Having spoken with many health-care and massage practitioners of varying levels of experience, I hear a lot of discussion about trigger points and acupoints—and often it seems that these two terms are being used interchangeably. What I’d like to do in this and following articles is clarify the difference between acupoints and trigger points. I feel very strongly that precision counts in our field, as it does in all fields. The outcomes of our work (the relief our patients or clients derive from our treatments) depend on the precision of our touch when we are treating them. The precision of our touch is guided by the precision of our thought; hence, my need to clarify the difference between these two terms.
The first part of this article will focus on trigger points: what are they and how are they treated? A later article will focus on acupoints.
Part 1-–What is a trigger point?
The term trigger point was defined by Janet Travell, M.D., and David Simons in their encyclopedic work Myofascial Pain and Dysfunction, The Trigger Point Manual Volume I, (Williams and Wilkins, 1983, 1999). A trigger point is “ a hyperirritable locus within a taut band of skeletal muscle, located in the muscular tissue and/or its associated fascia.” (Travell and Simons, Myofascial Pain and Dysfunction, 1:12).
What exactly does this mean? First, it tells you a trigger point is located in a taut band in the muscle or in its fascia. So when you refer to a trigger point you are referring to point in a band of muscle tissue, unlike an acupoint, which is located along a channel, a meridian pathway. The first differentiation that must be made then when talking about trigger points and acupoints lies with their frame of reference, or what I would call the “lens” through which we see the patient. Trigger points exist within the frame of reference of the musculature; acupoints are part of the frame of reference of the Eastern model of health care. From my point of view, trigger points are most effectively used in the treatment of chronic or acute pain; acupoints are most effectively used in the treatment of disease and common ailments and in the maintenance of general health.
But back to trigger points. As we all know from our studies of anatomy, physiology and myology, skeletal muscle is formed from parallel bands of muscle tissue. The placement and direction of these bands, along with the placement of the muscle on the skeletal structure, will define the motion of the muscle. Normal, healthy muscle is supple and elastic. The underlying bones, joints and viscera can be easily palpated through healthy muscle tissue. Healthy tissue is not tender when palpated. It will contract in response to a nerve impulse and will return to its normal shape after contraction. Individual bands of muscle fibers, fascicles, cannot be differentiated during the palpation of normal muscle tissue.
Unlike the normal muscle, when a muscle is dysfunctional it will not return to its normal shape after contraction. It will remain in a shortened position. This predisposes the muscle to a local reduction of blood flow, lymphatic drainage and range of motion. Unlike healthy muscle tissue, dysfunctional muscle tissue will demonstrate increased muscle tone, greater resistance to palpation and decreased suppleness. A shortened muscle cannot perform its full range of motion and will be weaker than when it is in a healthy state. The muscle will often be tender when palpated. The patient will experience the muscle as tight, and the movement may cause varying degrees of discomfort. When comparing the two sides, the practitioner will find that the muscle is tighter than its (hopefully normal) bilateral counterpart.
Individual bands of muscle fiber, taut bands, can be palpated in a contracted muscle. These ropelike, or cordlike bands will range in thickness from the cables that can commonly be palpated in the large erector spinae group, to thin guitar-string like bands that may be palpated in much smaller scalenes when they are contracted. These bands will be tender when palpated. Underlying skeletal structures will be difficult to palpate; in highly contracted muscles, the underlying skeletal structures will be completely obscured to palpation.
All of us have areas of contracted musculature to varying degrees. Postural holding patterns, emotional stresses and work-related muscular usage all contribute to the differences in our musculature. Most of the time we aren’t aware of these habitual muscular restrictions. We won’t be aware of any particular difficulty with movement, and we will not experience pain or soreness. However, when constriction is chronic, essential physiological processes can be impeded: blood flow, lymphatic drainage, nervous innervation and cellular metabolism. Movement on all physiological levels is hindered, and over time this may affect our overall health.
Trigger points commonly develop within these chronically stressed muscles. A trigger point is a tender spot within a taut band of muscle tissue. Both active and latent trigger points commonly develop within chronically shortened postural muscles, and both will be tender to palpation. The major difference between the two is that unlike latent trigger points, active trigger points produce pain that is generally referred away from the affected muscle in a characteristic pattern. Active trigger points are the ones that we, as practitioners, need to be most aware of.
Active trigger points cause a steady, deep, aching pain in its referral zone that varies in degree from mild to severe and may occur with movement or at rest. In addition to pain, autonomic phenomena, such as tearing and redness of the eyes and dizziness, may result from the presence of trigger points in specific muscles. Tenderness may be present in a pain referral zone. Pain may increase with use of the muscle, stretching it, keeping it in a shortened position for a period of time, overusing the muscle through repetitive action, cold, damp weather, viral infections and stress. Pain will decrease with rest or light activity or stretching.
Unless there is direct intervention to eliminate the trigger point, it will not go away. The body will compensate for its presence—and we all know what that means. One muscle group will begin to work differently, compensating for the loss of strength in another, ultimately leading to a Gordian knot of muscular restrictions and physical pain.
How many patients have we treated where we start by working on an area they describe as being painful? After the treatment they may feel better for a bit, but the pain comes back—over and over again. The study of trigger points tells us that very often the source of the patient’s problem is not where his pain is. The actual cause of his pain lies in a muscle that may be far from the pain he is describing. So, our issue is first to conceptually understand this and then to learn to identify the muscles that are the source of our patients’ pain.
Each muscle’s trigger points produce a specific radiating pain pattern. So to really help our patients, it isn’t enough to just find tender spots within their muscles. It’s necessary to identify the specific trigger points in the specific taut bands of the specific muscle or muscles that are causing his pain. How do we do that? It begins with precision of thought. It begins with study and is manifested through palpation, precision of touch. A trigger point is a very focal spot within a specific muscle.
There are several very useful clinical manuals that describe trigger points and their associated pain patterns. Review them, and study them. Once you’ve identified the muscle you believe may be the source of pain, practice isolating the muscle through palpation. Compare it with its bilateral counterpart. Is this muscle generally tighter than the other? If so, it’s a good beginning. Then think about the direction of its muscle fibers when you are palpating, and see if you can isolate the specific muscle fibers. If trigger points are present, you will be able to isolate the taut bands within that muscle that harbor the trigger points. Directed palpation along the taut band will allow you to precisely identify the most tender, tight spot along that band. It is there that you apply direct digital pressure to begin to treat the trigger point. And it is there that the dance begins; compress the trigger point just to the point where you feel the muscle pushing back under your finger—I call that the “point of muscle resistance.” As you hold that point, and it does not take much force, you will begin to feel a very subtle softening of the tissue under your hand. Don’t let go and don’t press too hard. Follow the tissue with your finger, keeping the same gentle, but firm, pressure. You will feel the “dance of the tissues” as the tissues soften and the trigger point begins to release.
You may have to treat several different muscles in this way in order to treat your patient’s pain, and it may take a number of treatments to get lasting results. The patient can help himself by using moist heat on the areas you’ve treated for about 20 minutes a day and by following through with stretches specifically designed to lengthen the affected muscles.
So much pain stems from myofascial trigger points. It is far more common than tendinitis, nerve compression or herniated discs. It drives people from doctor to doctor in search of relief. And people end up swallowing untold numbers of analgesics and NSAIDs in order to rid themselves of it. The degree of relief that can be provided through the appropriate use of trigger point release techniques should not be underestimated. Through true understanding and precise use, the work that we provide can be of enormous benefit.
Give it a try. It is truly a wonder for patient and practitioner alike.
Donna Finando, L.Ac., L.M.T. is co-author with Steven Finando of Trigger Point Therapy for Myofascial Pain, The Practice of Informed Touch (Healing Arts Press, 1999, 2005). She is the author of Trigger Point Self-Care Manual (Healing Arts Press, 2005) and Acupoint and Trigger Point Therapy for Babies and Children (Healing Arts Press, 2008). Finando maintains a private practice on Long Island, New York, where she’s lived and worked for more than 30 years.