Trigger Point Therapy for Myofascial Pain Syndrome

Myofascial pain syndrome usually starts with overloaded muscles resulting from an event or a group of events. Myo means muscle and fascia is the three-dimensional connective tissue matrix within the entire human body. Pain can be felt as many types of negative sensation, and within the term syndrome we have an array of other symptoms.

An Example of Myofascial Pain Syndrome

Take this example: Your client’s history reflects an average level of health and fitness. They report taking daily walks, yoga once a week, and group fitness class twice a month.

Unfortunately, a toy was left on the bottom stair inside their home, and your client found themselves with a nice big ankle sprain and the usual symptoms that come with it: black and blue and swelling at the lateral side of the ankle. Immediately, they rest, apply ice, wrap and elevate the injury.

After a few days of walking with a limp, this client started to notice soreness in their glutes. Another few days go by and they developed lower back pain. Before you know it, they’re in your clinic with multi-regional pain that does not seem related to the original event, the ankle sprain.

This could have developed into what is commonly known as myofascial pain syndrome.

Let’s clarify: Again, myo means muscle and fascia is the three-dimensional connective tissue matrix within the entire human body. Pain can be felt as many types of negative sensation, and within the term syndrome we have an array of other symptoms, including local weakness, loss of range of motion, and the inability to relax the muscles.

Myofascial pain syndrome is generally identified as myofascial pain and dysfunction that can be felt in one or more regions of the body that does not seem to dissipate even with standard intervention. We trigger point therapists recognize that myofascial dysfunction is caused by trigger points (TrPs) in the muscular system.

TrPs are taut muscle fiber bundles stuck in a shortened position by altered local chemistry; add a sprain, strain, poor posture, or muscle overload in any one region or area of the body, and things get more complicated. The painful sensation and muscle problems are made worse by the long and often distant TrP referral pain patterns (consistent and predictable patterns of pain or sensation that can be elicited upon pressing into the tight muscle area) that have developed in other unaffected muscles as a result of altered biomechanics and muscle guarding.

We know that many muscles in the lower leg and foot get overstretched during an inversion sprain. Fibularis longus, tertius, and brevis for example. Each of these muscles has their own unique referral pattern up the side of the leg, into the ankle, and even onto the top lateral side of the foot. When we have a change in gait—like when a person walks funny on a sprained ankle—we now have mechanical dysfunction in other muscles of the body that could have latent trigger points (areas that only hurt when pressed on or when overused). We know for certain that the gluteus medius and minimus are strong stabilizers of the hip, specifically the femur.

When your client began to walk with a limp, it led to activation of the latent trigger points in the gluteus medius and minimus, and each of those muscles in turn has its own unique referral pattern.

Watch Mary Biancalana demonstrate “5-inch FitBall Myofascial Trigger Point Pressure Release for Gluteus Medius Muscle” in a video here

The trigger point pain or sensation referred from many muscles is the hallmark of myofascial pain syndrome. We have chemically and mechanically altered muscles, activation of trigger points, and lots of pain, weakness and negative sensations arising from this situation.

The gluteus medius trigger points can be found high along the iliac crest and they can refer pain into the low back, hip and sacroiliac joint area. The gluteus minimus trigger points can refer pain all the way down the side of the leg past the knee and into the lateral portion of the shin as far as the lateral malleolus. (This is the same area our client already has pain from the sprained ankle.)

So, now we have a distant muscle creating a referral pattern that is overlapping into another region that actually has been strained or sprained.

This sounds a bit complicated, but don’t worry; there is a road map to follow provided to us by a 7-step myofascial trigger point therapy protocol.

Why Won’t My Myofascial Pain Syndrome Go Away?

With myofascial pain syndrome, there is often a precipitating event; this could be a new or unaccustomed activity that creates an overload on muscles that are not prepared to perform the associated movements.

This new, demanding activity can lead to a biochemical deficiency that can prevent the muscles from fully relaxing or fully returning to the normal resting length.

In the short run, the contraction in the muscle is an adaptive response to an overloaded muscle, but in the long run this contracted region prevents the muscle from fully functioning.

This state can be exhausting to the person, which makes the chemical deficiency worse, especially for adenosine triphosphate (ATP), which is the fuel that muscles use for our engines of metabolism. It is here we have the most egregious of all the characteristics of myofascial pain syndrome: the feedback loop of pain, spasm or tightness and further pain, which begets more chemical imbalance and loops back into spasm or tightness.

This is where a well-trained massage therapist comes in.

Myofascial trigger point therapy as a massage therapy modality is an excellent way to help eliminate and reduce the symptoms created by myofascial pain syndrome. We are grateful to the pioneers in this field, specifically Janet Travell, MD, David Simons, MD, PhD, and Bonnie Prudden. These three practitioners set the stage for a drug-free, pain-relieving, hands-on massage modality that can change lives for the better. I am honored to have been a part of this amazing field for 22 years, and am amazed every day by the value that trigger point therapy brings to my work.

Stop the Feedback Loop of Pain-Spasm-Pain

We know myofascial pain syndrome is a chemically and mechanically perpetuated syndrome. The muscle problems are unconsciously perpetuated by each person’s own habits. We have to stop the feedback loop of pain-spasm-pain. As massage therapists, we are certainly capable of knowing the difference between functional and dysfunctional tissue; our job is to identify those dysfunctional areas and provide treatment.

This is where the 7-step trigger point protocol comes in. We use clinical reasoning, based on the road map provided to us by experts in the field: Travell and Simons, contemporary writers like Claire Davies and Amber Davies, and myself. When we follow the list of muscles as provided by Travell and Simons that can contribute to pain in a particular area—even if that muscle is far away from where the pain or sensation is felt—we treat those muscles first

Some will have a mechanical relationship with the area and some will not. While the seven steps—history, referral pattern assessment, ROM assessment, treatment plan, use of applied manual techniques, post-treatment assessment and self-care education—are all important, we will focus on three parts of the TrP protocol here.

Here are the three key steps to eliminating myofascial pain syndrome for our clients:

Step 1: An understanding of the full and complete 7-step trigger point protocol helps the massage therapist unravel the key factors perpetuating the syndrome of pain and dysfunction in the first place. In step 1, the client history, we uncover protective factors: things that help our fascia and muscle system stay healthy and well.

We also find risk factors: negative impacts on our overall wellness, such as poor sleep posture, too much sitting, poor nutrition, or lack of adequate water. In step 4 out of 7, as we develop the treatment plan, e can explain this to our clients and make sure they eliminate the risk factors and develop as many protective factors as possible to allow for optimal muscle wellness and rehabilitation.

Step 2: Assess and treat the muscles one to two joint segments above or below where the pain is felt, as per step five of the trigger point therapy protocol.

With trigger point pressure release, active and passive PNF techniques, and applied modalities like percussion or FSM microcurrent (within SOP), the massage therapist has a chance to deactivate the primary trigger points as well as the satellite trigger points that are causing the problem.

Step 3: Teach the client home-care activities to break the feedback loop. Within its 7-step protocol, the trigger point trained massage therapist knows how to use step #7 to empower the client by teaching them to perform at-home self-applied trigger point pressure release, movement and stretching. This will help to rehabilitate the contracted sarcomeres and to restore normal, pain-free resting length within the trigger point in the complex and the whole muscle.

These activities might need to take place up to 10 times per day. A simple tennis ball, a Tiger Tail roller or a Backnobber all can serve as trigger point compression tools to aid in breaking the pain-spasm or tightness-pain cycle.

Can I Help My Clients With Myofascial Pain Syndrome?

You absolutely can. Advanced training is always the best way to keep our massage therapy practice up-to-date and fact-based. Besides Drs. Travell and Simons, and Prudden, there are so many contemporary leaders who help us understand fascia and muscles. I have been greatly honored to study with so many, including Leon Chaitow, DO, Antonio Stecco, MD, Bob Gerwin, MD, David Lesondak, BCSI, Jay Shah, MD, Jim Fricton, MD, and Shannon Goossen, LAc, to name a few.

This advanced information helps us understand the most recent science describing what is actually happening when we apply trigger point pressure release or other manual techniques, including PNF. I have incorporated information from all these leaders in my continuing education programs for massage therapists.

While a diagnosis of myofascial pain syndrome can be surprising or overwhelming to your clients, don’t worry; there is a comprehensive road map that was created for us. This road map can be found in continuing education classes for myofascial trigger point therapy massage. Over the past 22 years, I have dedicated myself to fine-tuning the 7-step myofascial trigger point therapy protocol. The knowledge is there; all you have to do is seek it and follow the road map, and you will have success.

About the Author

Mary Biancalana, M.Ed, LMT, CMTPT, is an award-winning massage therapy educator, president of the National Association of Myofascial Trigger Point Therapists and owner of the Chicago Center for Myofascial Pain Relief, Trigger Point Sports Performance and Chicagotriggerpointseminars.com. Visit her YouTube channel, “Chicago Center for Myofascial Pain Relief” to view free educational videos.