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What is trigger point therapy?

Trigger points exist all over the body, many hundreds of them, from your jaw to your heel, from your pectoralis minor to your peronius tertius. All of which can produce symptoms which are amenable to my approach, one of multiple techniques all blended into one. 

Trigger points, also known as trigger sites or muscle knots, are hyper-irritable spots or areas in skeletal muscle that are associated with nodules and tight zones in muscle fibres. Trigger points are small zones of contracted muscle knots and are a common cause of pain. 

Compression of a trigger point may cause sensations of local tenderness, referred pain, or local twitch response. 

The trigger point model states that pain frequently radiates from these points of local tenderness to broader areas, sometimes distant from the trigger point itself.

Trigger points have a number of qualities. They may be classified as potential, active or latent and primary or secondary.
There are more than 100 potential trigger points in the lower upper limb and hands alone.

These trigger points, when they become active or latent, show up in similar places in muscles in every person. An active trigger point is one that actively refers pain either locally or to another location.
A latent trigger point is one that exists, but does not yet refer pain actively, but may do so when pressure or strain is applied to the myoskeletal structure containing the trigger point.


The trigger points are generally located at the muscle origin, middle of the muscle, at the myotendinous junction ( where the contractile portion of a muscle becomes the non-contractile tendon portion ), in the middle of the tendon and final insertion points of the tendon. 
Great attention must be taken to the ranges of movement of the carpal bones of the wrist, for if they are lacking in their full range, symptoms will occur. This needs the ability to articulate and to manipulate the carpal bones. There are many of us who have such joint adhesions especailly of the scaphoid, lunate and hamate bones where they join with the forearm bones, the radius and ulna.
Elbow joint problems can also be at the root of apparent RSI, these need to be manipulated as above. The radial head is a common site of irritation, often with the patient feels the pain elsewhere, farther down the top of the forearm.

History of similar techniques

Neuro-muscular technique has been around since humans first experienced pain in their muscles. It is a natural instinct to squeeze and rub a painful area of muscles. The Naturopaths of the late 19th century evolved the technique.
Myotherapy was developed in the USA after the second world war. It is similar to trigger point therapy.
Myo-articulation uses triggerpoints but also employs simultaneous stretching of the trigger points and areas in the muscles. The technique was developed by me over many years of practice and observation. It is profoundly more effective than trigger point therapy or myotherapy alone.
Trigger points are self-evident 
By exploring the anatomy of the individual we will discover the points and areas which cause pain and dysfunction. Then, when the application of trigger point techniques brings about great relief which lasts, more knowledge is added to our experiental database. Trigger points are self-evident when one has truly explored the myriad of painful syndromes presented over many years. The trick is not only to find the points and areas but to change them, physically. This is usually easily acheived but must be done in the 'right' way. It is definitely a fine art and supreme skill combined.
On our first day at college we were told that over the next four years we would learn the entire anatomy of the body 7 times and forget it only 6 times. We thought this was a joke but it definitely turned out to be true except for the bit about forgetting it 6 times. We studied General medicine, differential diagnosis, the 3 divisions of the nervous system, Histology, Pathology, Orthopedics, Osteopathic treatment techniques, and, of course, highly detailed Anatomy.
There are two levels of anatomical study of the muscles, that of the superficial layers and that of all 850 muscles. Most physical therapists such as masseurs, physiotherapists, acupuncturists and other variations and other mini-specialisations learn only the superficial layer of muscles. This lessens their abilities dramatically. We were taught the origin, insertion, function, blood supply and nerve supply to every muscle in the body. We were also taught about the organs of the body, their physiological functions as well as the hormonal system and the glorious control mechanisms of entire human edifice. I took a deep liking to the subject of the obscure subject of the hydrodynamics of the brain in relation to the cranium and have published and lectured on the subject. I now realise that my education at the European School of Osteopathy was par excellence.



Maps of the main trigger points




Myo-fascial pain syndromes


This section will interest anyone who may be  complaining of the remarkably common myofascial pain that originates in muscle. Pain and tenderness are characteristically referred from myofascial trigger points (TPs) that are located in muscle remote from the site of the pain.

This is confusing to the patient and misleading to the practitioner.

Despite its cryptic origin, referred pain from TPs can be devastatingly severe. Fortunately, pain due to myofascial TPs can be identifiable by careful history and skillful physical examination; it is quickly responsive to

physical medical management in the absence of serious perpetuating factors.


Skeletal muscle is the largest organ of the body. It makes up nearly half of body weight. Muscles are the motors of the body. They work with and against the ubiquitous

spring of gravity. Together with the cartilage, ligaments, and intervertebral discs, they serve as the body's mechanical shock absorbers. Each one of the approximately 500 skeletal muscles is subject to acute and chronic strain. Each muscle can develop myofascial TPs

and has its own characteristic pattern of referred pain.

Acute cases of a single-muscle myofascial pain syndrome (MPS) can often be treated readily and effectively when the specific muscle harboring the TP responsible for

the pain is promptly recognized. Prompt resolution of an acute single-muscle MPS prevents the needless persistence

of disabling pain. Perpetuating factors can increase irritability of muscles, leading to the propagation of TPs and increasing the distribution and severity of pain. This

progression leads, in time, to the complex disaster, chronic pain.


A myofascial TP is defined as "a hyperirritable spot, usually within a taut band of skeletal muscle or in the muscle's fascia, that is painful on compression and that can give rise to characteristic referred pain, tenderness,

and autonomic phenomena. The term myofascial pain syndrome is used here either

with a specific or a collective meaning. A single-muscle MPS refers to the signs and symptoms caused by active TPs in one specific muscle. Generically, MPS as used in

the title, refers to the diagnosis and the signs and symptoms associated with one or many single-muscle myofascial pain syndromes due to TPs.


Confusion developed over the past century because successive research authors recognized different, often overlapping,

aspects of pain due to myofascial TPs and sometimes included features of other conditions. Many authors used general terms applicable to the whole body, such as fibrositis (which has accrued multiple meanings through the

years), fibromyalgia, muscular rheumatism (used in Europe for nearly a century), nonarticular rheumatism, myogeloses (muscle gelling), Muskelharten (muscle

hardenings) in Germany, interstitial myofibrositis in America, myalgia or myalgic spots in England, and osteochrondrosis in Russia.


Other authors used terms applicable to one region of the body without noting its muscular origin or its commonality with other parts of the body. Examples include: occipital neuralgia, tendinitis, tennis elbow,16 chest wall syndrome, scapulocostal syndrome, lumbago, and

sciatica. Each of these terms may be used to identify at least two conditions, one of which is often MPS due to TPs.



Trigger point pathology

Shortened sarcomeres

Figure 1

Schematic of sarcomeres that are of equal length in normal muscle fibers as compared with the likely distribution of unequal
sarcomere lengths in the fibers of a palpable taut band passing through a trigger point. Shortened sarcomeres in the region of the trigger point would increase the tension in the fascicles of the taut band and restrict the stretch range of motion of the muscle. The ropy sensation produced by rubbing the tip of the palpating finger across the muscle fibers of a palpable taut band at the TP can be
explained by contracture. 
Palpation of the muscle reveals increased muscle tension
due to tautness of the palpable band.

Metabolic distress

Figure 2

Schematic of a cycle of events that could maintain sarcomere shortening. The process would begin with release of ionized calcium
from ruptured sarcoplasmic reticulum. Vigorous contractile activity increases local metabolic'demand. Vigorous local sarcomere shortening compromises local circulation producing anemic hypoxia, which could compromise the adenosine triphosphate (ATP) energy supply of the sarcoplasmic reticular compartment. The resulting failed calcium pump of the sarcoplasmic reticulum (SR) would leave the ionized calcium free to maintain the spontaneous contractile activity.

Some trigger points

Sub-occipital 

Lateral malleolus

Trapezius

Brachio-radialis

Technique for the forearm extensor muscles

The movie above demonstrates the skill of myo-articulation. This a method which combines an incremental stretching of the muscle and tendon whilst fixating the muscle at the various trigger points or tight zones along its length.







Trigger point techniques when combined with myo-articulation resulting in the lengthening of the sarcomeres (the little squares of the grid).

Above all these techniques require great palpatory skill and a deep knowledge of the structures and tissue behaviours involved.

It is important that therapists do not not 'damage' the muscles due to heavy, sudden and irritating technique application. All pain is NOT gain.





How does a muscle/tendon get shortened in this way?

There are various general factors involved in the pathological process.

1. Habit

2. Previous strains

3. Over-use

4. Tissue type

5. Reflex threshold of an individual

6. Underlying medical conditions

7. Dehydration

8. Mineral deficiencies

9. Reflex sympathetic dystrophies

10. Joint injuries

11. Spine tension patterns

12. Lack of sleep


The most common precipitating cause of problems in the forearm and hand appears to be long, intense periods of work. For example working 14 hours a day for two weeks on an IT project or rehearsing for a performance in the case of musicians.


This period makes the deep, stabilising muscles gain tone (hypertonus). These muscles tend not to relax when not in use.. Thus tension can build in them until the 'last straw' comes along and the muscle seizes up with pain.


Very minor repetitive activities such as using your thumbtip to navigate your mobile phone can cause problem in the little thumb flexor tendons. this can proceed to osteo-arthritic changes in the local joints.

Any  reduction of the range of movement to the joints will be a major contributing factor. These need to be mobilised, their ligaments stretched and the joint space to be increased via various techniques. 



I hope that this has been of help to your understanding of this most important subject.



Now, if you would like to take a further step in defining your problem,
please take advantage of the online case history process that I have designed and coded at workplacewellness.london.

Your business and employees deserve better, give yourselves a 360 review of their physical and mental health.


Paul Manley Back Pain and RSI Clinic at The London Natural Health Centre