8 Myofascial Triggerpoints
Myofascial Trigger Points
Convergent Thinking and Myofascial Trigger points
The concept of sore spots that can be leveraged for therapeutic purposes have been independently discovered by several different cultures in Europe, Africa and Asia. One of the oldest examples on record is a 5,300 year old naturally preserved human body discovered in the Tyrolean Alps of Austria called Otzi “The Iceman”. This frozen body has 61 tattoos that correspond to myofascial trigger points and traditional acupuncture points that are commonly utilized to treat musculoskeletal pain. This 5300 year old preserved body gives insight into ancient medical practices, as it is believed that these tattoos represent an early form of therapeutic treatment similar to acupuncture used to treat low back and knee pain (Kean et al., 2013; Zink et al., 2019).
It is well documented in Asian cultures that traditional healers would therapeutically treat sore spots with manual therapy or acupuncture needles, one example is ASHI (ah yes!) points, a central tenant in acupuncture for over two thousand years. Many years later in the 1930’s Jonas Henrik Kellgren started the scientific investigation into these sore spots or what he called Referred Pain from Muscle (Kellgren, 1938). This was then followed up by years of research and documentation by Janet Travell and David Simons, the result of their cumulative work was the textbook – Travell, Simons and Simons’ Myofascial Pain and Dysfunction (now in its 3rd edition).
Myofascial Trigger point Pathophysiology: Sore Spots Exist, But Their Etiology is Still Not Well Understood.
Early research into myofascial trigger points often focused on a physiological dysfunction involving local soft tissue, but recently clinicians have spoken out against these traditional narratives to say that the explanations used in the past of this observable phenomenon are flawed in reasoning. They posit that what we call a myofascial trigger point may represent a form of nociplastic pain where there are neuroplastic changes of the peripheral or central nervous system (Quintner et al., 2015).
Moving forward as a profession we ought to acknowledge that there is uncertainty about myofascial trigger points and update the way we communicate with patients and other healthcare providers. One issue is that ascribing a patient’s pain solely to myofascial trigger points or other tissue-driven pain problem is often an oversimplification of a complex process. When it comes to myofascial trigger points there are several competing hypothesis, including, but not limited to:
- Cinderella Hypothesis – low-level, continuous muscle contractions overload tissues and makes “Cinderella” fibers susceptible to calcium dysregulation and subsequently sarcomere contracture (Bron et al., 2012).
- Integrated Hypothesis – the zone around a myofascial trigger points seems to be in an ischemic state resulting in a shortage of glucose and oxygen for metabolism and subsequent contracted sarcomeres in skeletal muscle (Gerwin et al., 2004; Gerwin et al., 2020).
- Neurogenic Inflammation – the release of inflammatory substances from the nerve axon, results in a lower threshold for depolarization and hyperalgesia in innervated tissue (Quintner et al., 2015).
- Central Sensitization – several studies support the hypothesis that persistent nociceptive input from myofascial trigger points contributes to the development of central sensitization and/or changes in the dorsal horn. In contrast, preliminary evidence suggests that central sensitization can also promote myofascial trigger points activity (Fernández-de-las-Peñas et al., 2014).
International Consensus on Diagnostic Criteria and Clinical Considerations of Myofascial Trigger Points
In an effort to establish standard terminology an international panel of 60 clinicians and researchers was recently consulted to establish a consensus for identification of a myofascial trigger point. The panel agreed on two palpatory and one symptom criteria: a taut band, a hypersensitive spot, and referred pain (Fernández-de-Las-Peñas & Dommerholt, 2018).
Myofascial Trigger Points: Examination and Treatment Considerations
It has been demonstrated in a number of studies that patients benefit from hands-on work aimed at myofascial trigger points, but this may not always be due to reasons we once were taught. Even if some of the traditional narratives around myofascial trigger points may be flawed, myofascial trigger points describe an observable phenomenon that may be help clinicians investigate common pain patterns, such as:
• Temporomandibular Disorders (Moayedi et al., 2020)
• Facial Pain (Gerwin, 2020)
• Neck Pain (Morikawa et al., 2017; Castaldo et al., 2019)
• Migraine Headaches (Landgraf et al., 2018)
• Tension-Type Headache (Fernández-De-Las-Peñas & Arendt-Nielsen, 2017; Palacios-Ceña et al., 2018)
• Carpal Tunnel Syndrome (Meder et al., 2017)
• Low Back Pain (Takamoto et al., 2015; Kodama et al., 2019)
• Chronic Pelvic Pain (Fuentes-Márquez et al., 2019)
Myofascial Trigger Points: What Are They, Really?
From a clinical perspective, myofascial trigger points describe an observable phenomenon that may help clinicians investigate common pain patterns. There is still no consensus on the etiology of these sore spots and what role they play in the generation and propagation of myofascial pain syndrome.
References and Sources
Bron, C., & Dommerholt, J. D. (2012). Etiology of myofascial trigger points. Current pain and headache reports, 16(5), 439–444. doi:10.1007/s11916-012-0289-4
Castaldo, M., Catena, A., Fernández-de-Las-Peñas, C., & Arendt-Nielsen, L. (2019). Widespread Pressure Pain Hypersensitivity, Health History, and Trigger Points in Patients with Chronic Neck Pain: A Preliminary Study. Pain medicine (Malden, Mass.), 20(12), 2516–2527. doi:10.1093/pm/pnz035
Chen, Q., Wang, H. J., Gay, R. E., Thompson, J. M., Manduca, A., An, K. N., … Basford, J. R. (2016). Quantification of Myofascial Taut Bands. Archives of physical medicine and rehabilitation, 97(1), 67–73. doi:10.1016/j.apmr.2015.09.019
Dorfer, L., Moser, M., Bahr, F., Spindler, K., Egarter-Vigl, E., Giullén, S., … Kenner, T. (1999). A medical report from the stone age?. Lancet (London, England), 354(9183), 1023–1025. doi:10.1016/S0140-6736(98)12242-0
Fernández-de-las-Peñas, C., & Dommerholt, J. (2014). Myofascial trigger points: peripheral or central phenomenon?. Current rheumatology reports, 16(1), 395. doi:10.1007/s11926-013-0395-2
Fernández-De-Las-Peñas, C., & Arendt-Nielsen, L. (2017). Improving understanding of trigger points and widespread pressure pain sensitivity in tension-type headache patients: clinical implications. Expert review of neurotherapeutics, 17(9), 933–939. doi:10.1080/14737175.2017.1359088
Fernández-de-Las-Peñas, C., & Dommerholt, J. (2018). International Consensus on Diagnostic Criteria and Clinical Considerations of Myofascial Trigger Points: A Delphi Study. Pain medicine (Malden, Mass.), 19(1), 142–150. doi:10.1093/pm/pnx207
Forstenpointner, J., Wolff, S., Stroman, P. W., Jansen, O., Rehm, S., Baron, R., & Gierthmühlen, J. (2018). “From ear to trunk”-magnetic resonance imaging reveals referral of pain. Pain, 159(9), 1900–1903. https://doi.org/10.1097/j.pain.0000000000001279
Fuentes-Márquez, P., Valenza, M. C., Cabrera-Martos, I., Ríos-Sánchez, A., & Ocón-Hernández, O. (2019). Trigger Points, Pressure Pain Hyperalgesia, and Mechanosensitivity of Neural Tissue in Women with Chronic Pelvic Pain. Pain medicine (Malden, Mass.), 20(1), 5–13. doi:10.1093/pm/pnx206
Galasso, A., Urits, I., An, D., Nguyen, D., Borchart, M., Yazdi, C., Manchikanti, L., Kaye, R. J., Kaye, A. D., Mancuso, K. F., & Viswanath, O. (2020). A Comprehensive Review of the Treatment and Management of Myofascial Pain Syndrome. Current pain and headache reports, 24(8), 43. https://doi.org/10.1007/s11916-020-00877-5
Gerwin, R. D., Dommerholt, J., & Shah, J. P. (2004). An expansion of Simons’ integrated hypothesis of trigger point formation. Current pain and headache reports, 8(6), 468–475. doi:10.1007/s11916-004-0069-x
Gerwin R. (2020). Chronic Facial Pain: Trigeminal Neuralgia, Persistent Idiopathic Facial Pain, and Myofascial Pain Syndrome-An Evidence-Based Narrative Review and Etiological Hypothesis. International journal of environmental research and public health, 17(19), 7012. https://doi.org/10.3390/ijerph17197012
Gerwin, R. D., Cagnie, B., Petrovic, M., Van Dorpe, J., Calders, P., & De Meulemeester, K. (2020). Foci of Segmentally Contracted Sarcomeres in Trapezius Muscle Biopsy Specimens in Myalgic and Nonmyalgic Human Subjects: Preliminary Results. Pain medicine (Malden, Mass.), 21(10), 2348–2356. https://doi.org/10.1093/pm/pnaa019
Kean, W. F., Tocchio, S., Kean, M., & Rainsford, K. D. (2013). The musculoskeletal abnormalities of the Similaun Iceman (“ÖTZI”): clues to chronic pain and possible treatments. Inflammopharmacology, 21(1), 11–20. doi:10.1007/s10787-012-0153-5
Kellgren, J. H. (1938). Referred Pains from Muscle. British medical journal, 1(4023), 325–327. doi:10.1136/bmj.1.4023.325
Kodama, K., Takamoto, K., Nishimaru, H., Matsumoto, J., Takamura, Y., Sakai, S., … Nishijo, H. (2019). Analgesic Effects of Compression at Trigger Points Are Associated With Reduction of Frontal Polar Cortical Activity as Well as Functional Connectivity Between the Frontal Polar Area and Insula in Patients With Chronic Low Back Pain: A Randomized Trial. Frontiers in systems neuroscience, 13, 68. doi:10.3389/fnsys.2019.00068
Kosek, E., Clauw, D., Nijs, J., Baron, R., Gilron, I., Harris, R. E., Mico, J. A., Rice, A. S., & Sterling, M. (2021). Chronic nociplastic pain affecting the musculoskeletal system: clinical criteria and grading system. Pain, 10.1097/j.pain.0000000000002324. Advance online publication. https://doi.org/10.1097/j.pain.0000000000002324
Landgraf, M. N., Biebl, J. T., Langhagen, T., Hannibal, I., Eggert, T., Vill, K., … Heinen, F. (2018). Children with migraine: Provocation of headache via pressure to myofascial trigger points in the trapezius muscle? – A prospective controlled observational study. European journal of pain (London, England), 22(2), 385–392. doi:10.1002/ejp.1127
Mazza, D. F., Boutin, R. D., & Chaudhari, A. J. (2021). Assessment of Myofascial Trigger Points via Imaging: A Systematic Review. American journal of physical medicine & rehabilitation, 100(10), 1003–1014. https://doi.org/10.1097/PHM.0000000000001789
Meder, M. A., Amtage, F., Lange, R., & Rijntjes, M. (2017). Reliability of the Infraspinatus Test in Carpal Tunnel Syndrome: A Clinical Study. Journal of clinical and diagnostic research: JCDR, 11(5), YC01–YC04. doi:10.7860/JCDR/2017/25096.9831
Melzack, R., Stillwell, D. M., & Fox, E. J. (1977). Trigger points and acupuncture points for pain: correlations and implications. Pain, 3(1), 3–23. doi:10.1016/0304-3959(77)90032-x
Moayedi, M., Krishnamoorthy, G., He, P. T., Agur, A., Weissman-Fogel, I., Tenenbaum, H. C., Lam, E., Davis, K. D., Henderson, L., & Cioffi, I. (2020). Structural abnormalities in the temporalis musculo-aponeurotic complex in chronic muscular temporomandibular disorders. Pain, 161(8), 1787–1797. https://doi.org/10.1097/j.pain.0000000000001864
Morikawa, Y., Takamoto, K., Nishimaru, H., Taguchi, T., Urakawa, S., Sakai, S., … Nishijo, H. (2017). Compression at Myofascial Trigger Point on Chronic Neck Pain Provides Pain Relief through the Prefrontal Cortex and Autonomic Nervous System: A Pilot Study. Frontiers in neuroscience, 11, 186. doi:10.3389/fnins.2017.00186
Palacios-Ceña, M., Wang, K., Castaldo, M., Guillem-Mesado, A., Ordás-Bandera, C., Arendt-Nielsen, L., & Fernández-de-Las-Peñas, C. (2018). Trigger points are associated with widespread pressure pain sensitivity in people with tension-type headache. Cephalalgia: an international journal of headache, 38(2), 237–245. doi:10.1177/0333102416679965
Phan, V., Shah, J., Tandon, H., Srbely, J., DeStefano, S., Kumbhare, D., Sikdar, S., Clouse, A., Gandhi, A., & Gerber, L. (2020). Myofascial Pain Syndrome: A Narrative Review Identifying Inconsistencies in Nomenclature. PM & R: the journal of injury, function, and rehabilitation, 12(9), 916–925. https://doi.org/10.1002/pmrj.12290
Quintner, J. L., Bove, G. M., & Cohen, M. L. (2015). A critical evaluation of the trigger point phenomenon. Rheumatology (Oxford, England), 54(3), 392–399. doi:10.1093/rheumatology/keu471
Shah, J. P., Danoff, J. V., Desai, M. J., Parikh, S., Nakamura, L. Y., Phillips, T. M., & Gerber, L. H. (2008). Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Archives of physical medicine and rehabilitation, 89(1), 16–23. https://doi.org/10.1016/j.apmr.2007.10.018
Shah, J. P., Thaker, N., Heimur, J., Aredo, J. V., Sikdar, S., & Gerber, L. (2015). Myofascial Trigger Points Then and Now: A Historical and Scientific Perspective. PM & R: the journal of injury, function, and rehabilitation, 7(7), 746–761. doi:10.1016/j.pmrj.2015.01.024
Takamoto, K., Bito, I., Urakawa, S., Sakai, S., Kigawa, M., Ono, T., & Nishijo, H. (2015). Effects of compression at myofascial trigger points in patients with acute low back pain: A randomized controlled trial. European journal of pain (London, England), 19(8), 1186–1196. doi:10.1002/ejp.694
Thompson, E. N., & Usichenko, T. (2018). Pain in the hand caused by a previously undescribed mechanism with possible relevance for understanding regional pain. Scandinavian journal of pain, 18(4), 743–746. doi:10.1515/sjpain-2018-0090
Travell, J. & Rinzler, S.H. (1952). The myofascial genesis of pain. Postgraduate medicine, 11(5), 425–434. doi:10.1080/00325481.1952.11694280
Urits, I., Charipova, K., Gress, K., Schaaf, A. L., Gupta, S., Kiernan, H. C., Choi, P. E., Jung, J. W., Cornett, E., Kaye, A. D., & Viswanath, O. (2020). Treatment and management of myofascial pain syndrome. Best practice & research. Clinical anaesthesiology, 34(3), 427–448. https://doi.org/10.1016/j.bpa.2020.08.003
Vadasz, B., Gohari, J., West, D. W., Grosman-Rimon, L., Wright, E., Ozcakar, L., Srbely, J., & Kumbhare, D. (2020). Improving characterization and diagnosis quality of myofascial pain syndrome: a systematic review of the clinical and biomarker overlap with delayed onset muscle soreness. European journal of physical and rehabilitation medicine, 56(4), 469–478. https://doi.org/10.23736/S1973-9087.20.05820-7
Zhang, M., Jin, F., Zhu, Y., & Qi, F. (2020). Peripheral FGFR1 Regulates Myofascial Pain in Rats via the PI3K/AKT Pathway. Neuroscience, 436, 1–10. https://doi.org/10.1016/j.neuroscience.2020.04.002
Zink, A., Samadelli, M., Gostner, P., & Piombino-Mascali, D. (2019). Possible evidence for care and treatment in the Tyrolean Iceman. International journal of paleopathology, 25, 110–117. doi:10.1016/j.ijpp.2018.07.006