Trigger points, muscle knots, and myofascial pain syndrome

You can find the video after the text

In this video, I will tell you what trigger points, muscle knots, and myofascial pain syndrome are, if the conditions exist and how to treat painful muscles.

My name is Andreas Persson and I am a physiotherapist and specialist in pain and pain rehabilitation.

Trigger points

I want to start by saying that the phenomenon of trigger points probably does not exist, at least in the form that the proponents mean. I will talk more about that later but will first describe trigger points as described in educations and the literature for physiotherapists, massage therapists, and other therapists and how the therapists describe it to their patients.(1)

If you have a lump in the muscles or other soft tissues, it is important to have it examined by a physiotherapist, a nurse, or a doctor. Especially if it is firm, growing, and does not disappear when you massage it yourself. It could be a tumor, a swollen lymph node, or something else, but it could also be the type of muscle knot we will be talking about in the video.

How trigger points manifest themselves: As painful knots in muscles that often also cause pain in another area, which becomes more evident when you press on the knot.(2)

The cause of trigger points: The cause is considered to be muscle overload. Often through repetitive or static work.(2)

Myofascial pain syndrome: Myofascial pain syndrome is a diagnosis that is still used a lot in healthcare. The diagnosis means that you have pain that is caused by trigger points.(3) 

How trigger points are examined and diagnosed by a physiotherapist, a doctor, massage therapist, or other alternative therapists:

Either the therapist actively feels for a trigger point based on the area the patient describes as painful. There are maps of where the most common trigger points are and wherein the body they cause pain. Often the so-called trigger point does not hurt by itself except when you press on it, but the pain is located at some distance from the knot. If the therapist hears that it hurts in one of these areas that may be caused by a certain trigger point, the therapist examines the muscle that according to the map may be the cause of the pain.

The second way that is more common among massage therapists is that the therapist feels a lump in a muscle when massaging it. The therapist then tries to press on the lump to see if it hurts.

Criteria for trigger points:

The most commonly used criteria to determine that a trigger point is present and that it is the cause of a patient’s pain are: The therapist should feel a tense band of muscle fibers in the muscle and on the band, there should be at least one lump. When the therapist presses on the lump, it should lead to increased pain locally or in another nearby or referred area that the patient recognizes as the pain that he or she is usually bothered by.(2)

A phenomenon that is considered typical of a trigger point is that when the therapist pulls a finger over the tense band in the muscle, it leads to the muscle reflexively jerking.(2)

Trigger points and muscle knots

Trigger points are often called muscle knots by masseurs and by people in general.

What are the trigger points considered to be?

The most common explanation for muscle knots, or trigger points, is that overloading certain muscle fibers in a muscle leads to a lack of ATP. ATP is a local form of energy used by muscle cells. When signals are sent from the brain for a muscle to be activated, many different processes start in the muscle. ATP is required for the muscle cell to then relax again. When there is no ATP, the muscle fiber remains tense. The fact that the muscle fiber remains tense leads to a deficiency of blood circulation, that there is both a lack of oxygen and a lack of energy in the muscle, and the release of various substances that cause pain. It is these changes that are considered to create the knot in the muscle. The knots are believed to be in the areas where the nerve that controls the muscle has contact with it.(2)

How to treat trigger points:

Several different methods are considered to be able to dissolve trigger points and make the muscle relax.

  • Injection of a local analgesic into the trigger point (2)
  • Dry needling. A type of acupuncture where the therapist inserts a needle into the trigger point (2)
  • Stretching the muscle with the trigger point (2)
  • Spray and stretch: The therapist sprays a cold liquid over the muscle to distract the treated person, which allows the muscle to be stretched more forcefully (2)
  • Hard pressure on the trigger point (2)

History

The hypothesis of trigger points was created in the middle of the 20th century. The term trigger point was coined by an American doctor named Janett Travell. She was interested in muscle pain and used several different methods that at least to some extent seemed to have a good effect. President John F Kennedy had major back pain problems after several back surgeries. Travell was consulted and was able to help Kennedy, which later made her the president’s doctor. The results of her treatment of the president were probably a strong contributing factor to her hypotheses about trigger points becoming so well-known and widespread around the world, despite having so little scientific support.(4)

Evidence

When I started talking about trigger points, I said that the phenomenon probably does not exist. I’ll explain what I meant. I do not doubt that there may be soft lumps or knots in the muscles. Lumps that sometimes disappear if you massage them or treat them in any way. Of course, people also have pain in their muscles, often due to overload. There is good evidence for referred pain, that is, when there is an injury or when you press hard on one place on the body, it can hurt in another place.(5,6)

What probably does not exist is what is described as trigger points with the physiological process that the proponents believe leads to pain. I think the lumps in the muscles are something else and that the pain has other explanations.

Several reasons make me believe that trigger points do not exist.

The hypothesis behind trigger points, that overloaded muscles end up in a spasm where certain muscle fibers cannot relax, which leads to a lack of oxygen and pain, is not supported by any experimental evidence. (3)

In studies, scientists have injected botox into so-called trigger points without any positive effect on the pain. Botox blocks the connection between nerve and muscle and makes a muscle completely relaxed. In the study, the botox treatment caused the treated muscles to relax completely but it did not affect the pain. Should the pain be due to muscle fibers not relaxing, it should lead to the pain disappearing. But that was not the case.(3)

Although the concept of trigger points has existed since the 1950s, in diagnostic imaging studies (ie magnetic camera examinations and the like) or with techniques where muscle activity is measured, one has not been able to reliably see a clear connection between the changes that proponents of trigger points claim and pain in those examined.(3)

Diagnosis of trigger points is not reliable: Studies show that if several different experts on trigger points examine a person who is considered to have trigger points, they will not find the same thing. One expert finds a trigger point in a muscle while the colleague does not, but instead finds other trigger points in other muscles that the first colleague did not find. This indicates that the diagnosis is not reliable.(3)

Based on studies where the various treatments recommended for trigger points have been tested, there is no clear evidence that they help.(3) I believe that some of the treatments used against trigger points may help some, but not through the mechanisms that trigger point advocates believe.

Summary trigger points, muscle knots, and myofascial pain syndrome

Trigger points are a very commonly used explanation for muscle pain. The explanation is used by doctors, physiotherapists and also by massage therapists, and other alternative therapists. People in general often use the term muscle knots instead. Trigger points are considered to be caused by overexertion of muscles that leads to tense muscle fibers that can not relax, which leads to pain both in the muscle but also in other referred areas. There is no good evidence that muscle pain is caused by trigger points or that trigger points or the diagnosis of Myofascial pain syndrome as described at all exists. There is also no good evidence that the treatments used against trigger points are effective.

But now maybe someone is thinking, what is he talking about? I have felt that I have lumps in my muscles. When I press the lump, it hurts, not only where I press but also in another area.

Or you have been to a massage therapist where the therapist told you that you have muscle knots. When the therapist pressed on the muscle with muscle knots, it hurt. Maybe not just where the therapist pressed but it also radiated to another area. After the massage treatment and perhaps also the specific treatment of the muscle knot where the therapist pressed hard on the area, it felt much better. Is not that evidence enough that trigger points exist?

These are ordinary experiences, something I have experienced, both when I have been massaged and when I have massaged others.

Does this mean that trigger points exist! – Or ??? It is not entirely clear what the muscle knots are, but there is no doubt that they exist. However, it is good to know that you can also find knots in muscles that do not hurt. It may be that there are knots in different muscles in the body but that they are not related to pain in the muscle? It is quite clear that many people experience pain in various muscles in the body. But the cause is probably something else than trigger points.

Other explanations for muscle pain

But if muscle pain is not caused by trigger points then what is it caused by? I will now talk about a couple of causes for which there is much better scientific evidence than trigger points.

As mentioned in my previous video about pain without explanation, there are three types of causes of long-term pain. When it comes to pain in muscles where there is no clear loss of sensation or anything else that indicates nerve damage, it is most likely that the pain is due to inflammatory or nociplastic pain.

Inflammatory pain is often caused by overloading some part of the body, which then leads to inflammation in the tissue. The inflammatory substances in turn make the pain nerves in the body more sensitive. In some cases, the inflammatory pain can also be caused by a rheumatic disease where the immune system attacks body tissues, creating inflammation. (7)  

Nociplastic pain is caused by the pain system becoming more sensitive. There is good evidence for several different physiological processes in the central nervous system that cause nociplastic pain.(8-10) Nociplastic pain can have several different causes. There is a strong genetic component, which means that you have an increased risk of developing this type of pain if you have a close relative who also has the same type of pain.(11) But injury and inflammatory pain are also a clear risk factor.(12,13) If you have injuries that are not allowed to heal for a long time, it increases the risk of the changes that occur in the pain regulation system that makes it more sensitive. Other risk factors for nociplastic pain are stress and lack of sleep.(12,14) 

Treatment of muscle pain

But if the pain you have is not due to trigger points but instead inflammation, then how do you get rid of it. The first step is to find out what is causing the injury and inflammation. If you do something that repeatedly overloads, for example, a muscle, it is a good idea to change that activity so that the tissue gets the opportunity to heal. Properly dosed exercise of the injured tissue also tends to improve healing.

If the pain instead is due to the pain system becoming more sensitive, that is Nociplastic pain. How do you do that to treat it? If you can influence any of the risk factors, for example, stress and lack of sleep, it can be a good idea to do so because it can probably also reduce the pain. Even with nociplastic pain, physical exercise can help.(15)  With this type of pain, however, it is better to use a different strategy. With nociplastic pain, training of other parts of the body also helps to reduce the pain, while one must be more careful with the training of the painful muscle.(16) Being more careful does not mean that you should not train it at all, but the training probably needs to be much lighter. Just as with inflammatory pain, you need to review activities that strain the painful tissue. These can be activities both at work and in your free time. Maybe you can remove or change some activity so that the pain is reduced?

Sometimes one of the treatments used for the treatment of so-called. Trigger points also help against inflammatory and nociplastic pain. The treatment effect is then probably not due to local effects in the muscle being treated but by effects in the spinal cord and brain that the sensory stimulation of the treatments creates.(17) The sensory signals can inhibit pain signals both directly in the spinal cord but also through various systems in the brainstem.(18-20) If you have a positive effect of massage, acupuncture, or stretching, then continue with it by all means.

If you liked this video, press the like button. Check out my youtube channel if you want to see more videos about long-term pain. Subscribe and tap the clock icon if you do not want to miss any new videos in the future.

References

1. Simons DG, Travell JG, Simons LS. Travell & Simons’ myofascial pain and dysfunction Vol. 1 Upper half of body. Baltimore:Williams & Wilkins;1999.

2. Shah JP, Thaker N, Heimur J, Aredo JV, Sikdar S, Gerber L. Myofascial Trigger Points Then and Now: A Historical and Scientific Perspective. PM R. 2015;7(7):746-61. 

3. Quintner JL, Bove GM,  Cohen ML. A critical evaluation of the trigger point phenomenon. Rheumatology (Oxford). 2015;54(3):392-9. 

4. https://en.wikipedia.org/wiki/Janet_G._Travell

5. Doménech-García V, Palsson TS, Herrero P, Graven-Nielsen T. Pressure-induced referred pain is expanded by persistent soreness. Pain. 2016;157(5):1164-72.  

6. Doménech-García V, Skuli Palsson T, Boudreau SA, Herrero P, Graven-Nielsen T. Pressure-induced referred pain areas are more expansive in individuals with a recovered fracture. Pain. 2018;159(10):1972-9.

7. Alam J, Jantan I, Bukhari SNA. Rheumatoid arthritis: Recent advances on its etiology, role of cytokines and pharmacotherapy. Biomed Pharmacother. 2017;92:615-33. 

8. http://andreasfysio.se/darfor-gor-det-ont-vid-fibromyalgi/

9. http://andreasfysio.se/forstarkt-smarta-och-vilovark-vid-fibromyalgi/

10. http://andreasfysio.se/eftersmarta-och-spridd-smarta-vid-fibromyalgi/

11. Nielsen CS, Knudsen GP, Steingrímsdóttir Óa. Twin studies of pain. Clin Genet. 2012;82(4):331-40.

12. Hawkins R. Fibromyalgia: A Clinical Update. J Am Osteopath Assoc. 2013;113(9):680-9. 

13.  Ji RR, Nackley A, Huh Y, Terrando N, Maixner W. Neuroinflammation and Central Sensitization in Chronic and Widespread Pain. Anesthesiology. 2018;129(2):343-66. 

14. Harte SE, Harris RE, Clauw DJ. The neurobiology of central sensitization. J Appl Biobehav Res. 2018;23(2):e12137. 

15. Macfarlane GJ, Kronisch C, Dean LE, Atzeni F, Häuser W, Fluß E, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis. 2017;76(2):318-28. 

16. http://andreasfysio.se/nine-rules-for-exercise-with-fibromyalgia/

17. Norrbrink C, Lundeberg T, Molin B, Lund I, Lundebergi S. Om smärta – ett fysiologiskt perspektiv. Lund: Studentlitteratur;2010.

18. Littlejohn G. Neurogenic neuroinflammation in fibromyalgia and complex regional pain syndrome. Nat Rev Rheumatol. 2015;11(11):639-48. 

19. Lockwood S, Dickenson AH. What goes up must come down: insights from studies on descending controls acting on spinal pain processing. J Neural Transm. 2019;127(4):541-9. 

20. Coutaux A. Non-pharmacological treatments for pain relief: TENS and acupuncture. Joint Bone Spine. 2017;84(6):657-61. 

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