Fibromyalgia Basics

Identifying & Treating MTPs

Do you have knotted or ropy muscles that feel lumpy under your skin and hurt when you press on them? These painful areas radiate pain and sometimes tingling sensations to other regions of your body. They are myofascial trigger points (MTPs). Many regional pains, such as headaches, tennis elbow, jaw pain and low back pain, are caused by the presence of one or two MTPs that are overlooked by the treating physician. These regional pains are collectively called myofascial pain syndromes.

You have MTPs throughout your body that are contributing to your muscle pain and stiffness. Identifying and treating these pain-generators is essential for getting your fibromyalgia under control.

MTPs are identified by physical exam, but the catch is that the examiner must be experienced in searching for them. In an era of the seven-minute office visit, physical exams are often rushed, and too much reliance is placed on blood tests and X-rays. Hopefully, you can find a physician, physical therapist, chiropractor, or massage therapist who possesses the skills needed to identify your MTPs. But if you can’t, this article consists of self-help measures you need for tending to your MTPs.

Locating MTPs

Where do you normally find MTPs? They typically reside in the belly of muscles and they feel like a hard knot or bulge in a firm cord running the length of the muscle. Not only does it hurt to press on an MTP, but it can generate severe pain where the muscle attaches to the bone. The physiological state of contraction is what causes the MTP knot in the muscle and it will not return to its relaxed state unless properly treated. The perpetuating factors that contribute to MTPs must also be resolved (see the last section).

If you have read the other articles in this section, you know that MTPs are the source of many muscle symptoms other than pain. For example, they make the muscles feel tight and stiff, and they restrict range of motion. Latent versions of MTPs don’t hurt until pressed, but active versions are more evolved and spontaneously emit pain without any prodding. As a fibromyalgia patient, you probably have a dozen active MTPs and another dozen latents.

When MTPs are pressed, they shoot or refer pain to other regions. The pattern of referred pain can be predicted based on the exhaustive research pioneered by David Simons, M.D., and Janet Travell, M.D. ^1,2 Perhaps you have even seen body diagrams showing these referral patterns in your healthcare provider’s office. The point is, the pain pattern generated by every MTP in each muscle in the body has been thoroughly mapped out by Simons and Travell. But why is this important?

When an examiner presses on a painful area in one of your muscles and you describe the pain pattern it produces, it’s akin to providing “fingerprint proof” that you have an MTP. Your pain description also helps the examiner pinpoint which MTP in a given muscle is the source of your grief. Conversely, if the examiner presses on a muscle area but it doesn’t generate any referred pain, then the examiner knows that they are not pressing on an MTP.  

Making the Diagnosis

If a provider is going to treat an MTP, they may look for additional evidence that they have located the heart of the MTP. Being a centimeter away may still generate some of the painful symptoms, but one must be right on top of the MTP for the most effective treatment results. For this reason, MTP treatment experts look for additional evidence that they have accurately located the trigger.

“A ‘taut band’ must be present in a muscle to have an MTP,” says Barbara Headley, P.T., M.Sc., an experienced physical therapist and electromyographic researcher in Longmont, CO. However, taut bands can be present without trigger points and may represent a group of muscle fibers that have undergone high levels of stress. “Because MTPs cause a shortening of a group of muscle fibers,” says Headley, “the most common description of how an MTP feels is a ‘nodule.’” When muscle fibers shorten (bunch up in a sustained contraction), Headley comments that this can cause stress and additional pain where the muscle attaches to the bone. 

Pain and tenderness in your muscles can certainly exist without MTPs. For the nodule to be diagnosed as an MTP, Headley says the following guidelines are used:

• A painful nodule must be found in a taut (ropy-like) band.
• When the nodule is rolled or snapped, the patient “jumps”— (a jump sign) an involuntary response to the pain of snapping the nodule, but if the MTP is deep within the muscle, this reaction may not be seen.
• Direct pressure on the nodule causes pain. In other words, the patient’s pain is reproduced for active MTPs. For either latent or active MTPs, the pattern of referred pain usually resembles one of the documented patterns by Simons and Travell. The pressure may need to be applied for up to two minutes for the full referral pattern to appear.
• When some MTPs are snapped, a “local twitch response” in the same and sometimes also a nearby muscle can be seen. It is a tiny ripple or twitch of a muscle contraction that can be seen or felt a few inches away from the MTP. The local twitch response provides strong evidence but is not mandatory for making the diagnosis. However, it must be observed to assure that the MTP is being deactivated by a needling technique (dry needling or trigger point injection).

If an MTP is caused by a problem in the muscle, then treating the involved muscle should relieve the MTP.  Hal Blatman, M.D., a holistic pain physician in Cincinnati, OH, says, “At least 70 percent of the pain that causes people with fibromyalgia to suffer is due to myofascial trigger points. Unfortunately, the importance of trigger points is very much underappreciated.”

Blatman claims that treating the MTPs present in fibromyalgia patients offers a tremendous opportunity to reduce the pain. This is why it’s advantageous to have a healthcare team who will help you identify and treat your MTPs. However, studies show that fibromyalgia patients are fairly good at locating MTPs based on examining their muscles for firm nodules that radiate pain. So, if you lack a skilled provider, you can still relieve some of your MTP pain yourself. 

MTP Chain Reactions

People with fibromyalgia have lots of active and latent MTPs, unlike people with regional pain who have just one or two nagging triggers. The purpose of this section is to help you understand why getting a handle on your MTP therapy may take some time. And once you have made progress, it is essential that you adhere to a home program to prevent your MTPs from spiraling out of control.       

Pain can be referred to other body regions from three different types of trigger points: active, latent and satellite. The active MTP is the one that reproduces part or all of your pain when pressed, while latents cause less intense pain when pressed. The referred pain can feel like shooting, aching, throbbing, or tingling sensations. Fortunately, Blatman has written an excellent book on the subject, loaded with illustrations and clear explanations to help patients understand how MTPs work.

If you look at the diagram below (taken from Blatman’s book), the active MTP is the key source of pain and muscle dysfunction. It is the area that is most painful at rest and more so when the muscle “housing it” is used. Latent MTPs are sensitive areas that may become active in generating pain, but as the diagram shows, they are “snoozing” with regard to pain.

According to Blatman, a common example of latent MTPs that become activated is the phenomenon known as the stiff neck. “This may occur when latent trigger points in the neck and upper shoulder musculature activate during the night, causing extreme neck pain and stiffness the next morning,” writes Blatman.

What about satellite MTPs? They used to be latent, but when the active MTP formed, they became more sensitized to produce pain because they are in the “referral zone.” While active MTPs usually develop after trauma or strain to the muscle, the satellite trigger points form in muscles that have not been traumatized.

Satellite regions can behave just like the active MTPs to produce pain, restrict motion, and cause muscle weakness, according to Blatman. Obviously, it is important to treat active MTPs before too many latent trigger points are turned into satellite pain generators. But once satellite MTPs have formed, they must be treated too.

Nervous System Dialogue

Before addressing how to treat MTPs, you should understand that they give off spontaneous electrical signals that feed into the central nervous system (CNS). In turn, the dysfunctional CNS amplifies the MTP inputs and spits signals to other body regions. This is why using your arms to scrub a grill can result in increased pain in your legs. And the more you move muscles with active MTPs, the louder the chatter between the MTPs and the CNS becomes.

The dialogue between your MTPs and CNS becomes a viscous cycle. But more than one study in fibromyalgia patients has shown that treating one MTP can raise pain thresholds (which is a sign of improved CNS function). Yet if either your MTPs or CNS get out of hand, your muscle pain can snowball. On the flip side, anything you can do with medications or nondrug treatments to tone down your CNS may help you get your MTPs under better control.

Muscles with MTPs fatigue four times faster than those without MTPs. Compounding the problem are the findings that blood flow and oxygen delivery to the muscles are greatly reduced in fibromyalgia patients. Unaccustomed work or repetitively straining a muscle could further impair its function and cause MTPs to develop.  

“When a muscle decides to protect against trauma, it does not go into “spasm” as everyone once thought,” says Headley. “It does something much smarter; it becomes as short as it can and it ‘shuts off’ so that the whole muscle is no longer in use. This method of ‘guarding’ does not require a continued energy supply, and the body compensates by using other muscles.” After the healing process is complete, Headley says that the brain may forget to turn the muscle back on. Using equipment that measures muscle activity, Headley identifies inactive muscles and helps patients get them functioning again.

Treating MTPs

What type of treatment should you try first to get rid of your MTPs? C-Z Hong, M.D., of Taiwan, has been researching myofascial pain for 30 years, and comments that “the effectiveness of a certain modality or manual therapy is case by case in fibromyalgia patients.” In addition, deep tissue therapies designed to work out the MTPs are usually too painful for patients, at least in the beginning. For these reasons, “Medication is usually my first choice with fibromyalgia patients,” says Hong. “It may be cheaper and more convenient.” 

Hong may prescribe serotonin-raising agents to increase the pain threshold (e.g., antidepressants) or muscle relaxants to help loosen the knotted muscles as a first step. Next, patients should be able to tolerate a home program that involves gentle stretching of the muscles and therapies aimed at working out the MTPs. 

“I like my patients to feel that they have control over their pain, at least to some degree,” says Headley. “Patients should be taught some techniques to do themselves, but the trick is in the instructions.” If the patient causes their muscles to hurt more, “other MTPs will form to ‘defend against the trauma’ of the treatment,” says Headley. To avoid making matters worse, see Headley’s “how-to” instructions in the next section. 

Using a tennis ball or a “softer” rubber ball placed against a hard surface (a wall, the floor or a table), you can also use the techniques illustrated in Blatman’s book to get at hundreds of common MTPs. The take-home message is, Hong, Headley and Blatman all endorse a home program to help patients gain some control over their MTP pain.

Where or how do you start? You don’t want to stretch muscles containing MTPs without applying pressure to minimize your nodules or MTPs. This could easily make your pain worse.

“Think of your muscles as a set of springs, with the area in the MTP being the tightest wound spring in the entire muscle,” says Headley. “If you stretch the muscle, all of the other ‘springs’ will stretch before the tight spring where the taut band and the MTP are located. You will end up with an overstretched muscle, but the MTP will remain. For this reason, stretching alone (without also applying pressure on the nodule) should be done after the MTP has been released (i.e., worked out), or when it first starts to tighten up again.”

If you seek out a professional to perform hands-on therapies to ease your MTPs (such as massage), Blatman says, “The key to body work is that the patient must be able to relax during the session. A seriously uncomfortable level of pain is absolutely not acceptable. In fact, it will cause excessive soreness and increased pain afterward because the work was too deep and made the person stress and tighten up. The treatment must be soft enough so that the person can totally relax.”

If you are just too sensitive to be touched by a therapist and cannot tolerate pressure on your trigger points, then as Hong suggested, medications may have to be your first step.  Blatman’s strategy is to target sleep and pain. For sleep, he uses sedating antidepressants, and sometimes zolpidem or eszopiclone. “Some people need combinations of these choices,” says Blatman. He advises against the use of anti-inflammatory agents due to their harmful side effects, but may use other medications, such as gabapentin, pregabalin, or muscle relaxants. 

A trigger point injection (with a local anesthetic) may be used to treat a stubborn MTP, but not unless a home program and manual therapies accompany it. Hong compared the effectiveness of injection therapy in people with regional pain versus those with fibromyalgia. He found three differences: (1) pain improvements were immediate for the regional pain group while it took up to two weeks for the fibromyalgia patients, (2) post injection soreness was gone in one day in the regional pain group but lasted two weeks in fibromyalgia patients, and (3) the pain decreased by 83 percent in the regional pain group while the average pain reduction was 27 percent in the fibromyalgia group.³

“Regional pain patients may have remarkable pain relief immediately after the injection,” says Hong. “However, for fibromyalgia patients it is much different. They may have complete pain relief or no improvement at all.”

Headley’s “How To”
Guide for MTPs

You can use your thumb, index finger, or a rubber ball to place pressure on your trigger points to help “work them out.”  Or better yet, you may wish to purchase a Thera Cane to get to hard-to-reach spots and to prevent strain on your fingers/hands (see the illustrations to the side and the instructions below for how to obtain your Thera Cane).  Throughout the procedures below, remember to breathe so that your muscles receive plenty of oxygen.

1. Start with a moderate amount of pressure. You should feel some discomfort, and perhaps the referred pain pattern will become evident. Plan on holding that pressure for 10-12 seconds. (At first, you may want to do this in a hot tub, bath, or shower to help relax your muscles and increase blood flow to them.)
2. If the pressure increases the symptoms in those 10 seconds, then the pressure is too much. You will need to get off the point, let it relax for a minute and then try it again with less pressure.
3. When you are using the correct amount of pressure, the sense of how much pressure you are applying will decrease over the 10-12 seconds, even though you do not change how hard you are pushing. That change in sensation of pressure is a partial release of the MTP.
4. You may then increase the pressure by a very small amount and hold it for 10-12 seconds. You should get another release.
5. Repeat this procedure up to 4-5 times. The release may start to come more slowly. After the fourth time, let go and work on another point. In a few minutes you could go back and work on the same point again.
6. If you are pushing too hard, you will cause an increase in the symptoms; if you are pushing just enough, you will feel another release. If the MTP has been present for a long time, it is unlikely you will get the knot to completely release in one session. Don’t expect that to happen. It may not be until the next day that you experience the full benefit of treatment.
7. Keep the muscle lengthened to its full comfortable stretch length while pressing on the MTP. This will greatly facilitate the effectiveness of your therapy.
8. Think about how long it took you to develop some of these MTPs; allow your body some time to adjust and relearn healthier muscle habits.

A Thera Cane is a fiberglass stick that is curved at one end like a cane and has various knobs that can be used as handles or to apply pressure to a trigger point.  More detailed illustrations and video on how to use it are provided at: www.theracane.com.You can order the Thera Cane from Amazon for $34.

Perpetuating Factors

Factors that may encourage the development and perpetuation of MTPs must be resolved to increase the effectiveness of therapies. Simons’ Trigger Point Manual contains a full chapter that addresses these factors, and a summary is provided below.¹ As you will notice, all perpetuating factors work by creating an “energy tax” on the muscles, leaving them more vulnerable to developing MTPs.

Mechanical Stress: If one leg is shorter than the other, this will cause the whole pelvic structure to tilt and force the muscles in the lower half of the body to work extra to compensate for the structural defect. A shoe lift can be used if structural leg length differences have been confirmed by proper X-ray techniques. A dysfunctional pelvis can cause symptoms similar to a short leg, but the therapy is different. Working in a chair that does not have support for the lower back, performing repetitive actions, or tilting one’s head forward for long periods of time to read are other examples of mechanical stressors that need to be corrected.

Nutritional Inadequacies: Proper nutrient supply to the muscles and the nerves that regulate their movement is essential for a healthy neuromuscular system. When certain nutrients are in the low range, but not necessarily deficient, these inadequacies can interfere with the resolution of the MTPs. “The five vitamins of special importance to myofascial pain syndromes,” writes Simons, “are vitamins B₁, B₆, B₁₂, folic acid, and vitamin C.” Minerals that should ideally be in the normal range for proper muscle functioning include iron, calcium, potassium, and magnesium.  

Metabolic Conditions: The three main conditions known to exacerbate MTPs are hypothyroidism, hypoglycemia, and allergy. The thyroid regulates the speed at which metabolic processes operate. If it is working slowly, then the supply of nutrients to the muscles will also be slowed down. Hypoglycemia causes low blood sugar, which leads to a depletion in the supply of energy to the muscles. Uncontrolled allergies aggravate MTPs due to their effects on the immune system that also influence MTP activity.

Psychological Factors: Depression, anxiety, and tension may all aggravate and lead to a delayed recovery from MTP pain. However, Simons cautions: “It is all too easy for the physician to blame the patient’s psyche for the inability of the physician to recognize the musculoskeletal sources of the patient’s pain.” 

Other Factors: Chronic viral infections and impaired sleep are also likely to contribute to the perpetuation of MTPs.

Winner’s Guide To PAIN RELIEF by Hal Blatman, M.D., and Brad Ekvall, BFA, is full of illustrations on all the common referral pain patterns that you will likely encounter and why it is that these particular referral patterns develop. The book teaches patients how to massage muscles and MTPs with a rubber ball, and then how to stretch muscles from your jaw and head down to the bottoms of your feet. There are a few hundred original drawings that illustrate the techniques and make them easy to understand. Available online at blatmanhealthandwellness.com for $24.95 (plus $5.95 shipping & handling). Published by Danua Press, Cincinnati, OH. ISBN: 0-9729680-0-8.

1. Simons DG, Travell JG, Simons LS. Myofascial Pain and Dysfunction – The Trigger Point Manual – Volume 1. Upper Half of Body 2^nd Ed. Williams & Wilkins, 1999.
2. Travell JG, Simons DG. Myofascial Pain and Dysfunction – The Trigger Point Manual – Volume 2. The Lower Extremities Williams & Wilkins, 1992.
3. Hong CZ, Hsueh TC. Arch Phys Med Rehabil 77:1161-6, 1996.