Myofascial Trigger Points: A Common Cause of Chronic Pain and Limited Range of Motion
Myofascial trigger points are a ubiquitous problem that can lead to severe pain and sometimes puzzling symptoms, which often end up misdiagnosed.
Myofascial trigger points are painful, hyperirritable areas in muscles that can cause pain, stiffness, limited range of motion and sometimes other symptoms. Nearly everyone has experienced them — if you’ve had tense shoulders that were relieved by massage, these were trigger points.
Trigger points can refer pain to other parts of the body, sometimes far from their original location. This contributes to their potential to be misdiagnosed. Trigger points are always created in certain places in a muscle and always refer pain to the same areas. However, because there are hundreds of muscles in the body, there are numerous locations for trigger points. Also, trigger points in one muscle tend to create trigger points in other nearby muscles.
When trigger points are a major problem, this is sometimes called myofascial pain syndrome (MPS). In MPS there is evidence of central nervous system involvement (central sensitization).
What Causes Trigger Points
Repetitive movements and prolonged use of the same muscles are common causes of trigger points. On the other hand, a sedentary lifestyle is also a risk factor. As a result, almost any job can cause trigger points, whether it involves physical labor or long periods of sitting or standing. Poor posture promotes trigger points, but the reverse is also true.
A single strained movement can lead to trigger points, such as may happen in sports, falling or trying to prevent falling. Carrying or lifting heavy objects frequently promotes trigger points — which also includes pregnancy. Surgery and dental operations are also common causes. Emotional stress often leads to muscle tension and thus trigger points. Cold temperatures can aggravate the problem.
Certain illnesses and metabolic conditions make one more prone to myofascial trigger points. These include Ehlers-Danlos syndrome (EDS) and other conditions causing hypermobility, anemia and some other nutritional deficiencies, viral infections, hypothyroidism, adrenal insufficiency and hypoglycemia. Genetic predisposition can be a factor for some people. Some medications like lithium and calcium channel blockers like nifedipine may also be to blame.
Chronic Pain from Trigger Points
Besides pain in the muscles, myofascial trigger points can cause joint pain, headaches (of practically all types) and other kinds of pain, such as eye pain, toothache (which may be indistinguishable from dental problems), earache and pain in the genitals. The pain is often severe and may not respond to painkillers, such as paracetamol and NSAIDs.
Myofascial pain can be misdiagnosed as a serious condition, such as arthritis, bursitis, carpal tunnel syndrome or degenerative spinal changes. Even when these conditions are present, trigger points often contribute to the pain. Trigger points may explain so-called growing pains and some of the pain and balance problems associated with old age.
While myofascial pain is different from fibromyalgia and trigger points are not the same as fibromyalgia tender points (though even doctors often confuse the two), these conditions often coexist. Trigger points can be an important source of pain in e.g. endometriosis, interstitial cystitis and temporomandibular joint pain (TMJ/TMD), even complex regional pain syndrome (CRPS).
Most physical injuries are also complicated by trigger points, which may explain why such conditions often persist, even when the original injury should have healed. Untreated, trigger points can cause problems for years or even decades.
Other Symptoms and Misdiagnosis
Myofascial trigger points also affect the circulation and function of the autonomous nervous system. Depending on their location, this can lead to such symptoms as blurry vision, nasal congestion, restless legs, tinnitus, muscle weakness and atrophy, problems swallowing, urinary frequency and incontinence, intermittent claudication, numbness, cold extremities, dizziness and dyspnea (air hunger).
Trigger points in the torso, including on the back, can promote digestive symptoms like stomach ache, bloating, heartburn, diarrhea, constipation, nausea and even vomiting. Pelvic trigger points can be behind sexual dysfunction such as impotence and pain during and after intercourse. They often contribute to dysmenorrhea (painful periods).
Dentists, physiotherapists and massage therapists are often knowledgeable about trigger points, but the same can’t be said about most physicians. Because of this, symptoms caused by trigger points are usually attributed to other ailments. In extreme cases, this has lead to misdiagnosis of a serious condition such as appendicitis or a heart attack and/or even unnecessary surgery.
Home Treatment of Myofascial Trigger Points
Self-applied massage therapy, also known as myofascial release, is the easiest way to treat trigger points. It’s important to work on the actual trigger point, not the area where it refers pain. After the trigger point is located, it is vigorously “knead” with fingers, knuckles, another body part (such as knee or elbow) or with a massage tool, such as a foam roller or the TheraCane. A tennis ball or a smaller ball used against a wall, chair or bed works well for many trigger points.
A single massage session does not have to last for long, even less than a minute may be enough. All trigger points in the affected area should be located and treated for the best efficacy.
Some older sources recommend static pressure (ischemic compression or ischemic pressure) on the trigger point, but massage is now considered more helpful.
Trigger point massage is painful, but it will usually result in quick relief. The treated area tends to get more sore for a couple of days and there may be bruising, but it is no cause of concern.
Against conventional wisdom, exercise, including stretching, can make myofascial pain worse, though rest is not a solution, either. Gentle forms of bodywork such as yoga, Feldenkrais and Alexander technique may help to prevent the formation of trigger points, but aren’t treatments as such.
A stretching method for areas affected by myofascial trigger points, called “spray and stretch”, used to be popular, but is not used much anymore. It involves first using ice or cold spray to numb the trigger point, then stretching and applying heat on the area afterward. This can be cumbersome to pull off if there are many trigger points. Stretching in a warm bath or hot shower is much better than doing it without heat. An infrared lamp can also be used to provide heat for stretching.
TENS (transcutaneous electrical nerve stimulation) is a good way to help trigger points without causing residual soreness, unlike most other treatments. The prices of TENS machines start from about $30. There is some evidence for the use of kinesiotaping.
Other Ways to Manipulate Trigger Points
Acupuncture can help with deactivating trigger points. Most acupuncture points correspond with trigger points and the concept of “meridians” in traditional Chinese medicine appears to correlate with the ways the trigger points refer pain to other areas.
In conventional medicine, the most common treatment is trigger point injections. Typically lidocaine or another local anesthetic is injected directly into the trigger point. This can produce long-lasting relief. Corticosteroid injections have not been shown helpful. The jury is still out on the efficacy of botulinum toxin (botox) injections, as studies have produced conflicting results, but they appear to help prevent migraines caused by trigger points.
Another common and widely studied treatment method is dry needling, where a needle is inserted into a trigger point but nothing is injected, similar to acupuncture. It appears to be as effective as lidocaine injections, but results in more soreness after the procedure.
Many physiotherapeutic interventions have been studied in the treatment of trigger points, e.g. interferential current stimulation therapy, low-level laser therapy (LLLT), ultrasound therapy, various vibration therapies, repetitive magnetic stimulation (rMS) and extracorporeal shockwave therapy. Whether they provide benefit over other approaches is unclear.
In recent years, more and more experimental treatments have cropped up, e.g. using phonophoresis instead of injections to deliver medications directly into the trigger points. Some other injections have also been tried, such as hyaluronidase and plasma rich in platelets or growth factors. The research on these is very preliminary.
Medications and Supplements
Painkillers are rarely very effective in the treatment of chronic pain caused by trigger points. Oral NSAIDs and acetaminophen (paracetamol) generally prove useless, although they can alleviate headaches caused by trigger points. Locally administered NSAIDs, e.g. gels or patches, appear potentially helpful.
Some muscle relaxants like tizanidine (Zanaflex), clonazepam (Klonopin) and baclofen (Lioresal) may provide relief, as can cannabinoids. Herbs with muscle relaxant properties like cramp bark and valerian can possibly be useful for myofascial pain.
Lidocaine can be used topically on trigger points as a cream or patches, though this is less helpful than lidocaine injections. Another local anesthetic called dimethisoquin may be even more effective than lidocaine. There is some evidence for capsaicin cream.
If trigger points result from underlying condition such as anemia or vitamin D deficiency, hypothyroidism or adrenal insufficiency, treatment for the condition is likely to offer relief, but deactivation of existing trigger points may still be needed.
Notes: This is a combination of two short articles I wrote back in 2010, which has been offline for years. I’ve read thousands of pages on the subject and would like to write a better and longer article, but due to my very poor health, that isn’t likely to happen. Because there still isn’t a better basic reference on the subject in English, I’m putting this piece back online, with minor edits and updates.
References
Simons DG, Travell JG, Simons LS. Myofascial Pain and Dysfunction: The Trigger Point Manual. Williams & Wilkins 1999.
Davies C. The Trigger Point Therapy Workbook: Your Self-Treatment Guide for Pain Relief (Second Edition). New Harbinger Publications 2004.
McPartland JM. Travell trigger points — molecular and osteopathic perspectives. J Am Osteopath Assoc. 2004 Jun;104(6):244–9.
Dorsher PT. Myofascial referred-pain data provide physiologic evidence of acupuncture meridians. J Pain. 2009 Jul;10(7):723–31.
Galasso A, Urits I, An D. A Comprehensive Review of the Treatment and Management of Myofascial Pain Syndrome. Curr Pain Headache Rep. 2020 Jun 27;24(8):43.
Rashiq S, Galer BS. Proximal myofascial dysfunction in complex regional pain syndrome: a retrospective prevalence study. Clin J Pain. 1999 Jun;15(2):151–3.
