Myofascial trigger points can cause many problems in muscles, including, but not limited to, referred pain, reduction in range of motion, weakness, loss of endurance, numbness, tingling and a host of other often-overlooked problems.

Myofascial trigger points can cause many problems in our muscles, including referred pain, limited range of motion, weakness, loss of endurance, numbness, tingling, and more.

I’m sure we all have had clients who report feeling nagging pain or tension in their mid-back between or below the shoulder blades. To really get to the center of it all there may be a bit of detective work needed to find the true source of the problem.

For example, many of our clients spend all day in front of a computer hunched over. In this position, the back and front of the upper torso are two key areas that are in direct opposition of each other during work.

As a busy day goes on, and they continue to use the arms in front of the chest and lean over a desk, this leads to myofascial dysfunction and problems in muscles that can grow from a slight twinge of discomfort into burning, stabbing, aching, or just shadowing pain that they wish they could have someone just press an elbow into it to make it go away.

That’s where we come in—but a bit more training is necessary.

Massaging where the client feels pain may not be the technique to use if the goal is to get rid of pain. Trigger point pioneers, Janet Travell, M.D., David G. Simons, M.D., and Bonnie Prudden, provided this road made to follow to find the source of the problem in an effort to provide long-losting relief.

Multifidi on stretch with resistance

Source Trigger Points

According to Travell and Simons, who co-authored Myofascial Pain and Dysfunction: The Trigger Point Manual, there are nine muscles that, when harboring trigger points, can cause pain in the mid back. Of these nine, five are not technically located in the mid-back.

The untrained massage therapist might spend a whole hour working on the area where it hurts, but the pain will not go away until the source trigger points are identified and eliminated. This is where the complete trigger point protocol guides clinical reasoning.

• The scalenes are in the neck yet refer strong pain into the mid-scapular area.

• The levator scapulae and serratus posterior superior can cause mid-back pain, but they arise from near the superior scapular border and end at the cervical vertebra.

• The infraspinatus—a shoulder girdle muscle—can cause referred pain in the front of the arm and into the mid-back.

• Finally, don’t even get me started on those pesky latissimus muscles, always overused by novice massage therapists when they work. When harboring trigger points the latissimus dorsi can cause referred pain down the inside of the arm to the pinkie or a strong, almost stabbing pain into the mid-back to just about the medial edge of the inferior scapulae border.

Multifidi on stretch with resistance

Take Chest Pain Seriously

According to Renee Hartz, M.D., a retired cardiac and thoracic surgeon who is now a trigger point expert and medical director of The Chicago Center for Myofascial Pain Relief, it is always best to refer clients for a visit to their primary care physician if they present with chronic pain in the chest area.

The physician can do an assessment to rule out any cardiac or vascular conditions and clear the client for treatment. Hartz reminds us that many patients with true coronary artery disease are misdiagnosed because their chest pain is reproducible.

In other words, his or her doctor presses somewhere on the chest, the patient has pain, so the doctor presumes the patient has chest wall pain and sends the patient home—and the patient then has a heart attack. Trigger points and coronary heart disease can co-exist so be sure a full work-up has been done.

If your client has chest, neck, arm, or jaw pain or pressure, especially with nausea, think heart disease and refer them to his medical doctor—and by all means call 911 if he or she is sweaty or feels anxious along with the pain.

For clients with no medical reason for chest pain, trigger points can often be the cause. Knowing which muscles are the culprits requires a bit of detective work. Of the 12 muscles that cause chest pain, seven of them are not located in the chest area:

• The scalenes and sternocleidomastoid are both located in the neck

• The illiocostalis thoracis and cervicis and serratus posterior superior are located in the back

• The external abdominal obliques and diaphragm are located in the abdomen.

You can see that it is important to understand the full trigger point protocol to ensure identification of the key muscles causing pain no matter what area that pain is felt in.

The Short and Long of it

For every action, there is an equal and opposite reaction. In the human body, it is all too easy to see how habitual actions and postures lead to problems in other, often opposite areas. The chest and mid-back are probably the most obvious examples to see how short muscles in one area pull another area on the long.

For our clients, sitting all day working on a computer can train the muscles and fascia of the front of the chest and the arms, including pectoralis, coracobrachialis, pectoralis major, pectoralis minor and rectus abdominis, to be short. This, in turn, creates a classic hunched, or kyphotic, mid-back and spine with retracted scapulae because the posterior muscles and fascia, including the rhomboids, mid and lower traps, latissimus and serratus anterior are spinal erectors and are inhibited.

It is the job of the clinically minded massage therapist to return full function to the chronically shortened tissue in the anterior torso and to improve function of the tissue chronically inhibited in the stretched position in the posterior torso.

So, how do we do this and where do we start to figure out what needs to be addressed for any given problem? There is a system for that.

Lattisimus dorsi and serratus anterior

The 7-Step Protocol

Because I run a clinic that works directly with medical doctors, chiropractors and osteopaths, it is very important that all my massage therapist clinicians have a set protocol to follow to best guide treatment and communication with medical care providers.

When beginning a treatment relationship with someone who presents mid-back or chest pain, a full and complete trigger point protocol is just the ticket for gathering information that will inform the treatment plan and will guide the implementation of therapeutic interventions used.

Mid-back pain, knee pain, shoulder pain or any other pain problem can then be seen through this framework. The only thing that ever changes are the muscles being treated.

To replicate clinical reasoning for all client problems, follow these seven key steps and you will be on your way to becoming a trigger point therapist or a successful pain-relief practitioner who serves as a valuable option for your clients and nearby health care providers.

1. The client history. A full and detailed client history tells a story of each client’s current and past events. This can uncover key perpetuating factors that create the problems or are preventing them from going away. These factors might include sleeping with arms overhead, for example, which can stress the muscles and fascia in the chest and shoulder, leading to the formation of trigger points, subsequent chest pain and muscle dysfunction.

2. The assessment-of-pain chart. When the client draws her pain on this chart, we can compare it to the illustrations provided us by Travell and Simons to determine which key muscles we will be treating to eliminate the underlying problem. This pain chart also serves as a talking point to better understand a client’s pain and ensures she is being heard in order for the therapist to best tailor a treatment plan to fit her most important problem areas.

3. ROM assessment tells us how key areas are able to stretch or shorten and can provide objective data that shows deficits and then improvement as the treatment plan is implemented over a certain number of visits. For chest-area pain, often trigger points in the pectoralis and coracobrachialis restrict shoulder extension. For mid-back pain, the latissimus muscles and teres major can restrict shoulder flexion.

Pectorals and deltoids

4. Treatment plan development. This step clearly outlines the areas and muscles needing to be treated and provides a series of measurable outcome goals to track progress and improvement over a certain number of visits during a specified number of weeks. The treatment plan also ensures accurate communication between practitioners as each one can clearly see the outcome goals and areas needing to be addressed.

5. Use of trigger point pressure release techniques. Once the key muscles have been identified and goals have been set, systematic treatment of muscles gets underway. Dynamic treatment positions are used that allow for the most supported and most stretched position, while also allowing for full, active ROM during treatment. (This is a very participatory treatment—no lounging around allowed!)

A constant dialogue occurs between the practitioner and client to communicate details about the sensation during treatment and to be sure the discomfort level is kept below pain, which may be about 4 to 6 out of 10 on a 10-point pain scale. We are also seeking information about any referral phenomenon; if felt, these referral patterns are considered clinical findings and should be noted on SOAP notes.

6. The post-treatment assessment. We are looking for and measuring all objective improvements in ROM, overall function and strength, and subjective improvements, such as the patient’s pain or discomfort as reported pre-treatment compared to post-treatment. No matter the area or muscles, we are here to get rid of pain so we should be asking the client to report his changes to us.

7. Self-care education. This is where the client is taught how to treat and move the specified muscles based on the clinical findings of the assessment and treatment, and may be the most important component of the treatment model.

Education is power; knowledge is power. When a person has the power to reduce and eliminate her own muscle problems, she is more apt to comply with requested changes and adaptations to her poor habits and life postures.

Pectorals and deltoids

Follow the Map

Chest-area pain and mid-back pain due to myofascial trigger points can seem like challenging problems to fix in a client, but with the road map given to us by trigger point pioneers, the massage therapist can effectively eliminate and rehabilitate these muscles and fascia.

Keep in mind the suggestions provided by Hartz to consider true cardiac-origin chest pain; referring a client to a physician for assessment can be a necessary step. Once cleared, follow the 7-step Trigger Point Protocol for any area of the body.

You will find it is easy to get to the point. The trigger point, that is.

About the Author:

Mary Biancalana, L.M.T., C.M.T.P.T., is a board-certified myofascial trigger-point therapist. She is also founder and owner of Muscle Health LLC, the parent company for the Chicago Center for Myofascial Pain Relief, Advanced Trigger Point Seminars and Trigger Point Sports Performance. She authored an article in the April edition of Better Homes and Gardens and “Self-Care of Trigger Points and Referral Patterns” for