the tissue (tonus, size, hardness, displacements etc.).

Conclusion: The trigger point chart shows the same distribution area for the muscle Pronator Teres trigger point as the peripheral nerve chart does for the Median nerve (13, 17, 18).

You should suspect a certain degree of damage to the myelin sheath of the nerve if the surrounding tissues have been allowed to compress and damage it for a long time (friction and pressure). This will probably affect the prognosis (longer recovery). You should also suspect that the nerve structure itself also has lost some of its gliding capacities due to biomechanical soft tissue compensation and/or if the nerve is entrapped (19).

Please do the following:

1. Compare the Peripheral nerve chart with the Trigger Point chart. Check also the referred pain/distribution areas. What do you find?
2. Ask yourself, would you like someone to compress and twist, or needle your ex. median nerve where it penetrates the Pronator Teres muscle?
3. Now, let us say we are pretty much sure that a nerve is involved in the picture. How can we determine the cause of the nerve symptoms? Entrapment by adhesions? Entrapment by muscle tonus? Friction? Loss of gliding capacity? Lack of blood supply? Damage to myelin? Tumor? etc.

YES! YES! YES! Most “real” tender spots you find that radiates/refers neurological symptoms actually are nerves firing (Patient complains about radiating pain or other neurological symptoms in the respective distribution area. These symptoms are often reproduced or increased when the spot is compressed).

In basic terms, we know (don’t we?) that friction, compression and pressure (given by fingers/hands/tools or internally by adhesions or other structural alternations) on soft tissue structures can, and most probably will cause local tissue damage. As we know, tissue injury causes more rigid fibers to lie down in the area. Why do we choose approaches that are meant to do the same kind of damage to the tissue as an injury?

The “reasoning” for these treatments are always; “I have to cause more tissue damage so that the repair process (healing) kicks in”. Think about the football player when he gets a knee into his quadriceps causing a crushing injury in the tissue. That is actually what we are doing when using compressive modalities with direct force. It just does not make any sense to try and cause more injury to the tissue, whatever the original problem is.

There is a more reasonable approach to our treatments

We need to turn our thoughts around dear fellow practitioners. Instead of approaching a “Trigger Point” on the basis that it is a muscle knot that needs to be compressed/crushed with some sort of direct force, think about what can be done to create relative motion in, and between the structures involved without a vertical direct force into the tissue. The reason for this approach is simple. If you are able to eliminate the cause of the nerve compression/entrapment by reintroducing gliding potentials of the local surrounding structures, you will be able to eliminate the “pressure” on the nerve itself.

NO pressure/friction on the nerve = NO pain or other neurological symptoms in the distribution area + NO hypersensitivity of the nerve locally (excluding a damage to the myelin sheet). Typical example is Carpal Tunnel Syndrome.

Most of our tender spots or pain areas in soft tissue are developed over a period of time. These soft tissue changes happen due to compensatory patterns, when over-trained, after an injury and/or in combination with underlying diseases and lifestyle. I always ask myself the question “WHY” until I stop from lack of knowledge, or because the reasoning of my findings suggested I am on the right track. There is a reason why the soft tissue changes its working load and/or function (secondly developing into a soft tissue symptom or syndrome, thirdly to functional impairment etc.).

timeline

 

Examples of some natural nerve tunnels (often also vascular) in the body:

A. Between the muscles Psoas and Iliacus (Femoral nerve)
B. Coracopectoral tunnel (Chord)
C. Between the Median and Anterior Scalene muscles (Plexus)
D. Arch of the Soleus (Tibial nerve)
E. Through the muscle Pronator Teres (Median nerve)
F. Between the muscles Trapezius and Levator scapulae (Spinal accessory nerve)
G. Between the muscles Extensor carpi radialis longus and brevis (Superficial radial nerve)
H. Trough and/or by the hip rotators in the hip like the muscle Piriformis (Sciatic nerve)
I. Between the two heads of the muscle Flexor Carpi Ulnaris (Ulnaris nerve)
J. By the muscle Superior Oblique (Suboccipital nerve)

painpoints1

 

painpoints2

 

Note 1. Tender spots that radiates are NOT inflammatory problems. Therefore NO usage of NSAID’s is necessary.

Note 2. Using Trigger Points as references to determine vague and misguiding diagnosis such as Fibromyalgia (general hypersensitivity – CNS – neuroplasticity) is way off target and causes more problems than it helps. A person with the alarm center switched on (over a long period of time), will most likely be hypersensitive in one or more of the Peripheral nerve pathways (20).

Closure

If you work with soft tissue you have to take the Peripheral nervous system into consideration in your examination and treatment. The Peripheral nervous system should not be neglected when approaching soft tissue problems. When doing so the practitioner risks causing more damage than good, especially when approaching the problem as discussed earlier.

When your findings suggest multiple triggering “spots” on both sides of the body (often with varied intensity, onset time and variations in symptoms), please be aware of the involvement of the Central Nervous System. It might not be a local problem at all.

If we accept that it does not make any sense to reinforce the ongoing Cumulative Injury Cycle (adhesions/scar formation) in the tissues involved, then we have to reconsider many of the treatment tools and modalities being used today. A more functional approach should be accepted at all levels of treatments, from the soft tissue treatment itself to the exercises and other necessary adjustments.

Remember to be curious about your patients’ soft tissue problems. Try to find a reasonable explanation for the symptoms described by the patient and provoked through testing. Most of our clues lies in the words from the patient, listen to what they say.

I hope that the paper can contribute to future research on the subject, and that it can be used as a guide to distinguish some common soft tissue problems from one and the other.

A special thank you to my wife Katrin van der Lagen and my colleagues at the clinic in Norway for contributing with case reports on the subject and for helping out with pictures and design. I would also like to give a BIG thank you to Dr. P. Michael Leahy in Colorado Springs for introducing and teaching me how to develop and refine my palpative skills through his own soft tissue system; Active Release Techniques®.

Personal recommendation for soft tissue practitioners: Active Release Techniques®

Anatomy pictures: Visible Body®’s 3D anatomical models of the human body. I use this app for learning and teaching purposes. The app is also used to educate patients at the clinic. www.visiblebody.com

About the writer            

www.vanderlagen.com/?page_id=41

www.linkedin.com/pub/nicolai-van-der-lagen/29/7b9/1ba

Reference list:

  1. www.medical-dictionary.thefreedictionary.com/hypoxiaAbout Hypoxia
  2. www.en.wikipedia.org/wiki/Repetitive_strain_injuryAbout RSI/CTD/CID
  3. www.en.wikipedia.org/wiki/Adhesion_(medicine)About adhesion
  4. www.macs.hw.ac.uk/~jas/researchinterests/scartissueformation.htmlAbout Scar tissue
  5. Integral Anatomy, V2 pt2: Deep Fascia and Muscle, Ph.D Gil Hedley – Video dissection
  6. www.youtube.com/watch?v=eW0lvOVKDxE - Strolling under the skin, Dr. Jean-Claude Guimberteau
  7. The Fuzz Speech, Ph.D Gill Hedley – Video presentation about “Fuzz”
  8. The Cumulative Injury Cycle. Dr. P. Michael Leahy Leahy, DC, CCSP, 1995
  9. www.en.wikipedia.org/wiki/Peripheral_nervous_system  - About the Peripheral Nervous System
  10. www.en.wikipedia.org/wiki/Myofascial_trigger_pointAbout Trigger Points
  11. www.triggerpointbook.comAbout Trigger Points
  12. Prometheus, LernAtlas der Anatomie, Michael Schünke, Erik Shulte, 2009
  13. Active Release Techniques for nerve entrapments, Dr. P. Michael Leahy Leahy, DC, CCSP.
  14. Travell & Simons’ Trigger Point Flip Chart
  15. www.en.wikipedia.org/wiki/Accessory_nerveAbout the Accessory nerve
  16. The Nervous System Chart, Medical Illustrations, Lippincott Williams & Wilkins
  17. www.en.wikipedia.org/wiki/Median_nerve – About the Median nerve
  18. www.neuromuscular.wustl.edu/nanatomy/median.htm median nerve – About the Median nerve
  19. www.wikipedia.org/wiki/MyelinAbout the Myelin Sheath
  20. Explain Pain. David Butler & Lorimer Moseley, 2003
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Written by Nicolai van der Lagen

Manager and Lead Instructor - Active Release Techniques® Europe Manager - Helsehuset Moss AS ART practitioner - ART Klinikken AS
Website: http://www.activerelease.com/europe