Fibromyalgia Basics

Identifying & Treating Trigger Point Pain

Do you have knotted or ropy muscles that feel lumpy under your skin? Do they hurt all the time and radiate pain when pressed? These areas are called myofascial trigger points (MTPs). Identifying and treating trigger point pain is essential for reigning in your overall discomfort. One or two MTPs cause regional pains in many people (such as tennis elbow, jaw pain, or low back pain). But fibromyalgia patients are different. An AFSA-funded study shows you have lots of MTPs sprinkled throughout your body.

MTPs are identified by physical exam, but the examiner needs to know how to find them. In the era of the seven-minute office visit, physical exams are often rushed. As a result, doctors rely on blood tests and X-rays. Hopefully, you can find a physician, physical therapist, chiropractor, or massage therapist who is skilled at locating MTPs. But if you can’t, this article consists of self-help measures you need for tending to your MTPs.

Identifying Trigger Point Pain

Where do you normally find MTPs? They typically reside in the belly of muscles. They feel like a hard knot or bulge in a firm cord running the length of the muscle. An MTP know represents an area where the muscle fibers are contracted and will not relax unless properly treated.

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. They hurt all the time, even 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 MTPs have been 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 is the source of your grief. Conversely, if the examiner presses on a muscle area but it doesn’t generate pain, 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. Successful treatment results are only achieved if the provider has accurately identified your trigger point pain.

“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. “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), this causes pain where the muscle attaches to the bone.

Pain and tenderness in your muscles can certainly exist without MTPs. Identifying the nodule as your trigger point pain, Headley uses the following guidelines:

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. It’s an involuntary response to the pain of snapping the nodule. However, 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.
When some MTPs are snapped, a “local twitch response” is often observed. 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.

MTPs: Treatment Opportunities

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 good at locating MTPs based on examining their muscles. 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 trigger points. 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 your pain when pressed, while latents cause less intense pain when pressed. The referred pain can feel like shooting, aching, throbbing, or tingling sensations.

If you look at the diagram below (taken from Blatman’s book), the active MTP is the key source of pain. 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 pain generators, but they are “snoozing” with regard to pain.

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

What about satellite MTPs? They used to be latent. However, once the active MTP formed, they became sensitized to produce pain because they are in the “referral zone.”

Satellite regions behave just like the active MTPs to produce pain, restrict motion, and other symptoms, 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

MTPs give off spontaneous electrical signals that feed into the central nervous system (CNS). In turn, the dysfunctional CNS amplifies the MTP inputs and spits out signals to other body regions. This is why using your arms to scrub a grill leads to 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. To counter this effect, you can treat your trigger points to get better control over your fibromyalgia pain.

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.’ The entire 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.” Naturally, this leads to dysfunctional movements.

Treating Trigger Point Pain

What type of treatment should you try first to get rid of your MTPs? C-Z Hong, M.D., an MTP researcher in Taiwan, comments that “the effectiveness of a certain modality or manual therapy is case by case in fibromyalgia patients.” For this reason, “Medication is usually my first choice with fibromyalgia patients,” says Hong. “It may be cheaper and more convenient.” See next section for advice.

Hong, Blatman and Headley all endorse a endorse a self-help program to improve treatment success. “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.

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.”

Headley’s “How To”
Guide for MTPs

Use your thumb, index finger, or a rubber ball to place pressure on your trigger points to work them out. For hard-to-reach spots, try a Thera Cane. And always remember to breathe so that your muscles receive plenty of oxygen.

Start with a moderate amount of pressure that produces mild discomfort. Hold that pressure for 10-12 seconds. (At first, try this in a hot tub or shower to relax your muscles and increase blood flow.)
If your pain increases, you are using too much pressure. Let the muscle relax for a minute and try it again with less pressure.
When using the correct amount of pressure, the pain should lessen. This changing sensation is a partial release of the MTP.
You may then increase the pressure by a very small amount and hold it for 10-12 seconds. You should get another release.
Repeat this procedure up to four 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 can work on the same point again.
Beware that pressing too hard will cause an increase in painful symptoms. If the MTP has been present for a long time, don’t expect the knot to completely release in one session. Also, you may not notice the full benefit of your treatment until the next day.
Keep the muscle lengthened to its full comfortable stretch length while pressing on the MTP. This facilitates the effectiveness of your therapy.
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.

Perpetuating Factors

Factors that may encourage the development and perpetuation of MTPs must be resolved for therapies to work. Simons’ Trigger Point Manual addresses these factors, and a summary is below.² Perpetuating factors work by creating an “energy tax” on the muscles. This leaves them more vulnerable to developing MTPs.

Mechanical Stress: If one leg is shorter than the other, your whole pelvic structure is tilted. This forces the muscles in the lower half of the body to work extra to compensate for the structural defect. If an X-ray confirms this issue, a shoe lift will correct it. A dysfunctional pelvis also causes problems. Avoid working in a chair without lumbar support, performing repetitive actions, or tilting your head forward to read.

Nutritional Inadequacies: When nutrients are low, but not necessarily deficient, these inadequacies can interfere with the resolution of the MTPs. “The five vitamins of special importance,” writes Simons, “are vitamins B₁, B₆, B₁₂, folic acid, and vitamin C.” Keeping calcium, iron, potassium and magnesium in the normal range is also important.

Metabolic Conditions: Hypothyroidism, hypoglycemia, and allergies exacerbate MTPs. 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 impaired. Hypoglycemia causes low blood sugar, depleting the supply of energy to the muscles. Uncontrolled allergies aggravate MTPs due to their effects on the immune system.

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 may contribute to the perpetuation of MTPs.

Resources for Trigger Point Pain

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. It also explains why certain referral patterns develop in the first place. 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 for $24.95 (plus $5.95 shipping & handling). Published by Danua Press, Cincinnati, OH. ISBN: 0-9729680-0-8.

For other articles on how to identify or treat trigger point pain in fibromyalgia, see Myofascial Trigger Points, What’s Driving Your Pain? and our section on Muscle Pain Relief.

For detailed illustrations and video on how to use a Thera Care: www.theracane.com. Amazon sells them for $34.

Simons DG, Travell JG, Simons LS. Myofascial Pain and Dysfunction – The Trigger Point Manual – Volume 1. Upper Half of Body 2^nd Williams & Wilkins, 1999.
Travell JG, Simons DG. Myofascial Pain and Dysfunction – The Trigger Point Manual – Volume 2. The Lower Extremities Williams & Wilkins, 1992.
Both volumes are now combined and updated in a third edition. Available from Amazon for $148. Or, you can get the eTextbook for $48.