What is a trigger point?

A trigger point is a knot in a band of muscle tissue, in which several fibres are in a state of permanent contraction. Typically, a trigger point is about the size of a pea, but it can also be as small as a pin-head. A trigger point keeps a muscle continuously under tension. In most people dozens of trigger points can be found and often you do not notice them at all in all day life.

How do trigger points develop?

The most frequent cause for a trigger point to develop is the overuse or overload of a muscle. Often, stress is a contributing factor. A trigger point is the last resource available to the body to contract a muscle when there is no energy left. Another frequent cause is tissue damage. By tensing certain muscles, the body tries to protect the damaged spot. The brain infers from messages from the nervous system, that something has been damaged. Unfortunately those messages are not always reliable. Therefore, trigger points can also be the consequence of a disturbance in the nervous system. A muscle can also develop trigger points if the motor nerve supplying it is dysfunctional. Trigger points can also induce new trigger points themselves, as explained later on this page. It is not always possible to find out why a trigger point has developed. Sometimes trigger points continue to exist when the reason for them has already disappeared. However, as long as the cause remains, trigger points will return after a treatment.

Trigger points and pain

Trigger points can arise from pain and can cause pain themselves. As a rule, the pain is felt at a distance from the trigger point. The trigger point itself hurts only when you firmly press or squeeze it. As an example, the following drawing illustrates the pain pattern of a certain trigger point in the front of the neck. The black cross is the position of the trigger point, the red area and the red spots are possible places where the trigger point can send its pain. This is one of the body's worst trigger points, because it is situated so close to a big nerve bundle. Fortunately trigger points are usually latent, meaning that they shorten the muscle in which they reside but do not refer pain. On the other hand, an active trigger point radiates pain and can baffle patients as well as physicians, because nothing special can be found at the painful place itself.

[Scalenus trigger point, Travell & Simons Vol. 1 Figure 20.1A]
Source: Travell & Simons, Myosfascial Pain and Dysfunction — The Trigger Point Manual, Volume 1, Figure 20.1A.

Other effects of trigger points

Trigger points can also influence the autonomous functions of the body, such as the digestion, the circulation, the sweat secretion, the sense of balance and the vision. Because they disturb the balance between synergists (muscles that contract together to accomplish the same body movement), trigger points can also lead to misalignment of limbs and incorrect movement patterns, which in turn result in wear and tear in joints. The tension in muscles harbouring trigger points can overload other muscles and in this way induce new trigger points. New trigger points can also develop in the area to where the trigger point sends its pain, for instance because the brain interprets the pain as tissue damage.

Trigger points can manifest themselves in still many other ways. Most of the ailments mentioned on my page Mobilising massage can be caused by trigger points. For further information I refer to the links in the last section of this page.

Via the nervous system, trigger points can in principle influence every bodily function, but that does not mean that every symptom or disease is always called by trigger points. Nevertheless, it is always worthwhile to try out trigger point therapy, provided there is no indication of a serious injury or disease that would require immediate medical intervention: A trigger point treatment carried out by a professional is affordable, safe and without adverse side effects.

Treatment of trigger points

In the beginning of my career as a massage therapist, I treated all trigger points I found and then hoped that they would stay away. Nowadays, I try in the first place to trace and treat the causes. A trigger point is a way in which the body adapts to a disturbing factor. For instance, in case of a head forward posture, trigger points in the back of the neck help to prevent the head from falling further forward. When a peripheral nerve is pinched, trigger points limit the motion in the limbs, so that the nerve cannot be damaged by excessive lengthening. In these examples, the treatment of the trigger points without treating their cause will result at best in a temporary relief of the symptoms, but at worst in later aggravation of the symptoms or even in new complaints. However, after treatment of their causes, many trigger points resolve by themselves.

The cause of a trigger point can also be another trigger point. When a client comes to a therapist, the trigger points usually have spread already in a long chain across the body. Treatment of a single trigger point in the chain makes no sense. Without treatment of the whole chain, the trigger point will return in no time.

If it is not possible to do something about the cause and the trigger point does not produce pain or other symptoms, it is generally the best to leave it alone. However, when the trigger point does cause symptoms and it is not possible to remove the disturbing factor, there are several possible choices:

  • treating the trigger point and asking the client to return regularly for a new treatment;
  • treating the trigger point and teaching the client its self-treatment too;
  • treating the trigger point and in addition giving the body an option to adapt itself in a better way to the disturbing factor.

My preference is the last choice, although it is not always the easiest one. For instance, if sitting in front of a computer causes trigger points, I can aid the client in finding a better posture. For this purpose, it is necessary to release all tension in muscles and connective tissue (fascia) that hinder the body from assuming and keeping up that better posture. Of course, the client should then really use that better way of sitting, without falling back into the old posture.

A wrong posture or movement pattern can also be maintained by factors outside the body. For instance computer screens, office chairs, car seats, multifocal or progressive lenses, running shoes and orthotic insoles can have been adjusted or selected such that they feel comfortable in the old posture. When these devices are not re-adjusted or replaced, it will be impossible to maintain a new posture or movement pattern. Therefore, the success of a trigger point treatment depends also on how well the client recognises these external factors and is willing or has the possibility to do something about them.

There are many ways to deactivate trigger points. Generally a therapist will select the applied technique in accordance with his or her education:

  • physicians prefer to inject an anaesthetic into the trigger point;
  • acupuncturists stimulate the trigger point by insertion of an acupuncture needle (dry needling);
  • massage therapists and physiotherapists are usually more familiar with compression techniques, similar to acupressure;
  • the Swiss approach to trigger point therapy combines local trigger point massage with treatment of the whole connective tissue sheath of the muscle in which the trigger point resides;
  • Fascial Manipulation, in contrast to the Swiss approach, is directed exclusively to a densified spot in the muscle sheath directly over the trigger point; this densification is seen as the cause of the trigger point as well as the radiated pain;
  • indirect techniques are not directed to the trigger point or the tissue immediately around it, but work by calming down the nervous system.

Because of my training in fascial treatments, I usually select the Swiss approach. Occasionally I also use indirect techniques. I consider also Kalevala bonesetting an indirect method, even though it has not been specially developed for trigger point therapy. The main advantage of indirect techniques is that they do not hurt. Therefore, they are the first choice in case of sensitization of the nervous system, e.g. in fibromyalgia patients. Another advantage is that they can be used when the trigger point is not accessible for direct treatment. The disadvantage of indirect techniques is that they are often not sufficient by themselves. In that case, they must be followed by a direct technique. Direct techniques hurt, but when carried out correctly, they feel relieving at the same time.

Regardless of the way in which the trigger point is treated as a symptom, in my view the most important part of trigger point therapy is to trace and — to the extent possible — treat the cause.

Further information on triggerpoints

The best place to learn more on trigger points is the web site of The Trigger Point Therapy Workbook by Clair Davies. I used this book to learn to treat my own trigger points. Davies has also written a book specifically on self-treatment of muscles involved in the frozen shoulder syndrome. Although Davies’ books are very well written, learning to find your way in your own body is not an easy task and it is possible that you will need additional guidance. I can recommend the books by Valerie DeLaune as additional resources. In my opinion, Davies gives more detailed instructions for self treatment, but DeLaune has better-looking illustrations. In contrast to Davies, DeLaune shows stretching exercises for the muscles and mentions possible causes outside the muscular system for the symptoms. Another useful place for general information about trigger points is the website of the NAMTPT. Devin Starlanyl discusses the relationship between trigger points, chronic myofascial pain and fibromyalgia.