A critical evaluation of the trigger point phenomenon
PainSci summary of Quintner 2015?This page is one of thousands in the PainScience.com bibliography. It is not a general article: it is focussed on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided at the bottom of the page, as often as possible. ★★★☆☆?3-star ratings are for typical studies with no more (or less) than the usual common problems. Ratings are a highly subjective opinion, and subject to revision at any time. If you think this paper has been incorrectly rated, please let me know.
Quintner, Cohen, and Bove argue that the common picture of trigger points as lesions in muscle and soft tissue, spelled out most formally in Gerwin 2004, is “flawed both in reasoning and in science,” and that treatments (e.g. massage, needling) based on that idea produces results “indistinguishable from the placebo effect.” They believe that all of the biological evidence put forward over the years (like Shah 2008) is critically flawed in one way or another, while other evidence leads elsewhere, and so the old picture of trigger points “remains conjecture in the face of conflicting data.” They also point out that the theory is inappropriately treated like an established fact by a great many people.
Not even these fierce critics of trigger points deny that people have pain that seems to come from their muscles. But if it’s not coming from the muscle, where is it coming from? They briefly discuss two other ideas of their own: inflamed nerve fibres, and referred pain and tenderness from deeper structures. They do not thoroughly explore or defend either idea.
Neuritis is undoubtedly worth investigating, but it requires us to believe that nerve axons are routinely inflamed for no apparent reason, which doesn’t seem much different than the theory it is supposed to replace. The evidence cited to support it is just as limited as the evidence for trigger points, if not more so (just a few papers, all from the authors themselves, or their research colleagues).
The proposal of “referred pain and tenderness” from deeper tissues with unspecified troubles and/or “altered central nociceptive mechanisms” is imprecise. We know that these mechanisms probably exist, but there is not a jot of evidence that they have anything to do with the subjective experience of “muscle pain.” This is just a proposal to look somewhere other than the integrated hypothesis.
This paper is an abridged version of a much more detailed argument laid out in a chapter of an extremely expensive textbook: see Quintner.
The theory of myofascial pain syndrome (MPS) caused by trigger points (TrPs) seeks to explain the phenomena of muscle pain and tenderness in the absence of evidence for local nociception. Although it lacks external validity, many practitioners have uncritically accepted the diagnosis of MPS and its system of treatment. Furthermore, rheumatologists have implicated TrPs in the pathogenesis of chronic widespread pain (FM syndrome). We have critically examined the evidence for the existence of myofascial TrPs as putative pathological entities and for the vicious cycles that are said to maintain them. We find that both are inventions that have no scientific basis, whether from experimental approaches that interrogate the suspect tissue or empirical approaches that assess the outcome of treatments predicated on presumed pathology. Therefore, the theory of MPS caused by TrPs has been refuted. This is not to deny the existence of the clinical phenomena themselves, for which scientifically sound and logically plausible explanations based on known neurophysiological phenomena can be advanced.
- “An expansion of Simons' integrated hypothesis of trigger point formation,” an article in Curr Pain Headache Rep, 2004.
- “Referred pain of peripheral nerve origin: an alternative to the "myofascial pain" construct,” an article in The Clinical Journal of Pain, 1994.
- “Myofascial pain: a bogus construct,” a chapter in the book Myofascial pain, by John L Quintner and Milton L Cohen.
Specifically regarding Quintner 2015:
- “A Critical Evaluation of Quintner et al: Missing the Point,” an article in Journal of Bodywork & Movement Therapies, 2015.
- “The Decline and Fall of the Trigger Point Empire,” a webpage on FMperplex.com.
- “A critical evaluation of the trigger point phenomenon,” a webpage on BodyInMind.org.
These fourteen articles on PainScience.com cite Quintner 2015 as a source:
- PS When to Worry About Low Back Pain — And when not to! What’s bark and what’s bite?
- PS Trigger Points & Myofascial Pain Syndrome — A guide to the unfinished science of muscle pain, with reviews of every theory and self-treatment and therapy option
- PS Save Yourself from Low Back Pain! — Low back pain myths debunked and all your treatment options reviewed
- PS Tennis Ball Massage for Myofascial Trigger Points — Some creative tips on using a tennis ball (and other tools) to self-massage myofascial trigger points
- PS Basic Self-Massage Tips for Myofascial Trigger Points — Learn how to massage your own trigger points (muscle knots)
- PS Review of The Trigger Point Therapy Workbook — A popular book that promises too much and ignores recent science and controversies, which alienates many physicians and sets patients up for disappointment
- PS A Historical Perspective On Aches ‘n’ Pains — We are living in a golden age of pain science and musculoskeletal medicine … sorta
- PS Toxic Muscle Knots — Research suggests myofascial trigger points may be quagmires of irritating molecules
- PS Therapy Babble — Hyperbolic, messy, pseudoscientific theories about therapy are all too common
- PS Three Muscle Knots That Broke The Rules — Three examples of myofascial trigger points that responded to therapeutic methods that usually don’t work
- PS Trigger Point Doubts — A thorough review of the problems with the science of “muscle knots” and myofascial pain syndrome
- PS The Trigger Point Identity Crisis — The biological evidence that a trigger point is a lesion in muscle tissue
- PS Trigger Points on Trial — A summary of the kerfuffle over Quintner et al., a key 2014 scientific paper criticizing the conventional wisdom about trigger points and myofascial pain syndrome
- PS The Basic Types of Pain — Nociceptive, neuropathic, and “other”