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Trigger points, also known as trigger sites or muscle knots, are described as hyperirritable spots in skeletal muscle that

are associated with palpable nodules in taut bands of muscle fibers.[1]Trigger point practitioners believe that palpable nodules are small contraction knots[ambiguous] and a common cause of pain. Compression of a trigger point may elicit local tenderness, referred pain, or local twitch response. The local twitch response is not the same as a muscle spasm. This is because a muscle spasm refers to the entire muscle contracting whereas the local twitch response also refers to the entire muscle but only involves a small twitch, no contraction. The trigger point model states that unexplained pain frequently radiates from these points of local tenderness to broader areas, sometimes distant from the trigger point itself. Practitioners claim to have identified reliable referred pain patterns, allowing practitioners to associate pain in one location with trigger points elsewhere. Many practitioners of chiropractic and massage therapy find the model useful, but the medical community at large has not embraced trigger point therapy. There is no consistent methodology for diagnosis of trigger points and a dearth of theory to explain how they arise and why they produce specific patterns of referred pain.[2]

1 Definition 2 Myofascial pain syndrome 3 Qualities of trigger points o 3.1 Potential causes of trigger points o 3.2 Diagnosis of trigger points o 3.3 Misdiagnosis of pain o 3.4 Demonstration and identification of myofascial trigger points 4 Treatment o 4.1 Injection o 4.2 Self-treatment

1 Janet G.  Palpation of the trigger point reproduces the patient's complaint of pain. Travell. and the pain radiates in a distribution typical of the specific muscle harboring the trigger point. 1994) have examined this problem. 1992. 1992.. found that independent examiners were generally able to identify myofascial trigger points (MTrP).  The painful point can be felt as a nodule or band in the muscle. Practitioners do not necessarily agree on what constitutes a trigger point. but only with sufficient training and agreement on the definition and features of MTrP's. Janet Travell to describe a clinical finding with the following characteristics: Pain related to a discrete. degeneration. Njoo and Van der Does. The present study shows that four examiners can achieve statistically significant agreement. about the presence or absence .4.. irritable point in skeletal muscle or fascia. Wolfe et al. and none of them could establish the reliability of MTrP examination in all of its major manifestations...  A study by Gerwin et al. MD 6 See also 7 References 8 External links o [edit]Definition The term "trigger point" was coined in 1942 by Dr. inflammation. neoplasm or infection.4 Research 5 History o 5. . They said: Three previous studies (Nice et al. not caused by acute local trauma. at times almost perfect agreement.3 Risks o 4.  The pain cannot be explained by findings on neurological examination. and a twitch response can be elicited on stimulation of the trigger point.

and claims for effective interventions in treating the condition should be viewed with caution. which is characterized by widespread pain and tenderness and is described as a central augmentation of nociception giving rise to deep tissue tenderness that includes muscles. found at multiple sites in a muscle and the fascia of muscle tissue. This establishes the MTrP as a reliable clinical sign. whether it be latent or active.. Until reliable diagnostic criteria have been established. Myofascial pain is associated with muscle tenderness that arises from trigger points. The present study also shows that these features are identified with greater or lesser reliability depending on the specific feature and the specific muscle being examined.of five major features of the MTrP and on the presence or absence of the TrP.. a few millimeters in diameter. A training period was found to be essential in order to achieve these results. . This is described as a focal hyperirritability in muscle that can strongly modulate central nervous system functions. myofascial pain is a primary cause of regional pain.[3] A 2007 review of diagnostic criteria used in studies of trigger points concluded that there is as yet limited consensus on case definition in respect of MTrP pain syndrome.[2] [edit]Myofascial pain syndrome The main innovation of Travell's work was the introduction of the myofascial pain syndrome concept (myofascial referring to the combination of muscle and fascia). focal points of tenderness. Studies estimate that in 75±95 percent of cases. Biopsy tests found that trigger points were hyperirritable and electrically active muscle spindles in general muscle tissue.[4] [edit]Qualities of trigger points . Further research is needed to test the reliability and validity of diagnostic criteria. there is a need for greater transparency in research papers on how a case of MTrP pain syndrome is defined. Travell and followers distinguish this from fibromyalgia.

either converting it from being active to latent or completely treating it. In contrast. active/latent and also as key/satellites and primary/secondary. Active and latent trigger points are also known as "Yipe" points. Treating the primary trigger point does not treat the secondary trigger point. A key trigger point is one that has a pain referral pattern along a nerve pathway that activates a latent trigger point on the pathway. activation by other trigger points (key/satellite. which can result in poorer muscle coordination and balance. [edit]Potential causes of trigger points Activation of trigger points may be caused by a number of factors. when they become active or latent. or creates it. homeostatic imbalances. There are a few more than 620 potential trigger points possible in human muscles. a primary trigger point in many cases will biomechanically activate a secondary trigger point in another structure. Latent trigger points can influence muscle activation patterns. but does not yet refer pain actively. A satellite trigger point is one which is activated by a key trigger point. That is. for obvious reasons. but may do so when pressure or strain is applied to the myoskeletal structure containing the trigger point. They may be classified as potential. including acute or chronic muscle overload. primary/secondary). Successfully treating the key trigger point will often resolve the satellite. trigger point maps can be made that are accurate for everyone. These trigger points.Trigger points have a number of qualities. direct trauma to the region. A latent trigger point is one that exists. accident trauma (such as a car accident which . disease. psychological distress (via systemic inflammation). An active trigger point is one that actively refers pain either locally or to another location (most trigger points refer pain elsewhere in the body along nerve pathways). show up in the same places in muscles in every person.

These in turn can pull on tendons and ligaments associated with the muscle and can cause pain deep within a joint where there are no muscles.[5] Usually there is a taut band in muscles containing trigger points.stresses many muscles and causes instant trigger points) radiculopathy. When muscle fibers contract. pain patterns and manual palpation. Clusters of trigger points are not uncommon in some of the larger muscles. they use biochemical energy. and depletion of these biochemicals leads to accumulation of fatigue toxins such as lactic acid. and some create reciprocal cyclic relationships that need to be treated extensively to remove them. When trigger points are present in muscles there is often pain and weakness in the associated structures. symptoms. infections and health issues such as smoking. The tightened muscle fibers constrict capillaries and prevent them from carrying off the fatigue toxins to the body's recycling system (liver and kidneys)[citation needed] . The buildup of these toxins in a muscle bundle or muscle feels like a tight muscle²a slippery elongate bundle. Pressing on an affected muscle can often refer pain. and a hard nodule can be felt. this twitch response often activates the "all or nothing" response in a muscle that causes it to contract. [edit]Diagnosis of trigger points Trigger points are diagnosed by examining signs. A 2009 review of nine studies examining the reliability of trigger point diagnosis found that physical examination could not be recommended as reliable for the diagnosis of trigger points. These pain patterns in muscles follow specific nerve pathways and have been readily mapped to allow for identification of the causative pain factor. Trigger points form only in muscles. . Often a twitch response can be felt in the muscle by running your finger perpendicular to the muscle's direction. They form as a local contraction in a small number of muscle fibers in a larger muscle or muscle bundle. Many trigger points have pain patterns that overlap.

MRE is a modification of existing magnetic resonance imaging equipment to image stress produced by adjacent tissues with different degrees of tension.[7] [edit]Demonstration and identification of myofascial trigger points A 2008 review in Archives of Physical Medicine and Rehabilitation of two recent studies concludes they present groundbreaking findings that can reduce some of the controversy surrounding the cause and identification of myofascial trigger points (MTPs). Travell and Simons hold that most of the common everyday pain is caused by myofascial trigger points and that ignorance of that basic concept could inevitably lead to false diagnoses and the ultimate failure to deal effectively with pain. Often there is a heat differential in the local area of a trigger point. In 2007. and gluteus minimus). and many practitioners can sense that. in weighing all the possible causes for a given condition. gluteus medius. but physicians. rarely consider a myofascial source. This report presents an MRE image of the taut band that shows the V-shaped signature of the increased tension compared with surrounding tissues. Referred pain from trigger points mimics the symptoms of a very long list of common maladies. The study of trigger points has not historically been part of medical education. The study by Chen on the use of magnetic resonance elastography (MRE) imaging of the taut band of an MTP in an upper trapezius muscle may present a convincing demonstration of the cause of MTP symptoms. a paper was presented describing images of trigger points taken by modified MRI.[8] Results were all consistent with the concept that taut bands are detectable and quantifiable with MRE imaging. The findings in the subjects suggest that the stiffness of the taut bands in patients with myofascial pain may be 50% greater than .such as the gluteus group (gluteus maximus.[6] [edit]Misdiagnosis of pain The misdiagnosis of pain is the most important issue taken up by Travell and Simons.

A successful treatment protocol relies on identifying trigger points.[9] In a June 2000 review. this involves stretching . if all trigger points have been deactivated. they have shown the feasibility of continuous.5% with similar pain indications. mechanical vibration. Practitioners use elbows. which is where most treatment occurs. finding that 92% of the 255 trigger points correspond to acupuncture points. electrostimulation. "spray-and-stretch" using a cooling (vapocoolant) spray. resolving them and. they have been able to investigate the biochemical milieu of muscle in subjects with active. elongating the structures affected along their natural range of motion and length. massage or tapotement as in Dr.[10] based on a 1977 paper by Melzack et al. pulsedultrasound. Low Level Laser Therapy and stretchingtechniques that invoke reciprocal inhibition within the musculoskeletal system.[12][13] [edit]Treatment Myofascial Trigger Point therapists may use myotherapy (deep pressure as in Bonnie Prudden's approach. injection (see below).[11] Peter Dorsher comments on a strong correlation between the locations of trigger points and classical acupuncture points. or absent myofascial trigger points (MTrPs) and to contrast this with that of the noninvolved muscle. Griner's approach). feet or various tools to direct pressure directly upon the trigger point.that of the surrounding muscle tissue. in vivo recovery of small molecules from soft tissue without harmful effects. to save their hands.[6] In the study by Shah and associates. In the case of muscles. dry-needling. including 79. Chang-Zern Hong correlates the MTrP "tender points" to acupunctural "ah shi" ("Oh Yes!") points. The findings suggest that MRE can quantitate asymmetries in muscle tone that could previously only be identified subjectively by examination. latent. and the "local twitch response" to acupuncture's "de qi" ("needle sensation").[14] ischemic compression. With this technique.

Fascia surrounding muscles should also be treated. but is not similar to. The results of manual therapy are related to the skill level of the therapist. muscle energy techniques(MET). Pain is also common after a massage if the practitioner uses pressure on unnoticed latent or active trigger points. and proprioceptive neuromuscular facilitation (PNF) stretching to be effective. active isolated (AIS). local anesthetics such as procaine hydrochloride (Novocain). or is not skilled in myofascial trigger point therapy. active.the muscle using combinations of passive.[16][17] [edit]Injection Injections. steroids. they may activate or remain active. an association has been made between fibromyalgia tender points and active trigger points. High concentrations or long acting local anesthetics as well as epinephrine can cause muscle necrosis. the pain felt days after overexerting muscles. possibly with myofascial release. A low concentration. Dry needling can be just as effective but causes more post-injection soreness.5% without steroids or adrenalin is recommended.[1] Despite the concerns about long acting agents.[15] More recently. while use of steroids can cause tissue damage. they may be irritated or the muscle may be bruised. If trigger points are pressed too short a time. if pressed too long or hard. delayed onset muscle soreness (DOMS). to elongate and resolve strain patterns. including saline.[18] A mixture of 1 part . short acting local anesthetic such as procaine 0. otherwise muscles will simply be returned to positions where trigger points are likely to re-develop.[1] a mixture of lidocaine and marcaine is often used. and botulinum toxin provide more immediate relief and can be effective when other methods fail. and may feel like. This bruising may last for a 1±3 days after treatment. resulting in pain in the area treated. Evidence based medicine researchers concluded as of 2001 that evidence for the usefulness of trigger points in the diagnosis of fibromyalgia is thin. Botulinum toxin is rarely indicated.

5% lidocaine and 0. treating the masseter muscle may damage the salivary glandssuperficial to this muscle. has some inherent dangers. The existence of tender areas and . This has the advantages of immediate anesthesia with lidocaine during injection to minimize injection pain while providing a longer duration of action with a lowered concentration of bupivacaine. especially with regard to the musculature. and HealthPartners began covering trigger point injections in 2005.2% lidocaine with 3 parts 0. Likewise. glands and vessels. Underlying any attempts at self-treatment should be a working knowledge of the area to be treated. It may lead to damage of soft tissue and other organs. whether by self or by a professional. [edit]Self-treatment There are a number of ways to self-treat trigger points and these methods are described in numerous texts.375% bupivacaine. Medica. for instance. Furthermore. [edit]Risks Treatment.[20] [edit]History Trigger points have been a subject of study by a small number of doctors for several decades although this has not become part of mainstream medicine. are very close to the kidneys and poorly administered treatment (particularly injections) may lead to kidney damage. [edit]Research Studies to date on the efficacy of dry needling have been inconclusive but weakly supportive. Health insurance companies in the US such as Blue Cross.5% bupivacaine (trade name:Marcaine) provides 0.[19] leading to plans for a larger phase III clinical trial with more statistical power. some experts believe trigger points may develop as a protective measure against unstable joints. nerves. The trigger points in the upper quadratus lumborum.

physical therapists. Janet G. [edit]Janet G. who was responsible for the most detailed and important work.[21] The latter two workers continued to publish into the 1950s and 1960s. dentists and acupunctu rists. Travell. and other hands-on somatic practitioners who have had experience or training in the field of neuromuscular therapy (NMT).zones ofinduration in muscles has been recognized in medicine for many years and was described as muscular rheumatism or fibrositis in English. Kennedy's back pain was so successful that she was asked to be the first female Personal Physician to the President. myotherapists. Travell. an American physician. typically only physiatrists (physicians . Among MDs. H. much treatment of trigger points and their pain complexes are handled by myofascial trigger point therapists.occupational therapists. Certified Athletic Trainer some naturopaths. In her later years Travell collaborated extensively with her colleague David Simons. this was followed by the second volume in 1992. MD It was. osteopathic physicians (DOs). German terms included myogelose and myalgie. Today. both of whom have survived Travell. in the 1930s and. Kellgren conducted experiments in which he injected hypertonic saline into healthy volunteers and showed that this gave rise to zones of referred extremity pain. Important work was carried out by J. chiropractors. by Michael Gutstein in Berlin and Michael Kelly in Australia. Kellgren at University College Hospital. massage therapists. Her work treating US President John F. independently. however. there was little agreement about what they meant. However. A third edition is has been published by Simons and his wife.[22] She published more than 40 papers between 1942 and 1990 and in 1983 the first volume of The Trigger Point Manual appeared. London. The trigger point concept remains unknown to most doctors and is not generally taught in allopathic (MD) medical school curricula.

and DOs treat trigger points in clinical practice. bad mechanics. Myofascial Pain and Dysfunction: The Trigger Point Manual. by chronically bad posture. and sciatic symptoms.[24][25] Travell and Simons' seminal work on the subject. angina pectoris. acupuncturists. repetitive motion. The following conditions are also frequently misdiagnosed as the cause of pain when trigger points are the true cause: carpal tunnel syndrome.[23] Other health professionals. tendinitis. or nutritional deficiencies.[1] states the following:    Around 75% of pain clinic patients have a trigger point as the sole source of their pain. chiropractors. massage therapists and structural integrators are also aware of these ideas and many of them make use of trigger points in their clinical work as well. . structural deficiencies such as a lower limb length inequality or a small hemipelvis. Arthritis is often cited as the cause for pain even though pain is not always concomitant with arthritis. normally activated by a certain activity involving the muscles used in the motion. along with many other pain problems.specializing in physical medicine and rehabilitation) are well versed in trigger point diagnosis and therapy. such as physiotherapists. however. The real culprit may be a trigger point. Osteopathic medical schools. bursitis. include trigger points in their Osteopathic manipulative medicinetraining.