Save Yourself From Trigger Point & Myofascial Pain Syndrome PDF

Trigger Point Tutorial (Advanced) http://saveyourself.ca/tutorials/trigger-points.
php
AN ADVANCED TUTORIAL FOR PATIENTS AND PROFESSIONALS
Are you
mus
by Paul Ingraham, Vancouver, Canada MORE
Credentials and qualifications
I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour
program). Im almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a
copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate
study, clinical experience, and constant conversations with readers from around the world, including many experts who have
provided countless suggestions and criticisms.
For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional
experiences for my readers and customers.
illustrations by Paul Ingraham, Shayne Letain, Alexia Tryfon
Welcome to the most detailed and current guide to muscle pain available. This is not just a web page:
its book-length. What are the controversies and myths about muscle pain? What works, what doesnt,
and why? This guide offers troubleshooting ideas for even the toughest cases much more than the
popular but out-of-date Trigger Point Therapy Workbook.1
Many people suffer from trigger point pain and myofascial pain muscle knots. And yet advanced
trigger point therapy is not rocket science!2 You just need a good selection of rational options a
bunch of creative tips, tricks, insights and perspectives, based on recent science and years of clinical
experience.
Learning even a little about trigger points can solve more pain problems more easily than anything
else I know of. If you have any problems with chronic muscle pain, if you have unexplained aching
and stiffness please keep reading!
1 of 25 02/03/2010 10:24 AM
Trigger Point Tutorial (Advanced) http://saveyourself.ca/tutorials/trigger-points.php
Trigger point therapy is not a miracle cure for chronic pain but its close
Trigger point therapy isnt too good to be true its just ordinary good. Its not miraculous or a cure
for all pain. Good trigger point therapy can be hard to find, and it doesnt always work. But its also an
amazingly under-rated therapy and self-treatment has good potential to quickly, cheaply and safely
help many common pain problems that wont respond to anything else.
Physicians & therapists need to learn about trigger points too
This tutorial is written for both patients and professionals. It includes analysis of recent research that you
wont find in any text, crafted to suit any skill level. Footnotes add an optional layer of detail.
Trigger points are much more clinically important than most health professionals realize.3 It is hard to
imagine a more rewarding topic, with science showing a clear new path to helping people you probably
couldnt help before. Even if you already know myofascial pain syndrome, you will get new ideas here.
For beginners with average muscle pain a typical case of nagging hip pain or back pain or neck
pain the advice given here may well seem almost miraculously useful. I get avalanches of email
from readers thanking me for pointing out simple treatment options for such irritating problems.
Many are stunned by the dicovery that their chronic pain could be treated easily.
For veterans who have already tried and failed to treat trigger points, this document is especially
made for you. You need more advanced methods before giving up. There are more ideas and tips
here than anywhere else I know of. This will get you as close to a cure as you can get; I can give you a
fighting chance of at least reducing your pain more than ever before. Maybe that is a bit of a miracle.
Does your body feel like a toxic waste dump?
It may be more literally true than you realized! A muscle

knot is a patch of polluted tissue: a nasty little cesspool of
waste metabolites. No wonder they hurt, and no wonder
they cause so many strange sensations: its more like being
poisoned than being injured. Garden variety back pain is the
best known symptom of the common muscle knot. However,
knots also cause an astonishing array of other aches and
pains, and misdiagnosis is common.
What exactly are muscle knots?
When you say that you have muscle knots, you are talking about myofascial trigger points.
2 of 25 02/03/2010 10:24 AM
A trigger point (TrP) is a small patch of tightly contracted muscle, an isolated spasm affecting just a
small patch of muscle tissue (not a whole-muscle spasm like a charlie horse or cramp5). That small
patch of knotted cuts off its own blood supply, which irritates it even more a vicious cycle called
metabolic crisis. The swampy metabolic situation is why I sometimes also call it sick muscle
syndrome.
A collection of too many nasty trigger points is called myofascial pain syndrome (MPS).
Individual TrPs and MPS can cause a truly spectacular amount of discomfort far more than most
people believe is possible as well as some surprising side effects. Its bark is much louder than its
bite, but the bark can be extremely loud. More about worst case scenarios below.
Why muscle knots matter so much
Trigger points matter. Aches and pains are an extremely common medical problem,6 and trigger
points and myofascial pain syndrome are the most common undiagnosed source. They are a key
factor in headaches, probably including migraine and cluster headaches as well,78 neck pain and low
back pain,910 and (much) more. What makes trigger points clinically important and fascinating is
their triple threat. They can:
1. cause pain problems,

2. complicate pain problems, and
3. mimic other pain problems.
Trigger points can cause pain directly. Trigger points are a natural part of muscle tissue.11 Just as
almost everyone gets some pimples, sooner or later almost everyone gets muscle knots and you
have pain with no other explanation.
Trigger points complicate injuries. Trigger points show up in most painful situations like party
crashers. Almost no matter what happens to you, you can count on trigger points to make it worse.
They can form in response to virtually any other kind of problem. In many cases they actually begin
to overshadow the original problem.
Trigger points mimic other problems. Many trigger points feel like something else. It is easy for an
unsuspecting health professional to mistake trigger point pain for practically anything but a trigger
point. For instance, trigger points are a much more common cause of pain than repetitive strain
injuries (RSIs).12 There are dozens of examples like that.
The daily clinical experience of thousands of massage therapists, physical therapists, and
physicians strongly indicates that most of our common aches and pains and many other
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puzzling physical complaints are actually caused by trigger points, or small contraction
knots, in the muscles of the body.
The Trigger Point Therapy Workbook, by Clair Davies and Amber Davies, p2
How can you trust this information about trigger points?
Im inspired by the MythBusters approach: I question everything and I have

fun doing it. (No explosions, alas.) I assume that anything that sounds too
good to be true probably is. I make no big promises, I do not claim to know
the one true cause of anything, and I am not selling a treatment system or my
own services. I say I dont know when I dont know and I say Im guessing
when Im guessing. I actually read scientific journals, I clearly explain the
science behind every key point (there are more than 190 footnotes here), and
I link to the original sources so you can check them yourself. I hang out with What would Ada
doctors. I study harder than I ever did in school. Much harder. Jamie do? You kn
they were docto
Some of my favourite
sources
I spend a lot of time on

PubMed, and I cite from the
best sources whenever
possible, like The Cochrane
Collaboration and The New
England Journal of Medicine
and PLoS Medicine.
Trigger points are good, hard

science
Trigger points are not a flaky diagnosis. This isnt hippie health care! You can:
No, none of these procedures are available as diagnostic tests for patients.13 However, keep reading to
learn how to identify TrPs.
take photomicrographs of TrPs,14

measure their electrical activity,15
take samples of their acidic and toxic tissue chemistry,16
and a new MRI-like technology can now show them as well.17
Trigger points rest on a bedrock of thousands of scientific papers published in mainstream,

peer-reviewed medical scientific journals.18 Detailed charts of the patterns of spreading pain that
they cause are widely available.19
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Trigger point charts
Many trigger point charts are

on the market. How are they
made? Believe it or not,
pain-causing solution is
injected into human subjects.
The injection causes such
strong pain that it spreads in
a clear pattern which the
subject can report accurately.
These pain patterns are often
strange, but they are so
consistent from one person to the next that they can be
mapped. I sure hope the subjects get paid well!
The pioneers of trigger point research still are and always have been primarily medical specialistss
and scientists like Janet Travell20, David Simons, and Siegfried Mense. The existence and importance
of trigger points is just not controversial. The problem is educating health professionals getting the
word out.
Although mild and moderate muscle knots are easily treated, myofascial pain syndrome is simply
unknown to many medical professionals, and unfamiliar to nearly all of them. Why?
Drs. Janet Travell & David Simons

devoted their careers to trying to
understand the science of muscle knots,
and sharing what they learned with other
health professionals. Dr. Travell died in
1997. Dr. Simons is still publishing
actively.
Why are trigger points so neglected?
Muscle is an orphan organ. No medical speciality claims it,21 Muscle tissue is the largest organ in
the body, complex and vulnerable to dysfunction, and the primary target of the wear and tear of
daily activities, nevertheless it is the bones, joints, bursae and nerves on which physicians usually
concentrate their attention.22 Family doctors are particularly uninformed about muscle tissue
health23 it simply isnt on their radar.
What about medical specialists? They may be the best option for serious cases. Doctors in pain clinics
to know about trigger points. But they often limit their treatment methods exclusively to injection
therapies a bazooka to kill a mouse and most trigger point pain wont qualify you for a pain clinic
5 of 25 02/03/2010 10:24 AM
anyway. Medical specialists may know quite a bit about muscle pain, but arent all that helpful to the
average patient.
An appallingly high percentage of doctors and other practitioners are still pretty much out
of the loop regarding trigger points.
The Trigger Point Therapy Workbook, by Clair Davies and Amber Davies, p2
Physiotherapists and chiropractors are generally preoccupied with joint function, biomechanics,24
and exercise therapy. These approaches have their place, but muscle tissue is routinely
underestimated. A lot of patient time gets wasted trying to straighten patients, when all along just a
little pressure on a key muscle knot might have provided relief.
Massage therapists have a lot of hands-on experience of muscle tissue, but know surprisingly little
about myofascial pain syndrome. Their training standards vary wildly. Even in my three years of
training as an RMT (the longest in the world), I learned only the basics barely more than this
introduction! The right hands can give you a lot of relief, but its hard to find or be the right
hands.
No professionals of any kind are commonly skilled in the treatment of trigger points. Muscle tissue
simply has not gotten the clinical attention it deserves,25 and so misdiagnosis and wrong treatment is
like death and taxes inevitable! And that is why this tutorial exists: to help you save yourself, and
to educate professionals.
Those clinicians who have become skilled at diagnosing and managing myofascial trigger
points frequently see patients who were referred to them by other practitioners as a last
resort. These patients commonly arrive with a long list of diagnostic procedures, none of
which satisfactorily explained the cause of, or relieved, the patients pain.
Myofascial Pain and Dysfunction, by David Simons, Janet Travell and Lois Simons, p36
Does your trigger point therapist have the big red

books?
In addition to dozens of scientific papers, this tutorial is based on medical

textbooks like the massive two-volume set, the big red books
Myofascial Pain and Dysfunction: The Trigger Point Manual26 and the
blue book, Muscle Pain: Understanding Its Nature, Diagnosis and
Treatment27 These are not easy reading!28
Every therapist who claims to treat trigger points should have the big red
books books in their office. If you dont see dog-eared copies, ask about
them its a fair, effective and polite way to check a therapists The Big Red Boo
competence.
Must-have text books
Muscle Pain (the blue one) is just as important. I highly recommend it to
therapist treatin
any professional who works with muscle (or should). Its more recent, and
trigger points.
it covers a much wider range of soft tissue pain issues, putting trigger
points in context.
6 of 25 02/03/2010 10:24 AM
A brief note about the relationship between fibromyalgia and myofascial

pain syndrome
Please note that fibromyalgia (FM) and myofascial pain syndrome are not the same thing. However,
they do have much in common, routinely coexist, and they are often confused.29 Fibromyalgia is a
disease, a significant failure of the entire pain system. Because FM patients usually have lots of trigger
points as well, some trigger point therapy is often useful for them.30 By contrast, myofascial pain
syndrome is a common dysfunction no more a disease than acne which is usually limited to an
area of the body. More about connections between myofascial pain syndrome and fibromyalgia
below.
Fibromyalgic Tender Points
The tender points of

fibromyaliga are not the
same phenomenon as
myofascial trigger points.
Tender points occur in
specific locations, and they
do not tend to release like
trigger points.
Trigger points also explain many odd aches and pains
This is where trigger points really get interesting. In addition to minor aches and pains, MPS often
causes unusual symptoms in strange locations. For instance, many people diagnosed with carpal
tunnel syndrome are actually experiencing pain caused by a muscle in their armpit (subscapularis).31
Seriously. Im not making that up!
This odd phenomenon of pain spreading from a trigger point to another location is called referred
pain. The neurology will be explained in detail below. Here are some other examples of referred
pain leading to misdiagnosis:32
Sciatica (shooting pain in the buttocks and legs) is more often caused by MPS in the piriformis
or other gluteal muscles, and not by irritation of the sciatic nerve. Many other trigger points are
mistaken for some kind of nerve problem.
Earaches, sinusitis, toothaches, ringing in the ears (tinnitus), and dizziness are often symptoms
of trigger points in the muscles around the jaw, face, head and neck.33
A sore throat or a lump in the throat is often caused or aggravated by trigger points anywhere
around the throat.
Appendicitis pain often turns out, sometimes after surgery, to be caused by a trigger point in
the abdominal muscles.
Severe MPS is often mistaken for fibromyalgia (and other diseases that cause hypersensitivity to
pain throughout the body).
And many more!
7 of 25 02/03/2010 10:24 AM
I recently treated a man for chest and arm pain he had been in the hospital for several hours being
checked out for signs of heart failure, but when he got to my office his symptoms were relieved by a
few minutes of rubbing a pectoralis major muscle trigger point.
Another client once spent three days in hospital for severe abdominal pain that doctors couldnt
diagnose we relieved her pain by massaging a trigger point in her psoas major muscle.
I myself once suffered a dramatic case of a toothache that was completely relieved by a massage
therapist the day before an emergency appointment with the dentist.
However, the vast majority of symptoms caused by myofascial pain syndrome are simply the familiar
aches and pains of humanity millions of sore backs, shoulders and necks. And some of those can
become quite serious.
Is this like you?
Muscle knot pain can be savage. Over

the years I have met many people who
were in so much pain from muscle
dysfunction that they could hardly
think straight. Is muscle pain trivial?
Not if you have it!
A couple of typical trigger point pain

stories
The relationship between trigger points and mild-to-moderate pain is often so straightforward that
therapy is virtually effortless. One of the nice things about working with trigger points is that
sometimes they do make me seem like a miracle worker, because they are such a clinical slam dunk
for garden variety persistent muscle pain pains that have gone unexplained by other health
professionals.
For instance, Lois McConnell of Vancouver came to see me complaining that shed had moderate,
chronic back pain for several years. Shed received some common misdiagnoses, particularly
sacroiliac joint dysfunction.34 But she had a prominent gluteus maximus trigger point (this one) that,
when stimulated, felt exactly like her symptoms a deep ache in the region of the low back and
upper gluteals. In just three appointments, her pain was completely relieved. She was quite pleased, I
can tell you!
Just wanted to give you a quick update my back has been absolutely fine. Unbelievable
or perhaps not, considering what Ive learned from you! A big thank you for all your
help.
Lois McConnell, retired airline executive, suffered chronic low back and hip pain for a few
years
8 of 25 02/03/2010 10:24 AM
Or consider Jan Campbell. Jan is a moderately active and healthy retired French teacher, but she
developed a hip pain sometime in early 2004 during a period of intense exercising. The pain quickly
grew to the point of interfering with walking, and was medically diagnosed as either a bursitis or a
piriformis strain. I did not believe that either of these could be the case, and treated a trigger point in
her piriformis muscle once on June 12, 2004. Her symptom was 100% relieved for about eight
months, before it slowly began to reassert itself (as trigger points often do, despite our best efforts
more about that to come).
One trigger point therapy treatment completely relieved a nasty stubborn hip pain that I'd
had for five months!
Jan Campbell, retired French language teacher, Palm Springs, recovered easily from
several months of hip pain
Every trigger point therapist has a seemingly endless list of such treatment success stories. Although
most such cases involve relatively minor symptoms, this is not to say that they were minor problems.
In almost every such case, the pain was relatively mild but extremely frustrating and persistent for
many years, then relieved almost effortlessly by a handful of treatments an incredible thing, when
you think about it. So much unnecessary suffering!
How can you tell if trigger points are the cause of your problem?
Trigger points have many strange features and behaviours, and can easily be confused with many
other problems. Because of their medical obscurity, they are often the last thing to be considered in
spite of their clinical importance and many distinctive characteristics. There are several things you
can look for that will help you to feel more confident that, yes, trigger points are the problem instead
of something else. The next several sections will discuss all of them in detail.
Whether you knew it or not, you were probably already familiar with trigger points even if youd
never heard of them before starting this tutorial.
Almost everyone has a head start in self-diagnosing trigger points, because almost everyone already
more or less knows what its like to have a muscle knot. If you have ever had muscle stiffness,
wrenched your neck around trying to stretch and wiggle your way free of discomfort, or gotten a
friend or partner to dig into that annoying spot in your back, then you already have some experience
with this you probably have trigger points!
But there may be many things you dont yet know about how trigger points behave and feel
End of free introduction to this tutorial
Full access to the rest of this tutorial is available immediately for USD$1995. Click the Buy
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9 of 25 02/03/2010 10:24 AM
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While you have access, you can read the tutorial online. To preserve your purchase, you can
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Almost certainly, but not for a while yet. For now I prefer to sell access to webpages. They are
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Do I have to download anything? Is there a PDF?
No, there is no file to download and store. There are several issues with PDFs: they are hard to
update, glitchy and unreliable, difficult for some beginners to use, and more. Tutorials in the
form of webpages are the superior product.
You can also print it, or save it. The full trigger points tutorial is about 85,000 words in 129
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all myths & controversies

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Testimonials
12 of 25 02/03/2010 10:24 AM
Here are some of the nicest things that readers have said about my trigger points tutorial over the
years. Thanks everyone!
I have been suffering from lower back pain for the last 5 weeks and found
your page to be very informative and interesting. I really cant thank you enough actually
because for the first time Im really starting to feel like Im on the right track here.
Glenn Hill, Canterbury, Australia
Thanks to your website, I pretty much got rid of my back problems almost
overnight. Its also fun and thought provoking to read!
Amsterdam Jeroen Strompf, MFA, Screenwriting, Chapman University
Im really enjoying your work!
Janice Kregor, competitive swimmer, retired pediatrician, medical school instructor
Your tutorial is great! It has humor and factual information presented in a

clear layman mode. Your writing has given me much mental clarity and power about a
subject that has been so confusing for so long. I am now in a much better position when I
see the muscle doctors, and it also made me look much smarter in dealing with the health
insurance people.
Melissa Rizio, a classic trigger sufferer suffering chronic pain since 1991
13 of 25 02/03/2010 10:24 AM
My husband had been suffering from shoulder and neck pain for years. He
had tried numerous medications, physical therapies, deep tissue massage, Bowen
technique, acupuncture and trigger point injection none of which provided anything
more than minor, temporary relief. Then I bought your tutorial on trigger points. I read it,
carried out your instructions to the detail, and after 5 sessions of the technique you
provided, the trigger points were gone! He has never felt better in years. Thank God I was
able to stumble upon your website by chance. I want to thank you for sharing your
expertise over the net.
June Lim, MD, Diplomate, Philippine Society of Anesthesiologists
First, THANK YOU for this information. Youve done all the heavy lifting:
reading the literature, the studies, et cetera. And youve presented all the information in a
concise, useful and entertaining format. I have learned a lot from reading these two
tutorials, including the miscellaneous articles you have referenced along the way.
Jan Nelson, pharmacist and power yoga practitioner
I am blown away by your trigger point eBook. It is fantastic! I wish I would

have come across your site sooner as I do serious research on just about any purchase I
make, and that goes double now that I have hand pain issues. I purchased Claire Davies
Trigger Point Therapy Workbook back in mid Dec, which has been great, but it was
lacking. By comparison, Im in awe of how well you illustrate and explain whats going on
with trigger points. Your analogies are superb and reading your book helps give so much
better an understanding of whats going on that I dont feel like Im shooting in the dark as
much. Im just surprised that I didnt find your site sooner. Ive done lots of research
online and could only find short one-page write ups on trigger points. From your
copyright, youve been up for 9-10 years and your content is superb. Thank you for such a
great book, well worth the $20.
Kevin Janisch
Thanks, Kevin Ive been coughing up good analogies even longer than that!
Since the early 1990s! Paul
14 of 25 02/03/2010 10:24 AM
Read 15 more testimonials
One more special testimonial. In the Spring of 2009, I received an incredible endorsement from
Jonathon Tomlinson, a GP in Hackney, East London, praising the whole website and every tutorial:
I'm writing to congratulate and thank you for your impressive ongoing review
of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital
in Hoxton. I originally stumbled across your website whilst looking for information about
pain for my medical students, and have recommended your tutorials to them. Your work
deserves special mention for its transparency, evidence base, clear presentation,
educational content, regular documented updates, and lack of any commercial
promotional material.
Dr. Jonathon Tomlinson, MBBS, DRCOG,MRCGP, MA, The Lawson Practice, London
High praise indeed! Thank you, Dr. Tomlinson testimonials just dont get much better than that.
15 of 25 02/03/2010 10:24 AM
Why not The Trigger Point Therapy Workbook?
One of the better books out there about trigger points is Clair Davies
mostly excellent The Trigger Point Therapy Workbook. There is one
thing in particular that The Trigger Point Therapy Workbook offers that
this tutorial deliberately lacks: detailed, muscle-by-muscle reference
material. His book is a better reference book than this document is.
Instead of reference material, this tutorial offers many advanced

troubleshooting concepts that cant be found in Davies book at all, not
even between the lines. Challenging cases of myofascial pain require
good understanding of the nature of the problem and clear guiding
principles not one-size-fits-all treatment recipes.
I have met many patients who got a lot of benefit from The Trigger
Point Therapy Workbook, got them started on the path to self-treating
muscle pain but then they couldnt take it all the way. The book
particularly does not help people successfully troubleshoot difficult
cases.
Clair Davies book is goo
My main beef with Davies is that he promises too much, giving the not quite good enough f
impression that self-massage is an infallible cure trigger point therapy of people.
is great stuff, but it isnt that good. His over-the-top enthusiasm is a
serious flaw. It sets patients up for disappointment, and it alienates
sensible doctors.
This tutorial has a more realistic tone, and is the superior resource in my completely biased
opinion! for people who are struggling with more serious trigger point pain.
See my full review of The Trigger Point Therapy Workbook for more information.
Appendix A: The Perfect Spots
As explained early in the tutorial that trigger point reference materials can be useful, but they also
confuse patients as often as they help, maybe more often. Therefore, descriptions and diagrams of
trigger point locations are deliberately left out of this tutorial!
That said there is trigger point reference material on SaveYourself.ca. Here are the perfect spots:
several of the most satisfying and therapeutically significant places on the human body to apply
pressure. What makes a spot perfect? A common trigger point, reasonably easy to find and treat, good
therapeutic bang for buck! All of these articles are completely free.
16 of 25 02/03/2010 10:24 AM
Acknowledgements
This document and all of SaveYourself.ca was, for many

years, created in my so-called spare time and with a lot
of assistance from family and friends. Undying thanks to
my wife, Kimberly, for countless indulgences large and
small, and for being my editor girlfriend; to my parents
for (possibly blind) faith in me, and much copyediting; and
to Mike Gobbi, buddy and digital mentor, for many of the
nifty features of this document (hidden and obvious). And
thanks to all of the above, and many others, for many
(many) answers to what do you think of this? emails.
Thanks finally to every reader, client, customer, and big

tipper for your curiosity, your faith, and your feedback and
suggestions and stores. Without you, all of this would be
pointless.
And a few thanks to some health professionals who have been particularly inspiring to me: Dr. Steven
Novella, Sam Homola, DC, Dr. Harriet Hall, Simon Singh, and Dr. Stephen Barrett.
Whats New In the Trigger Points Tutorial?
Most links to sections mentioned in the updates will work only for customers. To get access to all
sections, purchase the tutorial for $19.95. Youll receive the full version right away.
Saturday, February 13, 2010 A tiny-but-interestingupdate: added some pretty good evidence that
a muscle relaxant was no better for injured neck muscles than ibuprofen.
Tuesday, January 19, 2010 One refreshed section (The all-powerful acne analogy), and a
completely new one logically following from it: The evolution of muscle pain: does muscle burn
out?
Tuesday, January 12, 2010 Two heavily revised sections: What are the worst case scenarios for
myofascial pain syndrome? and Rare but extremely severe cases of myofascial pain syndrome.
Thursday, January 7, 2010 A small but significant update on nutritition, based on Bischoff-
17 of 25 02/03/2010 10:24 AM
Ferrari et al , which basically boils down to a recommendation to take vitamin D it might help.
Thursday, December 31, 2009 Minor update: just added a couple of references, Calandre et al and
Fernndez-de-Las-Peas et al , to substantiate the relationship between migraines and trigger points.
Tuesday, December 22, 2009 A substantial new section makes the case for self-treatment:
Fundamental limitations of trigger point therapy, and how to take advantage of them
Wednesday, November 25, 2009 Upgraded the quality of the writing in an important section,
Trigger point diagnosis is not reliable but it may not matter that much.
Tuesday, November 17, 2009 A little smorg of updates today: (1) A lovely new illustration by
Shayne Letain for the introduction! Look for the man with toxic waste signs sticking into his back.
And (2) a new case study section with a fascinating success story, demonstrating a terribly important
basic piece of wisdom to get for anyone who is prone to muscle pain. And (3) just a bit of updating
of the tools sections with the idea of a bucket of balls.
Friday, October 23, 2009 As promised last week, there are now four new advanced sections about
the use of medications to treat trigger point pain. These are major new sections with a whole bunch of
useful information for patients and pros. This is the kind of content update that I particularly hope
motivates past customers to pay a for a subscription renewal at a low renewal price, which
available to all past customers forever.
1. Meds: Anti-inflammatories and Tylenol

2. Meds: Voltaren Gel, an intriguing new option (or see the less detailed but free article
Voltaren Gel)
3. Meds: The nuclear option: Hillbilly heroin (Oxycontin), codeine and other opioids
4. Meds: The surprising futility of muscle relaxants such as Robax-whatever, Valium and other
benzodiazapenes
Also, all discussion of Botox (especially the Botox section) was updated with new scientific evidence
that its not as effective a therapy for trigger point pain as we all hoped.
Friday, October 16, 2009 Two new sections: Muscle knots are not inflammatory: the myth of the
inflamed myofascial trigger point and Common medications that might make a difference (and
might not). More advanced medication information to follow soon: this is just a summary of the
basics so far.
Wednesday, September 30, 2009 A substantial new section today: Trigger point diagnosis is not
reliable but it may not matter that much. I wrote about this a while back on the front page and it
will be there and free for a while longer, but Ive also added more information here and included
some references to other studies.
Wednesday, September 16, 2009 Several minor updates and refinements, not in any particular
section.
Saturday, August 15, 2009 Its come to my attention that the trigger point treatment method of dry
needling doesnt have as much going for it as I used to think. I discuss the (lack of) evidence and
problems in an overhaul of the section How about dry Needling and Intramuscular Stimulation (IMS)
therapy? Since Dr. Chan Gunn is the doctor behind one of the most popular methods of dry needling
(IMS), I also revised a section which was inspired by his ideas, The bamboo cage theory of muscle
18 of 25 02/03/2010 10:24 AM
pain.
Thursday, August 13, 2009 Completely re-wrote the section How about myofascial release and
fascial stretching? which is accompanied by a new (free) general review of myofascial release therapy
(MFR), as promoted by John Barnes.
Friday, July 24, 2009 Rewrote the section How about chiropractic joint adjustment and popping?
Its been condensed into more finely tuned summary, and links out to a new special supplement to
the tutorial: a separate article covering the topic in much greater detail, accessible to tutorial
customers only. As the SaveYourself.ca inventory of tutorials expands, such special supplements will
be a useful new way of providing detailed information without repeating it in multiple tutorials.
Please think of the special supplement as a part of the tutorial, that just happens to be on another
page.
Thursday, July 16, 2009 Physiatrists and rheumatologists added to Types of therapists and
doctors and their relationship to trigger point therapy.
Wednesday, July 1, 2009 Major bibliography update. The SaveYourself.ca bibliography has long
been the largest of its kind. It contains an incredible amount of surprisingly readable information
about musculoskeletal health science, and it is now possible for visitors to search and sort the
bibliography with powerful new features. For instance, every source about trigger points referenced
in this tutorial can now easily be displayed in a single search, with a variety of options. See the front
page for the announcement of the new features, or visit the bibliography itself.
Friday, June 12, 2009 New section: Quick-start trigger points (access for customers only)
describing the clinical characteristics and significance of extremely fast-activating and severe trigger
points.
Monday, May 18, 2009 Added an important point to the section, From the frying pan of injury
pain to the fire of trigger point pain, about injuries that are so severely complicated and
overshadowed by trigger point pain that the victims literally dont even know that there is a physical
trauma at the heart of the problem. This is also discussed in the recent article Widespread Chronic
Pelvic Pain In a Runner With a Surprising Cause.
Wednesday, April 1, 2009 The visual design of the site was upgraded over the past several days.
Although this is not an update to the content of this tutorial, it is nevertheless a significant upgrade
for all of them like publishing new editions of books with better typesetting and layout. The new
design is even cleaner and reader-friendly; it now looks that good in most web browsers; and pages
load as much as 50% faster. Many under-the-hood improvements will make it much easier for me to
improve tutorial content. The tutorials are now well-oiled machines of digital publishing goodness,
vastly superior to the low-production values of most eBooks. More information about the upgrade is
published on the front page.
Monday, March 16, 2009 Minor update. Added information about a massage tool product, the
ShiatsuBag, an 18" round satin-Lycra bag of massage balls. You can read the full review or buy one
now for USD $39.95 at ShiatsuBag.com, because its a bag of massage balls and you simply must
have one.
Sunday, February 15, 2009 Another new advanced tip section today: Dont be fooled by reverse
referral. This ones a head trip. Its so confusing, I left it out of earlier versions of the tutorial simply
because I still didnt know how to explain it. But I decided it was time to tackle it, and here you go I
19 of 25 02/03/2010 10:24 AM
think I more or less got the point across.
Monday, February 9, 2009 This tutorial has always been strong in the practical tips and tricks
department. Well, play to your strengths! Lately Ive been in the mood to add even more tips, and
heres another one today, Focussing on one trouble spot versus a little bit of everything which is
the better strategy?
Tuesday, February 3, 2009 Added new information about Traumeel, a popular but questionable
remedy that I often get asked about. See the section, Reality checks: some self-treatments that dont
work at all (or not nearly as well as you would hope) , or the free article, Does Traumeel Work?.
Monday, February 2, 2009 Improvements to the section, How about acupuncture? Some
optimism about acupuncture was removed from the section, and an important new reference was
added. Recent scientific evidence has continued to hammer away at acupuncture, and optimism
about it can no longer be justified. You can read about the most recent acupuncture evidence in, Does
Acupuncture Work for Pain?.
Tuesday, January 27, 2009 New section! Dont get hung up on anatomy, and be persistent.
Sounds like a bit of a no-brainer, but theres a couple ideas in there that patients often need to hear.
Its a nice addition in the tip category that really should have been there before.
Thursday, December 4, 2008 A new section, From the frying pan of injury pain to the fire of
trigger point pain, helps readers understand the unholy relationship between injury and trigger
points. For readers who have been injured, this is an important addition to the tutorial. Similar
information is also available in the form of a story in the article Into the Fire: Trigger point pain as a
major injury complication, and how I finally miraculously healed from a serious and stubborn
shoulder injury by untying the muscle knots. There is some overlap between the new section here and
the stand-alone article, but they both offer different information in different ways. If you are injured,
read both!
Monday, November 17, 2008 Added some information about some nice self-massage tools built by
Allan Saltzman of YogaTools.com in the section, Beyond the tennis ball: some of the best commercial
massage tools, as well as some self-massage tools and products I dont like, in the (now independent
and expanded) section Commercial massage tools to avoid.
Saturday, September 20, 2008 Added some information about the relationship between
myofascial pain syndrome and disease that obviously affect the harmony of the musculoskeletal
system, using Parkinsons disease as an example. See the section Are you a triggery person? The
relationship between trigger points and other physiological disorders and diseases, especially
fibromyalgia.
Monday, August 18, 2008 Corrections and minor improvements have been made by the hundreds
since the publication of the last major upgrade, which was three weeks ago. The polishing never really
ends!
Monday, July 28, 2008 Massive upgrade published. This is by far the largest single update a
SaveYourself.ca tutorial has ever gone through. The trigger points tutorial has more than doubled the
amount of information it offers, and is now book-length at around 80,000 words. Every single
customer who ever purchased the tutorial received 2 weeks of free access to the upgraded tutorial.
Heres a summary of everything thats changed:
20 of 25 02/03/2010 10:24 AM
There were only 50 sections of treatment recommendations before. Most were overhauled
and expanded significantly, and then 20 new ones were added.
A valuable new feature has been added, a downloadable Quick Reference Guide, which
somewhat miraculously summarizes all this information in a single page.
Lots of interesting new scientific evidence has now been integrated into the tutorial. There are
now around 150 footnotes (up from 60ish), all of them adding value with interesting tangents
and/or referencing hard science.
An incredible amount of work went into improving the organization and flow of the tutorial. A
small technological innovation, the addition of a table of contents button that is always
available on the left side of the screen, will make it much easier to get around such a large
document.
I added many new expanding sections with extra information for professionals and keen
patients sort of like super footnotes, readers can reveal them or ignore them as they wish.
(They appear in parentheses in the table of contents.)
Several of the Perfect Spots articles were revised and expanded as well they arent
technically part of the tutorial, but they are an important free accessory to the tutorial.
October 2007 through May, 2008 Fifteen substantive updates were published over eight months.
All of them were made more or less made obsolete by and rolled into the major update of the whole
tutorial, published July 28, 2008.
Notes
1. The most popular trigger point book for patients is still the Trigger Point Therapy
Workbook, by Clair Davies. It has some qualities, but its also simplistic and out of date. It was
never more than an introduction to the subject, and five long years of new scientific research
have left it in the dust. And it will never be updated again: Mr. Davies died in 2006.
Many people have written to me over the years to tell me how the Workbook did
not really do the trick for them, but this tutorial did. The Workbooks qualities
and limitations are reviewed more thoroughly below.
2. Heres a funny quote:
Rocket science isnt all that difficult. Its not brain surgery.
A rocket scientist
3. Commenting on two fascinating 2008 research papers (Chen and Shah), Dr. David Simons
wrote, Currently, consideration of the possibility of a myofascial trigger point component of the
pain complaint is commonly not effectively included in the differential diagnosis and therefore
is missed cold turkey, which can be very expensive for the health care system (expensive
examinations looking for a phantom diagnosis) and disastrous to the patient (wrong diagnosis,
wrong treatment).
4. Simons writes, Many authors through the years have discovered a new muscle pain
syndrome . The popular Dr. John Sarno is still stubbornly calling it tension myositis
syndrome to this day, the term he invented when he discovered MPS. MPS has been named
for the region a particular researchers finds it in. Its been thoroughly confused with
21 of 25 02/03/2010 10:24 AM
fibromyalgia, its been called fibrositis and muskelharten and myofascitis and myelgelosis. Its
been stuck with the labels non articular or soft-tissue, rheumatism, osteochondrosis, and
tendomyopathy. Every last one of them is a historical artifact.
5. Other muscle injuries are often confused with trigger points. But a trigger point is not a regular
whole-muscle spasm, or a muscle strain (torn muscle), which is an actual rip in muscle tissue
that occurs suddenly and is instantly very painful. The differences will seem obvious as you
learn more about trigger points.
6. Smith. Journal of Musculoskeletal Pain. 2007. Its amazingly difficult to find hard data on the
prevalence of musculoskeletal problems. However, this Australian study of medical students
found that almost 90% of them had some kind of body pain problem, mostly in the neck, lower
back and shoulders and these are young people. It may not be an exaggeration to say that
virtually the entire population of planet Earth has musculoskeletal pain!
7. Fernndez-de-Las-Peas et al . Current Pain & Headache Reports. 2007. This important review
of the scientific literature on the relationship between trigger points and neck and head pain
generally found that there is not much literature to review. Interestingly, the authors do note
that there is more evidence that both tension headache and migraine are associated with
referred pain from trigger points.
8. Calandre et al . Head & Face Medicine. 2008. Although this research was preliminary and
uncontrolled and is not powerful enough to prove anything, its results were certainly
noteworthy the sort of results that can inspire more research, hopefully. All of 12 patients
with chronic cluster headaches (a kind of migraine, nicknamed suicide headaches) had
myofascial trigger points, and treating them (with injection) produced significant improvement
in 7 of the 8 chronic cluster patients. The authors speculate that trigger points are not the cause
of cluster headaches, but a nasty complicating factor: chronic pain or repeated acute pain
sensitize muscular nociceptors creating active trigger points which, in turn, contribute to
potentiate headache pain. This kind of vicious cycle explains why the number of active trigger
points has been found to be higher in patients with chronic primary headaches than in healthy
subjects or in patients experiencing less frequent headache attacks.
9. Simons et al . Myofascial Pain and Dysfunction, pxi. Or, as stated more eloquently and
authoritatively by Drs. Travell and Simons, Myofascial trigger points are a frequently
overlooked and misunderstood source of the distressingly ubiquitous musculoskeletal aches and
pains of mankind.
10. Much more recently than in the previous footnote, in 2008, Dr. Simons writes: Currently,
consideration of the possibility of an MTP component of the pain complaint is commonly not
included in the differential diagnosis and therefore is missed cold turkey, which can be very
expensive for the health care system (expensive examinations looking for a phantom diagnosis)
and disastrous to the patient (wrong diagnosis, wrong treatment).
11. I believe that trigger points are essentially a by-product of the volatility of muscle. Muscle
tissue is incredibly powerful and complex, and like any finely-tuned machine, it breaks down
easily. I suspect that we get trigger points as a relatively small price to pay for having
high-functioning muscle tissue, an evolutionary compromise. Higher function would require an
escalating risk of dysfunction. Reduced function would probably result in fewer trigger points
but also in weaker and less responsive muscle.
12. Office Place RSIs Decreased in 1994. InteriorsAndSources.com. 1996. Estimates of the
incidence of repetitive strain injuries generally range from 3-6% of all cases requiring time away
from work. In comparison, MPS is ubiquitous. In my own clinical experience, treating RSIs
represent a negligible fraction of my work, whereas MPS is either a cause or complicating factor
in nearly every case I treat including the RSIs! In 1996, Interiors and Sources magazine
reported that, the total number of serious injuries or illnesses attributed to all repetitive
22 of 25 02/03/2010 10:24 AM
motion was just ... four percent of the total number of cases requiring time away from work. Of
those, the majority of cases or 53 percent were recorded in the manufacturing sector ... Clearly,
most repetitive motion injuries are not occurring in the offices of America, said PJ Edington
and executive director of the Center for Office Technology (COT). And the so-called epidemic
of office-related repetitive motion injuries reported in the media has been a clear case of
misdiagnosis.
13. I wish I could take a photomicrograph of my own trigger points, or my clients' trigger points. Or
sample the tissue fluid. Or use the new MRI technique. Or measure their electrical activity. But,
unfortunately, these procedures are not available to anyone, at all: some, like
photomicrographs, are advanced and expensive techniques that can be only done for the
purposes of research. (Also, though I'm not sure about this, I think it's possible that
photomicrographs can only been done on dead, excised animal muscle! I don't know if it's
possible to take photomicrographs of living tissue. If any of my readers knows more about this,
please let me know). Theres some hope that the MRI method will become practical for clinical
use, but even that is likely to be years off. Its strange, isnt it? We can put a man on the moon,
but we cant use high tech to diagnose muscle knots yet
14. So, wouldnt it be great if I had such a picture to show you? It sure would! But they are hard to
come by, and there are copyright problems. You can see one in Myofascial Pain Caused by
Trigger Points, a chapter in the book Muscle Pain, by David G Simons, Siegfried Mense and IJ
Russell.
15. Measuring trigger point electrical activity is also described in detail in Muscle Pain. That text is
one of the main sources for this tutorial, and I wont put it in a footnote every single time it
comes up just when in matters.
16. Two recent scientific papers, one in 2005 and then more convincingly in 2008, have shown how
the tissue fluid in and around a trigger point is painfully poisonous. This will be explored in
much greater detail further along in the tutorial.
17. Chen et al . Archives of Physical Medicine & Rehabilitation. 2007. This paper demonstrates the
use of a promising new method of imaging the taut bands of muscle associated with myofascial
trigger points, using a modification of MRI technology. It is thoroughly analyzed by Simons,
who writes that this technology may open a whole new chapter in the centuries-old search for a
convincing demonstration of the cause of MTP symptoms.
18. The clinical prominence of trigger point therapy is still not what it should be doctors as a
group are still barely aware of it but the scientific interest is quite strong, which bodes well for
the future. The amount of scientific attention that trigger points are getting can be verified by
searching PubMed for myofascial trigger points, which is the database of medical scientific
information 5248 papers, and the majority of those are recent. Browsing through the list of
titles, you can see an extraordinary array of scientific efforts to understand and explain the
phenomenon and the treatment options! Very exciting!
19. Of course, the existence of nice laminated wall charts hardly proves anything. There are
laminated charts available for many kinds of ineffective therapies! Any practitioner who hangs a
nice chart on their wall looks more credible, whether there is any basis to the chart or not.
However, trigger point charts are a by-product of an incredible amount of medical research,
and the pain patterns on the chart can easily be demonstrated for patients by any competent
therapist.
20. Dr. Travell died in 1997. Her lifes work was remarkable. Her daughter published a lovely
article about her in 2003. See Janet G. Travell, MD: a daughter's recollection
21. Simons in The Trigger Point Therapy Workbook: Your Self-Treatment Guide for Pain Relief,
from the foreword. The full quote reads: Muscle is an orphan organ. No medical speciality
claims it. As a consequence, no medical specialty is concerned with promoting funded research
23 of 25 02/03/2010 10:24 AM
into the muscular causes of pain, and medical students and physical therapists rarely receive
adequate primary training in how to recognize and treat myofascial trigger points. Fortunately,
massage therapists, although rarely well-trained medically [BC being one of the obvious
exceptions, see Massage Therapy In British Columbia (Canada) PI], are trained in how to find
myofascial trigger points and frequently become skilled in their treatment.
22. Travell et al . Myofascial Pain and Dysfunction. 1999. Vol 1, p13.
23. Most doctors are well aware that there are serious shortcomings in the medical management of
most musculoskeletal problems, especially chronic pain cases. Dr. Jonathon Tomlinson, an
instructor at St. Leonards Hospital in Hoxton, explains that undergraduate training is focused
on hospital orthopedics (broken bones and anything else thats amenable to surgery) or
rheumatology (nasty inflammatory diseases) which comprise a minority of the aches/pains
/strains and injuries that people actually suffer from.
Medical researchers have done many studies showing that most doctors do not understand
aches and pains or heed expert recommendations. A good recent example is a paper in the
Archives of Internal Medicine showing that family doctors frequently ignore guidelines for the
care of low back pain see Williams et al .
More generally, the Journal of Bone and Joint Surgery, and the Journal of the American
Osteopathic Association, have both published papers recently showing that physicians simply
do not have an adequate understanding of musculoskeletal medicine. In 2002, Freedman et al
felt that It is ... reasonable to conclude that medical school preparation in musculoskeletal
medicine is inadequate. Then again in 2005 in JBJS, Matzkin et al concluded that training in
musculoskeletal medicine is inadequate in both medical school and non-orthopaedic residency
training programs. Most recently, in 2006, Stockard et al wrote 82% of allopathic graduates ...
failed to demonstrate basic competency in musculoskeletal medicine.
24. Structuralism is an excessive clinical focus on posture, alignment, and symmetry and other
biomechanical factors crookedness, in other words, or what I call the biomechanical
bogeyman. Therapists who are into structuralism attribute virtually all pain problems to
alleged biomechanical deficiencies that are either entirely imaginary (sometimes absurd), or
just relatively unimportant factors in most cases. For much more information, see Your Back Is
Not Out and Your Leg Length is Fine.
25. See I See Muscle and A Historical Perspective On Aches and Pains.
26. Travell et al . Myofascial Pain and Dysfunction. 1999.
27. Mense et al . Muscle Pain. 2000. A dense text, important reading for professionals.
28. And not impossible reading, either. Over the course of a decade, I have seen several keen
patients tackle Travell and Simons massive red texts and get good value from them. The
diagrams are exceptionally clear, and the writing is generally quite good. Its not out of the
question for patients to try to work with them. But they are expensive reference books, filled
with jargon, and intended clinicians who are dealing with every area of the body on a daily
basis.
29. Fibromyalgia is common, but (much) less common than myofascial pain syndrome. It causes
you to hurt all over widespread chronic pain and causes many other symptoms,
especially the FM tender points, which are easily mistaken for trigger points. The main
difference between them: trigger points often go away, but tender points defy all treatment.
30. Staud. Curr Pharm Des. 2006. interventions aimed at reducing local FM pain seem to be
effective but need to focus less on tender points but more on trigger points (TrP) and other body
areas of heightened pain .
24 of 25 02/03/2010 10:24 AM
31. Travell et al., op.cit. (Virtually all information in this article is drawn from Travell and Simons,
so I wont cite page references for every instance.) The subscapularis case is a good example of
how MPS is probably much more clinically significant than RSIs: not only is MPS a causal or
complicating factor in many RSIs, it frequently imitates them and is the correct diagnosis! This
is why at least some RSIs do not respond to conventional treatment.
32. Its possible to richly reference this section with individual scientific papers backing up every
single example of trigger points mimicking some other health problem. This kind of information
is everywhere in the MPS literature. For now, heres just one of many, a 1995 paper, Myofascial
pain syndromes the great mimicker.
33. Theres a large body of research about this, but Rocha is a good recent example. In 2007, these
researched found that in 56% of patients with tinnitus and MTPs, the tinnitus could be
modulated by applying digital compression of such points, mainly those of the masseter
muscle. And how many people with tinnitus had trigger points? Quite a few. The researchers
found a strong correlation between tinnitus and the presence of MTPs in head, neck and
shoulder girdle.
34. As discussed above, such structural misdiagnoses are a common red herring, and almost
always wrong. Mistaking a gluteus maximus trigger point for sacroiliac joint pain is a
particularly common diagnostic error. See Massage Therapy for Low Back Pain (So Low That
Its Not In the Back) for more about this particular area.
There are 140 more footnotes in the full version of the trigger points tutorial. See
above for details, or click the buy button to buy it now.
25 of 25 02/03/2010 10:24 AM

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Trigger Point Tutorial (Advanced) http://saveyourself.ca/tutorials/trigger-points.

AN ADVANCED TUTORIAL FOR PATIENTS AND PROFESSIONALS

by Paul Ingraham, Vancouver, Canada MORE

Credentials and qualifications

illustrations by Paul Ingraham, Shayne Letain, Alexia Tryfon

Physicians & therapists need to learn about trigger points too

Does your body feel like a toxic waste dump?

It may be more literally true than you realized! A muscle

What exactly are muscle knots?

Why muscle knots matter so much

1. cause pain problems,

How can you trust this information about trigger points?

Im inspired by the MythBusters approach: I question everything and I have

I spend a lot of time on

Trigger points are good, hard

take photomicrographs of TrPs,14

Trigger points rest on a bedrock of thousands of scientific papers published in mainstream,

Trigger point charts

Many trigger point charts are

Drs. Janet Travell & David Simons

Why are trigger points so neglected?

Does your trigger point therapist have the big red

In addition to dozens of scientific papers, this tutorial is based on medical

A brief note about the relationship between fibromyalgia and myofascial

Fibromyalgic Tender Points

The tender points of

Trigger points also explain many odd aches and pains

Is this like you?

Muscle knot pain can be savage. Over

A couple of typical trigger point pain

End of free introduction to this tutorial

Payment takes 23 minutes, and its easy and secure!DETAILS

What does secure really mean?

Why do you ask for personal contact information?

What am I buying? Is there a physical book?

Id rather read a book. Will you be publishing a book?

Do I have to download anything? Is there a PDF?

More information about eBoxed sets

To get access to all 129

all myths & controversies

Glenn Hill, Canterbury, Australia

Amsterdam Jeroen Strompf, MFA, Screenwriting, Chapman University

Im really enjoying your work!

Janice Kregor, competitive swimmer, retired pediatrician, medical school instructor

Your tutorial is great! It has humor and factual information presented in a

June Lim, MD, Diplomate, Philippine Society of Anesthesiologists

Jan Nelson, pharmacist and power yoga practitioner

I am blown away by your trigger point eBook. It is fantastic! I wish I would

Read 15 more testimonials

Why not The Trigger Point Therapy Workbook?

Instead of reference material, this tutorial offers many advanced

Appendix A: The Perfect Spots

This document and all of SaveYourself.ca was, for many

Thanks finally to every reader, client, customer, and big

Whats New In the Trigger Points Tutorial?

1. Meds: Anti-inflammatories and Tylenol

think I more or less got the point across.

2. Heres a funny quote:

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