Intro to Trigger Points

What is a trigger point?

consistently produces a reflex mechanism that gives rise to referred pain and/or other manifestations in a consistent reference zone that is consistent from person to person

Trigger points vs Tender points

Trigger points cause referred pain, tender points do not.

Who treated JFKs lower back pain with procaine injections to his lumbar spine and became appointed as personal physician to the President as a result?

Dr. Janet Travell

What are some common findings of trigger points

• Palpable taut band with cross-fiber flat or pincer palpation

• Hypersensitive spot within the taut band

• Local Twitch response when adequately stimulated

• May produce motor and autonomic phenomena

• May prevent full lengthening of the muscles

• May cause inhibition weakness of the muscles

What characterizes an active trigger point?

produces the patient's pain and symptoms

can cause spontaneous pain (no need to set it off)

easily reactivated

What characterizes an latent trigger point?

unrecognized pain

only works when palpated

does not reproduce patient's symptoms

Trigger Point vs Counterstrain Point

trigger point has characteristic pattern, in a taut band, radiates, twitches, treated with stretching

In a few words, differentiate between trigger points, counterstrain points, and radiculopathy.

Trigger points = non-dermatomal referral + taut band

Radiculopathy = dermatomal pattern +neurologic signs

Counterstrain = local tenderness

In which muscles can trigger points commonly occur?

scalenes

SCM

upper traps

infraspinatus

QL

glutes medius and minimus

gastrocnemius

vastus medius

TFL

What are the 6 Osteopathic Treatment options for trigger points?

TRIGGER POINT PRESSURE RELEASE/ISCHEMIC (DIRECT) COMPRESSION

MUSCLE ENERGY (POST-ISOMETRIC RELAXATION OR RECIPROCAL INHIBITION)

STRAIN-COUNTERSTRAIN

MYOFASCIAL RELEASE (DIRECT OR INDIRECT)

DRY NEEDLING OR TRIGGER POINT INJECTION

SPRAY-AND-STRETCH

Which Osteopathic Treatment options for trigger points are manual?

Ischemic compression/Pressure Release, Muscle Energy, Strain-Counterstrain, Myofascial Release

Which Osteopathic Treatment options for trigger points are procedural?

Dry needling, Trigger Point Injection (lidocaine or saline), Spray-and-Stretch

How does TRIGGER POINT PRESSURE RELEASE/ISCHEMIC (DIRECT)COMPRESSION work?

Sustained, tolerable pressure on the nodule to lengthen sarcomeres and reset muscle spindle activity

What are some contraindications to TRIGGER POINT PRESSURE RELEASE/ISCHEMIC (DIRECT)COMPRESSION?

Acute fracture, local infection, open wound, severe coagulopathy, uncontrolled bleeding disorder

How does MUSCLE ENERGY (POST-ISOMETRICRELAXATION OR RECIPROCALINHIBITION) work?

Gentle isometric contraction followed by stretch to lengthen hypertonic fibers

What are some contraindications to MUSCLE ENERGY (POST-ISOMETRICRELAXATION OR RECIPROCALINHIBITION)?

Acute muscle tear, severe unrelieved pain, inability to follow commands

How does STRAIN-COUNTERSTRAIN work?

Position of maximal comfort shortens the muscle, decreasing gamma gain and muscle spindle firing

What are some contraindications to STRAIN-COUNTERSTRAIN?

Inability to tolerate positioning (fracture, vascular compromise)

How does MYOFASCIAL RELEASE (DIRECT ORINDIRECT) work?

Engages fascial tension to restore tissue mobility and circulation

What are some contraindications to MYOFASCIAL RELEASE (DIRECT ORINDIRECT)?

Acute cellulitis, open wounds, deep venous thrombosis, malignancy in treatment region

How does DRY NEEDLING OR TRIGGER POINTINJECTION work?

Mechanical disruption of the taut band and chemical modulation (with or without local anesthetic)

What are some contraindications to DRY NEEDLING OR TRIGGER POINTINJECTION?

Anticoagulation or bleeding disorder, local infection, patient refusal, allergy to anesthetic (if used)

How does SPRAY-AND-STRETCH work?

Rapid cutaneous cooling with a vapocoolant (e.g., ethyl chloride) followed immediately by gentle passive stretch

What are some contraindications to SPRAY-AND-STRETCH?

Hypersensitivity or allergy to vapocoolant ingredients, cold-related disorders (Raynaud's, cold urticaria, cryoglobulinemia), open wounds or skin infection at the treatment site, impaired peripheral circulation, or inability to protect skin from excessive cold

What is the difference between Wet Needling and Dry Needling?

Dry needling (DN): solid filiform needle (Acupuncture needle) into the trigger point; no injectate

Wet needling / Trigger point injection (TPI): needle plus injectate (e.g., lidocaine)

T/F - You can inject things like sterile water or saline in place of anesthetics in wet needling

T

No single pharmacologic agent has proven superior to others or to placebo for this

T/F - After needling the patient, you should apply pressure on the site needled for 30-60 sec and make sure the patient does NOT move the treated muscle

F

patient needs to move the muscle 3X after needling

AND THEN you need to give it a gentle stretch

T/F - Evidence shows no clear advantage of adding corticosteroid to local anesthetic for needling

T

What does "Spray and Stretch" do to the pain threshold?

Cryotherpy counteracts the change in pain threshold. Decreasing nerve conduction as well as nociceptive threshold, requiring more noxious input for perception of pain

decrease inflammatory changes reducing histamine, mast cells, substance P, calcitonin, bradykinin, and others which can potentially prevent central sensitization

What are some indications for using the Spray and Stretch?

• Active or latent myofascial trigger points causing:

• Local or referred myofascial pain

• Muscle tightness or spasm

• Limited range of motion

• Acute muscle strain where guarding prevents direct pressure

• Postural or repetitive-strain syndromes with shortened muscle groups

• Patients intolerant of needling or injection, or when invasive therapy is contraindicated

• Adjunct to rehabilitation: to allow pain-free stretching before strengthening or corrective exercise

What is the difference between Pain and Nociception?

Nociception: physiological process of detecting a noxious stimulus

Pain: subjective, multidimensional experienceshaped by sensory, emotional, and cognitive factors

Trigger Points can progress to ____________________

Myofascial Pain Syndrome (MPS)

Describe the pathophysiology of a trigger point

Triggered by acute trauma (injury) or chronic overload (posture, repetitive strain)

Muscle overload exceeds local metabolic supply

Sustained contraction → ischemia, impaired perfusion, energy crisis

Localized dysfunction leads to a taut band / trigger point formation

Fascia plays a role in distributing to and transmitting mechanical stress

Describe the cellular basis for the formation of a trigger point.

Overload leads to sustained sarcomere contraction → contracture knot Appears on EMG as endplate noise (physiologic marker of trigger points)

______________ on EMG is a physiologic marker of trigger points

endplate noise

Complete the Energy Crisis Model Description Below:

______________________________

-->Compression of vessels

--> (↑ or ↓?) acetylcholinesterase AND Ischemia, (↑ or ↓?) oxygen delivery, (↑ or ↓?) ATP production

--> ATP required for Ca²⁺ reuptake into sarcoplasmic reticulum

--> Without ATP → Ca²⁺ accumulates, sarcomeres remain contracted

--> (↑ or ↓?) Energy Supply + (↑ or ↓?) Energy demand

Sarcomere contracture

↓, ↓, ↓

↓, ↑

What is a hallmark of pain pathophysiology?

Central sensitization

Hyperalgesia, allodynia

Inhibitory interneurons fail → loss of normal "braking" of pain signals

What can OMT do for trigger points? Fill in the chart below:

• (↑ or ↓?) nociceptive input

• (↑ or ↓?) dorsal horn sensitization

• (↑ or ↓?) sympathetic drive

• (↑ or ↓?) endorphin release (decreases nociceptive input and sensitization)

• (↑ or ↓?) circulation and (↑ or ↓?) ischemia

• "Reboots" the whole system to the present moment (new pattern)

↓

↓

↓

↑

↑, ↓

________________ + ________________ → contracture knot

energy crisis, NMJ dysfunction

What is the relationship between Trigger Points, MPS, and CPS?

Trigger Point - hyperirritable spot in a taut band with end plate dysfunction

persistent nociception gets CNS involved and progresses to MPS (Myofascial Pain Syndrome)

when the CNS "pain alarm" is active for months beyond when the injury should have healed and continues to be active regardless, it has progressed into CPS (Chronic Pain Syndrome)

T/F - Estrogen can influence pain while testosterone tends to have a protective, anti-pain effect

T

______________________ is associated with muscle pain and TrPs (trigger points)

subclinical hypothyroidism

A lack of sufficient __________ is strongly associated with muscle pain and can be a perpetuating factor for myofascial pain syndrome

sleep

A link has been shown between __________ deficiency and chronic widespread pain, including fibromyalgia

Vitamin D

In addition to vitamin D, there are 2 minerals that play a role in trigger points. What are they?

iron, magnesium

What are some things people can do for at-home trigger point care?

localize to the trigger point with a lacrosse ball or foam roller and self treat using trigger point release compression

make sure to gently stretch the muscle after this treatment

What are some risk factors for trigger points?

bad posture

fascia can transmit pain

forward head posture

hypermobility

____________ is a risk factor for tension headaches

forward head posture

What can someone do to prevent trigger points?

• Move Regularly• Keep Your Core Strengthened• Maintain Physiologic ROM• Consider early treatment for TrPs

• Hydrate and Optimize Fascia• Address postural asymmetries early• Nutrition, sleep, and hormonal balance• Maintain a healthy narrative of pain• Prevent CNS Hypersensitivity