Trigger Points

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Trigger points are “knots” in muscle that are more painful than expected and/or cause pain in other areas of the body. Although their true nature is uncertain, the dominant theory is that a trigger point (TrP) is a small patch of tightly contracted muscle; an isolated spasm affecting just a small patch of muscle tissue (not a whole-muscle spasm like a “charlie horse” or cramp).  The classic trigger point is defined as the presence of discrete focal tenderness located in a palpable taut band of skeletal muscle, which produces both referred regional pain (zone of reference) and a local twitch response. (ie. Tight muscle hurts somewhere else and twitches when pressed and plucked like a guitar string).  Myofascial Pain Syndrome (MFPS) occurs when multiple trigger points cause bigger patterns of pain and loss of function.

The most common symptoms are persistent pain and muscle and joint stiffness. These include muscles used to maintain body posture, such as those in the neck, shoulders, and pelvic girdle. Trigger points may also manifest as tension headache, tinnitus, temporomandibular joint pain, decreased range of motion, and low back pain.  Other symptoms include numbness, tingling, brain fog, vision changes, chest pain, increased pain a few days before a low-pressure weather system, continued pain after a joint replacement and some strange ones like vomiting and belching.  Beyond the immediate symptoms caused by trigger points, I believe trigger points to be a significant factor in development of degenerative arthritis due to increased compression of joints by tightness of muscles associated with trigger points. 

There is no single identified reason why trigger points develop. Common causes are thought to involve a combination of mechanical and health related factors such as incomplete healing of a muscle, bone or joint injury, overuse of a single muscle or muscle group, poor nutrition, smoking, hypothyroidism, and many more. Acute sports injuries caused by acute sprain or repetitive stress (e.g., pitcher's or tennis elbow, golf shoulder), surgical scars, and tissues under tension frequently found after spinal surgery and hip replacement may also predispose a patient to the development of trigger points. These factors by themselves would not likely be a problem but given a combination of circumstances and timing, trigger points are activated and can become a truly difficult problem to both diagnose and treat.  

Medications for treatment of patients with chronic musculoskeletal pain include antidepressants, neuroleptics, nonsteroidal anti-inflammatories, analgesics and medications to induce sleep and relax muscles.  Most of my patients report most medications help for a week or two at most.  Nonpharmacologic treatments include physical therapy, injections of spine, joints and bursa, acupuncture, osteopathic manipulation, massage, acupressure, ultrasonography, application of heat or ice, diathermy, transcutaneous electrical nerve stimulation, ethyl chloride Spray and Stretch technique, cold laser therapy, dry needling, and trigger-point injections with local anesthetic, saline, or steroid.  Response to these treatments can vary for a number of reasons. The most effective treatment has been shown to be ultrasound guided trigger point injections.  

Using a thin needle to inject a small amount of local anesthetic “numbing medicine” into the trigger point area of muscle spasm can “turn off” the trigger point allowing the muscle to relax. We use high-quality ultrasound with doppler image processing during injections to help identify trigger points and avoid tissues that shouldn’t be poked.  We use Marcaine (bupivacaine) or Xylocaine (lidocaine) without epinephrine for the injections.  Steroids are not typically used in trigger point injections as they have side effects such as impairing the immune system.  If the number of trigger points is more than can be addressed at one session, more than one appointment will be needed to adequately treat your pain.

Depending on where your trigger points are located, you may be asked to wear a gown. You will be placed in a position that allows for the best visualization of your painful area. You will help to identify the location of the trigger point(s)s to be injected as you provide feedback while the doctor touches or presses over the sensitive area. Once the correct area is identified, the skin will be cleansed with a disinfectant solution. Prior to the “poke”, we may use a freezing spray on the skin to help lessen the sensation at the skin. Each trigger point is then injected with a small amount of numbing medicine. Sometimes the muscle will twitch and recreate the sensation of pain associated with that trigger point. Pain during injections is similar to what is experienced with firmly pressing over the sore muscle with a thumb or finger. An ultrasound machine is used during injections to assist in confirming the precise location of the trigger point and to safely navigate during the procedure. When treating MFPS, vascular Doppler ultrasound may be used to identify trigger points that may be decreasing blood flow to other muscle groups.  Your feedback is very helpful during the injections, especially if the injection recreates the pain or symptoms that brought you to our clinic. 

Avoid participating in new or strenuous activities due to numbness and weakness of the muscles that may lack the sensation that usually keeps you from straining a muscle too hard.  Avoid driving or operating heavy machinery until you are back to normal strength and sensation. When the anesthetic wears off (this is usually 2-6 hours after using Marcaine, 1-3 hours with Xylocaine depending on how good the circulation is in the area to flush it away) you may have tenderness, slight swelling, or bruising at the injection sites, similar to an immunization.  Using ice over the area is helpful for the first few hours but be careful to not freeze the skin.  After that, applying heat helps to relax the muscle (be careful to not burn or “slow cook” the muscle). All of these sensations are temporary.  After trigger point injections, many patients find that taking a muscle relaxant medication before going to sleep may help the night go smoother.  Frequent stretching and movement of the muscles that were injected is encouraged as long as pain from stretching goes away within a minute of stopping the stretch.

The goal of treating trigger points is to turn off the painful trigger points. However, if the reasons they first developed are not changed they will likely return.  Often times, getting you to the place where you can move and function more normally may be enough to keep them from recurring but it takes several weeks to months for the tissues of the body to heal and remodel. It is important to work on stretching and motion exercises several times throughout the day to keep these tissues stretched and mobile to help the body with your new normal.  Please call our clinic to make an appointment as soon as you know your pain is returning.  It is best to evaluate and treat the pain earlier rather than when the symptoms become severe.  

1. Before the procedure, report the following to your doctor or nurse:

        • Allergies, especially to numbing medicine (such as novocaine or lidocaine)

        • You are taking any blood thinners (Plavix, Coumadin, Aspirin)

        • Diabetes

        • Pregnancy

2. Please take your routine medications on the day of the procedure (including pain medications – we will still be able to find the painful spots). 

3. There are no restrictions on food prior to the procedure.

4. You may return to your regular activities the next day. (If you feel better, please don’t rush back to doing all the activities you have avoided before as this will reinjure the muscles.)

5. Once you are home, we ask you to watch for fever, redness, swelling, increased pain, drainage (white-yellow-green with or without a foul odor).  Please call our clinic if you develop any of these symptoms. Infections after trigger point injections are rare. 

6. You may experience a short-term increase in pain the following day as a result of irritation from steroid if a steroid was used in your injection. You may apply ice to the area if needed.

7. If you have any other questions, please call our clinic for additional information.

On the Internet:

Research

Decent review that doesn't make it seem like trigger points are the only cause for pain.

For Self Management

Therapy Cane