Here's how to treat them when they occur, and stop them happening in the first place
Last issue we looked in depth at why it's so important for athletes to know what trigger points are because they contribute so often to an injury or impede performance. This time we will discuss how to treat them and how to prevent them occurring before you're faced with an injury.
With many sporting injuries, it can be a real challenge to ascertain where and how they started. Therapists in the sports medicine fields often have to dig deep to find the clues that will lead to the answer. Yet it is vital to do so in order to prevent recurrence. The first point of damage in your body is often the formation of a trigger point, and it then snowballs from there into outright pain, weakness, nerve irritation, and finally structural breakdown.
Just to remind you, the last article (Sports Injury Bulletin June) explained what trigger points are and what causes them. The treatment of these underlying causes was also discussed, as this is the way to prevent trigger points from recurring after direct treatment. For instance, poor foot biomechanics are a breeding ground for trigger points all over your lower limbs, and so orthotics must be prescribed as part of the holistic treatment of the trigger points. Or if a muscle imbalance exists between opposing rotator cuff muscles, it stands to reason that this must be addressed as well as directly treating the trigger point.
Almost all of the references for this second part are also to be found at the end of the previous article.
Let's first look at how one can assess a trigger point to locate it and determine its severity. Then we'll explore ways of treating and getting rid of the actual trigger point, with a special section detailing how, if you're an athlete and not a therapist, you can treat yourself at home.
Assessment of a trigger point
TPs are assessed primarily by palpation with the fingers, although Electro-myographical (EMG) studies and Thermography also are valid procedures for locating them since altered nerve signals and increased temperature can be detected with some trigger points. Research using instrumentation which reads the level of pain associated with a particular pressure (Pressure algometry) has proven that therapists can be quite consistent in locating trigger points, showing that those familiar with trigger points can reliably identify the same trigger point in the same spot again at a later time (17). Interestingly, the same research has also shown that different therapists will often not point to the same spot as the location for a trigger point. There is, therefore, a certain subjective 'feel' element in assessing and treating trigger points.
So while the art of palpation is important for locating more specialised or subtle trigger points, anybody can stick their own fingers into their sore muscle and feel around for a trigger point. For those with experience or a copy of Travell and Simon's 'Trigger Point Manual', the area of pain referral can give big hints as to where the trigger point is.
How to find your own trigger points
Make sure you and the affected muscle are completely relaxed, not on stretch. One of the following techniques can be used to palpate the trigger point (20,30):
Flat Palpation involves simply moving the fingertip(s) transversely across the muscles fibres with some pressure until a 'taut band' is located. Having found this tight section of the muscle, explore along its length to locate the spot of maximum tenderness with minimum pressure: that is the trigger point. With some practice it doesn't take long to find the taut bands in a muscle - don't be too worried about the pain you might elicit, because you can't do yourself any harm here!
Pincer Palpation is similar to the above, only some muscles can be lifted from surrounding tissue between the thumb and forefinger and in this manner the trigger point can be located, eg, the upper trapezius (neck) or gastrocnemius muscle (calf).
The muscle will usually contain a 'taut band' which contains the trigger point within it (13,20) and if you flick over the right area it should cause a twitch in the muscle or that part of the body - this is called the 'Local Twitch Response' (LTR) (3,12,13) and helps to identify the exact location of the trigger point. If there is no LTR the trigger point may be more chronic, and instead a part of the muscle will feel like a lumpy rope or knot.
To determine whether the trigger point is 'active' or 'latent' (ATP/LTP) apply some firm pressure to the sore area - an ATP will be extremely tender compared to a LTP, but more importantly, an ATP should refer pain to another area in the body (3,11,30,32). While different trigger points refer to different areas, the referred pain pattern is quite similar from person to person. Sometimes a trigger point needs to be pressed or flicked over for up to 10 seconds before the referred pain becomes evident.
'TP treatment is more an art than a science, in that it relies more on the instinct and sensitivity of the therapist than on any amount of science'
Direct treatment of the trigger point, as opposed to treating the whole problem of which the trigger point is just a part, is relatively straightforward, and relies mostly on having good 'hands' that can feel what is happening to the muscle. A muscle that has been released from a trigger point will feel softer, more malleable and 'loose' to the touch. In this respect trigger point treatment is more an art than a science, in that it relies more on the instinct and sensitivity of the therapist as he or she works with the patient, than on any amount of science or theory. It is for this reason that many people end up only 80% better after a course of treatment - because the muscle has not been completely released from trigger points. It takes persistence and patience (and strong hands!) to stick at it until the trigger points are released enough to stop causing pain.
The hands-on approaches
Let's deal first with the different hands-on techniques that can work wonders in easing the pain and stiffness in muscles.
(1) Ischaemic compression
TPs can be 'deactivated' by temporarily occluding their blood supply and causing a reactive hyperaemia (increase in blood supply), effectively flushing out the muscle of inflammatory exudate and pain metabolites, breaking down scar tissue, and reducing muscle tone. The muscle is nourished by the extra flow-through of blood, nerve endings are desensitised, and scar tissue is broken down so that the muscle fibres can move better.
Ischaemic compression can be viewed as a sustained stretch to a specific point in the muscle, or as the most effective way possible to stretch because it gets right to the tight or restricted area in a muscle.
Essentially it involves applying sustained pressure to the trigger point with sufficient force and for long enough to slow down the blood supply and force the tension out of the muscle (30). The muscle should be placed in position of mild stretch, with little or no pain present. The patient must be comfortable and relaxed, and the compression gradually applied with the finger, thumb, or elbow. Such pressure should be relative to how much pain is being experienced, and how much the patient can tolerate (ie, it will be painful but in most instances too much pain will cause tension in the muscle and negate the treatment).
The pressure is gradually applied, maintained, and then gradually released. It can be held for as long as 60 seconds, but mostly the desired effect is achieved in 10-20 seconds. Pause before gradually reapplying pressure three or four more times, perhaps moving to another part of the muscle if the treated area felt 'looser' or softer to the touch. Initiating pressure on to a trigger point must be done gradually in an effort to minimise increases in tone, so you can get closer to the core of the trigger point. It is important to reproduce the LTR for a better treatment result (13).
Ischaemic compression can be used as a prophylactic or preventative measure (32) in athletes with Ltrigger points that effect their performance (see previous article), though must be used carefully in pre-race massage as it can leave a soreness afterwards. In a treatment situation, it has been the author's experience that ischaemic compress-ion is a better way of dealing with more acute (recently developed, inflamed) trigger points, as opposed to more entrenched and chronic ones which will need a firmer and more vigorous approach - more on that later.
Research in 1993 by Hong et al (11) lends credibility to the statement that ischaemic compression (or 'deep pressure soft tissue massage', as he calls it) is superior to other physical medicine modalities for treating trigger points. He compared spray and stretch, heat packs, ultrasound and ischaemic compression and found the latter to be the most effective.
Most trigger points will need a number of treatments to deactivate them (9) in addition to other related causal factors that must be dealt with. As the trigger point settles, there will be an accompanying decrease in referred pain, and an improvement in other related issues such as weakness, muscle spasm, joint impingement, etc. The trigger point itself should become less sensitive, and it will become harder to find a painful spot.
(2) Specific soft tissue mobilisations (SSTM)
SSTM is another manual technique used by physiotherapists to restore a tissue's ability to cope with the loading placed upon it. SSTM uses graded and progressive applications of force matched as closely as possible to the stage of the healing process, to return the tissue to its previous tensile strength.
This approach has been designed by Glen Hunter (33) to facilitate healing in tissues that have broken down; however, it is my own experience that SSTMs can also be effectively used in later stage and chronic trigger point treatment as well. This is due to the large stiffness component that characterises the late stage of trigger point development.
Following a thorough assessment process, an oscillatory force is applied to the site of the lesion or trigger point, in a direction perpendicular to and on the same plane as the line of its fibres. As with ischaemic compressions, the force of the pressure is also dependent on the stage of healing taking place.
These can be used in the same context as SSTMs, ie, for later stage treatment when multiple cross-linkages between collagen fibres results in considerable stiffness or scar tissue (7,19,28). Frictions 'free up' scar tissue within a trigger point, allowing muscle fibres to move more normally, increasing blood flow through the tissue and decreasing nerve sensitivity.
Frictions are performed transversely across the top of the tissue with some compressive force, for some minutes at a time. Initially pain levels will be quite high, but as the friction progresses it eases off.
The overall treatment of a tight or sore muscle and its trigger points can include any or all of the above treatments, as well as more standard massage techniques such as deep tissue (strong longitudinal strokes designed to promote length of tissue) or effleurage (wide sweeping movements that clear the tissue of excess lymphatic fluid).
In unison they provide a rich variety of effects that combine to firstly treat trigger points, then loosen muscle fibres bound by scar tissue, improve overall muscle flexibility, clear any oedema (fluid) collected and restore good nutrition to the muscle via an improved blood supply. A regular sports massage is a superb way to overhaul the muscular system and gain many of the above effects, albeit in smaller doses.
Other approaches to trigger point treatment
(1) Stretching: A huge topic in itself (see SIBs 1 and 2, etc!), but one that must be at least touched on in this discussion. There is no doubt that stretching helps prevent trigger points from two perspectives:
Warm-up routines. After doing some muscle-warming activity, some sports-specific stretching and drills (call it 'dynamic stretching' if you like), there is no question that you will significantly minimise the formation of trigger points through the increased blood flow and consequent malleability and better alignment of muscle fibres and fascia.
Flexibility. Regular day-in, day-out 'static stretching' will mean that you have that much more 'room to move' and 'give' in the joints and soft tissues before any trigger points develop. Similarly stiff joints will frustrate the muscles operating around them and that's when muscle or tendon breakdown occurs.
'The conclusion would seem to be that stretching alone is not enough but that as an adjunct to ischaemic compression it is helpful'
But what about stretching to repair the actual trigger point? This is a tricky one - there is no doubt that most therapists will prescribe stretching for muscle tightness, and there is no doubt in all the literature that this is valid, but to repair a specific muscle pathology such as a trigger point? We know from one study (9) that ischaemic compression with stretching is more effective than just doing mobility exercises, and from another study (11) that stretching is second only to ischaemic compression in its ability to treat trigger points. The problem is that it can be very challenging to isolate a stretch to a specific portion of the muscle where the trigger point is located. The conclusion would seem to be that stretching alone is not enough but that as an adjunct to ischaemic compression it is helpful.
(2) Spray and Stretch (30): This involves placing the muscle on stretch and applying cold spray to the length of the muscle in order to reduce the spasm, tension and inflammation that accompanies trigger point formation.
(3) Electrotherapeutic: Physiotherapists may use 'ultrasound' to improve the rate of healing of the trigger point (11,30), varying the strength of the dose according to the stage of the trigger point. Or they may use 'TENS' or other electrical machines to achieve the same effects; however, all of these are only add ons to the main course, which is hands-on treatment.
(4) Injecting / Needling: Relevant literature speaks volumes about the highly effective use of trigger point injections to achieve the most complete level of resolution of trigger points (1,3,5,6,12,20). This is the domain of only a few specialising musculoskeletal physicians and sports doctors - certainly in Australia there are precious few to be found who can be called highly competent in this area.
In essence there are two effects that take place: firstly the point of the needle is directed into the centre of the trigger point and gently divides muscle fibres and scar tissue bound together within the trigger point. Secondly, various mixtures can be injected to produce added benefits - the most notable being the reduction of post-treatment soreness by the introduction of 0.5% lidocaine (13).
To give an idea of how effective the injection of trigger points can be, a study in 1998 (15) looked at how much quicker full functional recovery was achieved for sufferers of plantar fasciitis (heel pain) who were treated by trigger point injections compared with heat, electric stimulation, stretching, and relaxation exercises. The result? Treatment time was reduced by a massive 83.9% and persisted two years after the treatment.
The bottom line is that some treatments, especially those directed towards trigger points, are vastly superior to others. Now let's look at methods of self treatment.
'If there is swelling in the area, or if it is warm inside or any nerve problems are present... do not try and treat the injury yourself'
Self treatment is a full topic in itself. It involves looking at the myriad ways that the motivated athlete can work on reducing and preventing the development of trigger points with a home programme. The most effective technique would be ischaemic compression as it doesn't require too much movement; the key is to think of ways of exerting deep pressure into muscle groups that aren't too taxing on your body as you do them.
While you really cannot go wrong with self treatment of trigger points, always go gently at the start until you have done it a few times and know what to expect. Remember that the pain felt during treatment may be quite strong, but never sharp and debilitating. If there is swelling in the area, or if it is warm inside or any nerve problems are present (ie, pins and needles, numbness or weakness), do not try and treat the injury yourself.
If the story of your injury suggests a muscle tear (ie, strong sharp pain, swelling/bruising, that occurred suddenly with rapid movement or exertion), you will need to let the injury settle right down and have professional treatment first for two to three weeks before you gently try your own home treatment.
Other safety precautions to be aware of include making sure you are not pressing on to a major nerve (resulting in pins and needles and, if persisted with, numbness and weakness), and making sure you don't move too much when the pressure is on the muscle, thereby causing aggravation.
Muscle Mate: A device called a Muscle Mate (and other forms of the same thing) has been designed by the Australian Institute of Sport for this purpose - although for most sports people a tennis or golf ball would easily suffice (10). You then treat yourself by lying, rolling, or leaning on to the device (see following exercises) and allowing your body weight to help exert pressure into the muscle.
Ice: If there is stronger or sharper pain with any swelling, the trigger point will likely be acute and 15 minutes of ice will be of added benefit (try ice cubes wrapped in a damp - not wet - towel), by helping prevent further infiltration of the area by inflammatory exudate, numbing nerve endings and reducing muscle spasm.
Warm Up - Treat - Heat: Light exercise or a brief warm-up routine is a good prelude to self treatment with ischaemic compression, especially for the more chronic trigger points. Then spend the 10-15 minutes self-treating and finally use heat (11) to finish. This is a lovely way to end off, with the heat helping to prevent soreness and assisting in fresh blood flow. It is easy to treat oneself with a hot water bottle or warm moist towel (or even a soak in the bath).
Low Back Pain: Take an object to exert pressure with (eg, a tennis ball) and place it under your back as you lie on the floor facing the ceiling with your knees bent and feet flat on the floor. Make sure the object is in the soft muscular areas either side of the spine and above the bony edge of the pelvis. Feel it sink into the tight and sore area. Take the same-side knee and hold it with both hands. Now use this as a lever to press your back gently down on to the object, as you pull up your knee slowly towards your chest. Spend 10 minutes pressing into all the tight trigger points and it should make a huge difference to how loose the area feels. You might even get closer to touching your toes immediately!
Calf pain or cramps (21): Sitting in a chair (no object required), cross the sore leg over the other knee but stop when the sore calf rests directly on the other kneecap. Hold the knee of the sore leg with both hands, and allow the sore calf to sink into the other kneecap. Now search for tender and tight bands all up and down your calf, spending time putting deep pressure into those you find. Every now and then move your foot around to help pump the blood out of the lower leg.
Heel pain (15,29): I recently read of the idea of sticking a Coke can in the freezer and rolling it under the arch to relieve the pain of plantar fasciitis - has anyone tried freezing a golf ball (or near equivalent) and using that instead? Worth a try because it would be much more specific to treating the trigger points in the plantar fascia and intrinsic muscles of the foot.
Hamstring soreness and tightness: Sitting on the edge of a bed or chair so your knees are at the edge, place massage object under your affected hamstring near where it is sore. While not letting your pelvis roll backwards, slowly straighten out the same knee until you feel the object under your hamstring dig deep into the sore area. In this manner treat and explore for other trigger points.
NB: Please remember that if the pain is severe or doesn't abate after a couple of attempts, you'll need an assessment by a physiotherapist - something a little more complex is probably going on.
So there it is - simple yet comprehen-sive - the story of trigger points and how they relate to your injuries or lagging performance. Now it is up to you to get down and try some of the ideas for yourself! And when you find a trigger point and hit the pain barrier at some stage into your home treatment, remember that you are targeting the bulls-eye centre of the problem. Just relax into the 'good pain' and feel the muscle tight spot let go gradually.
Persist with it and you will have learnt the magic key to releasing your muscles to new levels of looseness and power.
33. Hunter G, 1998. 'Specific soft tissue mobilisation in the management of soft tissue dysfunction.' Manual Therapy 3(1) 2-11