Trigger Points in Manual Medicine…let’s stop just rubbing muscles

Posted: November 24, 2013 in Manual Therapy

Trigger points are a hot button issue in manual medicine. The research on their existence is sparse and there is considerable amount of subjectivity in the ability to find a Trigger point (TrP). Although their true nature is uncertain, the dominant theory is that a TrP is a small patch of tightly contracted muscle, an isolated spasm affecting just a small patch of muscle tissue (not a whole-muscle spasm like a “charlie horse” or cramp). That small patch of knotted muscle cuts off its own blood supply, which irritates it even more — a vicious cycle called “metabolic crisis.” And when we have a lot of these Trps in various muscles within the body, we call it myofascial pain syndrome…a diagnosis given a lot!

TrP’s are tricky in that they can be elusive to find. For example, did you know anterior wrist pain that is often diagnosed as carpal tunnel actually stems from a TrP in the subscapularis muscle! (a muscle located under your armpit). Therefore, carpal tunnel release surgery may do nothing to help with wrist pain if the TrP of the subscap isn’t released (how that is done is highly debatable and will be discussed a bit).

How do we find these TrP’s?

Pragmatically speaking, I find them by trial and error. For example, if someone comes in with radiating pain down the leg stemming from their butt and I press on one of the hip external rotators (specifically the inferior gemellus muscle….what? You don’t know how to isolate that muscle? Shame on you 😉 and it reproduces their leg pain I can be reasonably assure that they have  TrP causing their symptoms. How these tender points developed is also up for debate. But there are schools of thought that say that a TrP can be caused by being sedentary (sitting on your ass all day), over activity within a certain muscle (think over training), trauma to a muscle (think falling down or car accident) or nutrition deficits (such as lacking vitamin D). In all honesty, if someone comes in with pain of insidious onset (no known injury), I have to look for trigger points…It’s a must!

 Okay, so I think I have found a TrP in a muscle, how do I get rid of it? 

This is a hard question to answer as there is no good evidence that any one method is superior to another. In my experience, pinning a muscle at the site of the TrP and having the client actively move through a non to minimally painful range of potion while the TrP is under compression tends to help..similar to ART I would say (?). I also employ proprioceptive neuromuscular facilitation (PNF) stretching to help “trick” the nervous system into letting go of tight bands of muscle. This ‘contract-relax’ method works only after manual “release” of the TrP in question has been achieved (that is my opinion only, FYI). I also know some physiotherapists who use intramuscular stimulation (IMS) to destroy TrP’ whereby a muscle is stabbed at various angles using an acupuncture needle…sound fun, right? Again, the science behind IMS is hit or miss, but anecdotally I have heard great success stories with its use. I commonly hear “it hurt more than pregnancy but it really helped my pain!”

To end off this small introduction on TrP’s I wanted to share with you the top 5 Trigger Points I treat and have had great success with. The “X” on the muscle shows where the trigger point is and the red dots show you where the trigger point can refer pain into….pretty cool pics from

1) Subscapularis  (posterior shoulder, lateral arm and anterior wrist pain)

Subscapularis Trigger Point Diagram

2) Levator Scapulae (chronic neck pain/tightness), pain along the medial scpaular border
Levator Scapulae Trigger Point Diagram

3) Pec minor (anterior shoulder and medial arm pain..symtoms of TOS or numbness into fingers 4 and 5 can be helped with pec minor relase)
Pec Min Trigger Point Diagram

4) Gluteus Medius ( “Sacroiliac joint” pain…always check glute med first! It’s rarely the joint itself causing the pain)

Glut Med Trigger Point Diagram

5) Solues (Plantar facitis..check the solues)
Soleus Trigger Point Diagram

Next time you have a patient with pain without any one particular reason, look for TrP’s…It just might help!

  1. Laura Wheeler says:

    Jesse Awenus, you are one kickass physiotherapist

  2. Bruno Campos says:

    Great post! Congrats. The problem with subscapularis is how do you get your fingers in there…:) I know I have a hard time on that one. What do you think about ME techinque?

    • jessephysio says:

      Thanks Bruno! By ME, I assume you mean muscle energy?

      • Bruno Campos says:

        Yes…for Trigger points. One of the theories is that there’s a compromisse at the end plate, releasing Ca to the extra celular space, further stimulating Ach release, producing more contraction to the point that there’s not enough ATP to bring back the calcium to the sarcoplasmatic reticulum, creating a vicious cycle… So…, ME makes sense in that stretching of the spindle and GTO, and schemic pressure works…just don’t understand how…:)

  3. So true. Not always do they need to be rubbed. I see here in China that their locals go around and rub harder, relaxed? no? ok rub harder! instead of thinking, why? why is the muscle tight? or is it even? is it overactive and thus need to be relaxed. Or is it just holding on tight, because of poor stability at the knee or lumbopelvic region (in the case of the hamstring) for example. Keep the normal thinking coming.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s