PainScience.com • Good advice for aches, pains & injuries

Legacy update log for the trigger points tutorial

This is a listing of older updates made to the trigger points tutorial. They are provided for historical interest only, a “paper trail” demonstrating how the document has been maintained. Newer updates are listed in the tutorial itself.

2016Science update: Added a few new citations about the prevalence of vitamin D deficiency and it’s correlation with chronic pain. [Section: Vitamin D deficiency.]

2016Rewrite: A new way of looking at how trigger points cause the sensation of “stiffness” and what happens when we try to stretch them out. [Section: Like a knot in a bungie cord.]

2016Modest revision: Reorganized presentation of the practical and theoretical challenges with stretching trigger points. [Section: The bad news about stretching for trigger points.]

2016Major update: Almost all of the stretching sections have been edited, revised, and modernized. [Section: Stretching: Stretching is generally over-rated … but it might be good for trigger points.]

2016Minor editing: Made the point of the section more clearly. [Section: The spray-and-stretch method, if it works, implies that stretch alone may not work.]

2016Edited: Thorough revision and modernization. Although I revised this section just five years ago, it needed it again! [Section: Slow checklist: a more detailed diagnostic checklist for myofascial pain syndrome.]

2016Simplified: This section has been simplified, and now only covers key points about opioids and the relevance of opioids to MPS specifically. Detailed information about opioids has been moved to a separate article, Opioids for Chronic Aches & Pains. [Section: The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids.]

2016Major rewrite: Thorough revision of the introduction to sarcomeres, inspired by the book Life’s Ratchet, about molecular machines. [Section: Micro muscles and the dance of the sarcomeres.]

2016Correction: Removed overconfident statements about the clinical significance of the effects of psychoactive drugs, plus related minor updates. [Section: Slow checklist: a more detailed diagnostic checklist for myofascial pain syndrome.]

2016Safety update: Updated for consistency with new CDC guidelines. Thorough editing of the section. [Section: The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids.]

2016New section: No notes. Just a new section. [Section: Lidocaine patches.]

2016Important new related reading: Although not an update to the book itself, I’ve published some important related articles about the scientific controversy over the explanation for trigger points: (1) a heavily referenced review of the evidence that a trigger point is a “tiny cramp”; (2) a summary of the academic controversy about trigger point science; (3) the story of my own doubts and how they’ve changed over the years (this is the “main” article on this theme; it was around before but has been revised heavily). All of this stuff is inside baseball, and not of interest to most readers, but it’s critical to my credibility as an author on this topic — it shows that I’ve really done my homework, and I’m not ignoring the concerns of skeptical experts — so for now I’ve made everything freely available to all site visitors instead of integrating them into the book. Nevertheless, the book has already been heavily influenced by this work, and will continue to be.

2016Minor update: Added a good new example of a trigger point “whisperer” myth. [Section: The myth of the trigger point whisperer.]

2016Minor update: Finally added lacrosse ball recommendation. [Section: Massage tools: 7 free (or very cheap) and tools from objects not originally intended for massage.]

2016Science update: More evidence about more serious side effects of statins, and controversy about prevalence. [Section: Pain-causing drug side effects.]

2016Science update: Beefy tune-up for the “pillars” of trigger point science: several new and carefully written footnotes, linking to many painstakingly summarized papers for readers who really want to delve. It’s a bigger update than it looks like on the surface. [Section: The science of trigger points: It’s a little half-baked, but at least it’s not boring.]

2015Edited: Yet more modernization and clarification. [Section: Massage quality control issues (“But I’ve already tried massage therapy … ”).]

2015Edited: Modernization and clarification. [Section: Pain in three flavours: the good, the bad, and the ugly.]

2015Edited: Modernization and clarification. [Section: The Pressure Question: how much is too much?]

2015Edited: Modernization and clarification. [Section: Two: Good pain (why pressing on trigger points hurts like hell but feels like heaven).]

2015Edited: Tuned for consistency with my current views. [Section: Two case studies: highly-trained therapists failing miserably.]

2015Science update: Added a footnote about trigger points being associated with jaw pain. [Section: Trigger points may explain many severe and strange aches and pains.]

2015Revised: Just modernizing and clarifying. [Section: How to find good trigger point therapy .]

2015Science update: Some referencing about central sensitization, especially this “fun” fact: muscle pain may be especially good at causing CS. [Section: Referred pain science (advanced).]

2015New Section: Better late than never, I’ve added a summary of the expanded integrated hypothesis from Gerwin et al. (2004). [Section: The dominant theory of trigger points spelled out in a little more technical detail.]

2015New section: No notes. Just a new section. [Section: Acupressure: what if we pressed those points instead of puncturing?]

2015Science update: Added three good references and a diagram about how much “wiggle” room nerve roots have. [Section: Nerve pain is overdiagnosed.]

2015Science update: Two new science reviews considered and cited. [Section: How about Botox injection therapy?]

2015Rewritten: Completely revised for the 3rd edition of the Workbook: I no longer recommend it. [Section: A brief detour: why not The Trigger Point Therapy Workbook?]

2014New citation: Added an important new reference to a scientific paper critical of conventional wisdom. [Section: The shabby state of trigger point science.]

2014Minor update: New footnotes about the theory of acupuncture/trigger point overlap. [Section: How about acupuncture?]

2014Science update: And, so sorry, it’s bad news. [Section: Maybe stabbing will help! Dry needling.]

2014Science update: Added evidence about the effect of massage on fibromyalgia. [Section: The relationship between trigger points and other physiological disorders and diseases, especially fibromyalgia.]

2014Editing: General revision for quality. Added the cheek-bite analogy story for colour. [Section: One: The vicious cycle (why trigger points are stubborn).]

2014Editing: General revision for quality. [Section: Micro muscles and the dance of the sarcomeres.]

2014Minor update: Added a story about phantom limb pain. [Section: Referred Pain Science (basic) .]

2013Minor update: Minor but fascinating new item about the myth of anaesthetic paralysis and the dominance of the CNS over muscle tone — the kind of nifty item I just love to add to the book! [Section: The surprising futility of muscle relaxants such as Robax-whatever, Valium and other benzodiazepines.]

2013New section: An introduction to one of the most important theoretical challengers to the traditional explanation for trigger points. [Section: Quintner: “It’s the nerves, stupid”.]

2013Science update: Good news update: new study shows a clear reduction in nonspecific musculoskeletal pain after vitamin D supplementation. [Section: Vitamin D deficiency.]

2013Minor update: Upgraded risk and safety information about Voltaren Gel. [Section: Voltaren® Gel, an intriguing new option.]

2013Minor update: Modernized and expanded a bit, a couple new references, and a generally much better explanation of what fibromyalgia is. [Section: A brief note about the relationship between fibromyalgia and myofascial pain syndrome.]

2012Science update: Some more evidence showing the role of smoking in chronic pain. [Section: Smoking.]

2012Science update: Added references showing connections between smoking and chronic pain. [Section: Smoking.]

2012Minor update: Added a funny sidebar about bad anatomy. [Section: Don’t get hung up on anatomy, and be persistent .]

2012Minor update: A minor case study and some science to help establish that muscle can indeed be the source of pain. [Section: The science of trigger points: It’s a little half-baked, but at least it’s not boring.]

2012New section: No notes. Just a new section. [Section: What about stretching the antagonist muscle?]

2012Minor update: Added an item about “mobile” bumps that people often mistake for trigger points. [Section: Negative checklist: signs/symptoms that are probably not caused by trigger points.]

2012Edited: Now more accurate and clearer. Edits in preparation for audiobook version. [Section: Predictably unpredictable: trigger point symptoms are erratic by nature.]

2012Major update: New evidence that massage can cause “rhabdomyolysis” makes it quite a lot easier to understand a lot of negative reactions to trigger point therapy. This is valuable perspective, and the section has been heavily revised to exploit it. [Section: Troubleshooting negative reactions to treatment.]

2012Minor update: This introduction now does a better (and more honest) job of mentioning some trigger point controversies, and links to an important companion article about them, for keener readers, Trigger Point Doubts. [Section: The science of trigger points: It’s a little half-baked, but at least it’s not boring.]

2012Minor update: A minor but good: clearer, better language. Editing continues as I work on the audiobook version. [Section: “Out of nowhere”: a signature symptom of trigger points.]

2012Minor update: More editing for clarity and thoroughness. This also happens to be one of the first edits I’m doing to prepare for audiobook production. [Section: Slow checklist: a more detailed diagnostic checklist for myofascial pain syndrome.]

2012Science update: I revised the warning away from hydration, and included some fun new myth-busting evidence about hydration and cramping. [Section: Reality checks: some self-treatments that don’t work at all (or not nearly as well as you would hope).]

2012New section: No notes. Just a new section. [Section: Neutral positioning: find a comfortable muscle length and rest there.]

2012Minor update: Added an item about non-pain symptoms, like itching. [Section: Negative checklist: signs/symptoms that are probably not caused by trigger points.]

2012Minor update: Important new, skeptical footnote about the dangers of the powerful narcotic drugs. [Section: The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids.]

2012Modest expansion (again). And the sassy new “muscle stabbing” section name.: [Section: Maybe stabbing will help! Dry needling.]

2011Science update: Added an interesting citation about the correlation (or lack thereof) between tissue hardness and sensitivity. [Section: Identifying your trigger points by feel: tissue texture and other palpable signs.]

2011Trivial update: Added minor but odd note about “sensory annoyances” and hats. Yes, hats. [Section: Diagnosis: How can you tell if trigger points are the cause of your problem?]

2011Products added: Three new product reviews, and some miscellaneous revision of the section. [Section: Beyond the tennis ball: commercial massage tools.]

2011Updated: Added new references to fascia science about the toughness and contractility of fascia, and some interpretation. This is also supported by a substantial new free article, Does Fascia Matter? [Section: How about myofascial release and fascial stretching?]

2011New section: No notes. Just a new section. [Section: Smoking.]

2011Minor update: Added a paragraph about magnesium. [Section: Vitamin B1, B2, folate, and magnesium deficiencies.]

2011New section: No notes. Just a new section. [Section: The myth of the trigger point whisperer.]

2011New section: Some new thoughts about how stretching for trigger points might work — quite different from the mainstream theory — inspired some new stretching science. [Section: What about neurology? Stretch tolerance.]

2011Major rewrite: This might as well be a new section — not only did I re-write it, I gave it a completely new purpose. Previously the “bamboo cage” was a minor metaphor used to illustrate a possible mechanism for sensitization of muscle tissue. Now it is the basis of an extended and (I think) interesting exploration of how the concept of trigger points might actually be debunked. Pretty weighty stuff, but delivered with a major effort to make it interesting to any reader. Hope you enjoy it! [Section: “The bamboo cage” — what immobilization torture can tell us about the nature of muscle pain and massage.]

2011Minor update: Added an interesting observation about how Vitamin D supplementation might work. [Section: Vitamin D deficiency.]

2011Minor update: Miscellaneous editing and improvements, plus a couple new items. [Section: Slow checklist: a more detailed diagnostic checklist for myofascial pain syndrome.]

2011Minor update: Added some basic information about the damage that “ugly pain” can actually do, inspired by a recent anecdote received from a reader. [Section: Pain in three flavours: the good, the bad, and the ugly.]

2011Science update: The Vitamin D advice provided to readers has not changed, but the science supporting it has been dramatically beefed up — more science, new science, better summarized — to confirm that D supplementation is a safe and sensible option for patients. See also the separate article, Vitamin D for Pain. [Section: Vitamin D deficiency.]

2011Major update: Major improvements to the table of contents, and the display of information about updates like this one. Sections now have numbers for easier reference and bookmarking. The structure of the document has really been cleaned up in general, making it significantly easier for me to update the tutorial — which will translate into more good content for readers. Care for more detail? Really? Here’s the full announcement.

2011Minor update: Edited to distinguish more clearly between “dependence” and “addiction,” to reduce alarmism about addiction or contributing to the excessive stigma against opioids. (Thanks to reader Evelyn D. for pointing out the issue to me — a good example of how readers contribute to the improvement of this tutorial.) [Section: The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids.]

2011Minor update: Updated the disclaimer (sidebar) about my “conflict of interest.” I no longer have it, since I am retired from my massage therapy practice. [Section: Getting Help: How do you find good therapy for your trigger points?]

2011Minor update: Added evidence showing that trigger point therapy improved ankle range of motion. [Section: Massage efficacy according to science.]

2011Minor update: Added a checklist item about muscle wasting. [Section: Negative checklist: signs/symptoms that are probably not caused by trigger points.]

2010Major update: Previously this section discussed ultrasound rather generally, without much discussion of the science; it is now beefed up with a thorough, fun discussion of the somewhat squishy evidence. [Section: How about ultrasound therapy? (ESWT and “Sonic Relief™”).]

2010Minor update: Added an interesting footnote about the Google Book Ngram for “trigger points.” [Section: Introduction.]

2010Many minor repairs: A large batch of minor errors and glitches were corrected today, thanks to the sharp eyes of readers Effie and Doris.

2010Modest expansion: [Section: Maybe stabbing will help! Dry needling.]

2010New section: Not just for customers: this particular section is a short version of a new free article. [Section: Case study: A cautionary tale of stretching: that time I almost ripped my own head off.]

2010Major update: Numerous repairs and upgrades to all of Dr. Taylor’s sections of the book, especially links to the clinics that Dr. Taylor recommends, some new charts, and a colorful anecdote about drinking blood (seriously). Thanks to several readers, and especially Elaine M., for their assistance with this. It’s quite amazing how the new chapter is driving immediate refinements. People read it and write to ask questions, and that spurs little email debates between me and Dr. Taylor, a trip to PubMed for more evidence or detail, or a clarification wrangle with the language ... and the results get put into the book within hours or even minutes … so cool! As reader Bill C. put it, “Your books are alive!” It does kind of feel like that. [Section: Medical Factors That Perpetuate Pain: The effect of statin drugs, nutritional and hormonal deficiencies, infections, and inflammatory diseases.]

2010Many new sections: An important new chapter (with several sections) by Dr. Tim Taylor. This is the first major collaborative effort on PainScience.com, and I’m extremely proud of it, and pleased with how well it went. [Section: Medical Factors That Perpetuate Pain: The effect of statin drugs, nutritional and hormonal deficiencies, infections, and inflammatory diseases.]

2010New section: Happy to add a whole small new section about evidence of the efficacy of trigger point therapy. [Section: Massage efficacy according to science.]

2010Minor update: I’ve done a bunch of work to continue integrating Dr. Taylor’s new chapter into the book: discussing perpetuating factors wherever they are relevant, and linking to the chapter. Thus there are many more spots in the book now where the importance and relevance of Dr. Taylor’s contribution is emphasized.

2010New cover: At last! E-book finally has a “cover.”

2010Corrected: Fixed some wrong science about hydrogen bonding and tissue adhesions. Hat tip to reader and chemist K.D. for the good catch. [Section: Adhesions and contracture: when trigger points freeze in place.]

2010Minor update: Updated the muscle relaxant section with a summary of a bizarre experiment with muscle relaxants that had quite surprising results. [Section: The surprising futility of muscle relaxants such as Robax-whatever, Valium and other benzodiazepines.]

2010Minor update: Added a nice anecdote from a doctor about a trigger point that was almost mistaken for a possible tumor. [Section: Trigger points may explain many severe and strange aches and pains.]

2010New section: This is a major upgrade to the presentation of PainScience.com’s own Perfect Spots series of articles. They have always been here, but perhaps not presented in as useful a way as they could have been. I’ve also made many upgrades to the articles themselves over the last 2 months. [Section: Appendix B: The Perfect Spots.]

2010New section: Reviews and recommendations of other sources. [Section: Appendix A: Trigger Point Reference Materials or: Diagrams, Diagrams, Diagrams!]

2010Major update: A weakness of this tutorial has finally been eliminated: reference material! Where are the trigger points? Although this is still not an encyclopedia of trigger points, and it never will be (by design), the book now helps readers find specific trigger point information in three new ways, in three new sections.

2010Many minor repairs: No specific update today, but a particularly large dose of editing love, with my thanks to reader Elaine M. for pointing out several errors that got me started. Elaine received some free product for her assistance, of course, and so can you if you send me any more than a few error reports.

2010Minor update: Improved description of physiatrists (a medical speciality). [Section: Types of therapists and doctors and their relationship to trigger point therapy.]

2010New section: Finally, I’ve added a (free) appendix of Appendix C: Trigger Point Therapy Resources.]

2010Tiny update: Tiny-but-interesting: I added some pretty good evidence that a muscle relaxant was no better for injured neck muscles than ibuprofen. [Section: The surprising futility of muscle relaxants such as Robax-whatever, Valium and other benzodiazepines.]

2010New section: No notes. Just a new section. [Section: The evolution of muscle pain: does muscle “burn out”?]

2010Minor update: A little revision, slight expansion. [Section: The all-powerful acne analogy.]

2010Major update: Section heavily revised, improved, and expanded. [Section: Worst Case Scenario 2: Rare but extremely severe cases of myofascial pain syndrome.]

2010Major update: Section heavily revised, improved, and expanded. [Section: Worst Case Scenario 1: Being triggery.]

2010Minor update: A small but significant update on nutrition, based on take vitamin D — it might help. [Section: Troubleshooting negative reactions to treatment.]

2009Minor update: just added a couple of references, Calandre et al and Fernández-de-Las-Peñas et al, to substantiate the relationship between migraines and trigger points.

2009A substantial new section makes the case for self-treatment: Fundamental limitations of trigger point therapy, and how to take advantage of them

2009Upgraded the quality of the writing in an important section, Trigger point diagnosis is not reliable … but it may not matter that much.

2009A little smorg of updates today: (1) A lovely new illustration by a new case study section with a fascinating success story, demonstrating “a terribly important basic piece of wisdom to ‘get’ for anyone who is prone to muscle pain.” And (3) just a bit of updating of the tools sections with the idea of a “bucket of balls.”

2009As promised last week, there are now four new advanced sections about the use of medications to treat trigger point pain. These are major new sections with a whole bunch of useful information for patients and pros.

  1. Meds: Anti-inflammatories and Tylenol
  2. Meds: Voltaren® Gel, an intriguing new option (or see the less detailed but free article Voltaren® Gel Review)
  3. Meds: The nuclear option: “Hillbilly heroin” (Oxycontin), codeine and other opioids
  4. Meds: The surprising futility of muscle relaxants such as Robax-whatever, Valium and other benzodiazepines

Also, all discussion of Botox (especially the Botox section) was updated with new scientific evidence that it’s not as effective a therapy for trigger point pain as we all hoped.

2009Two new sections: “Muscle knots are not inflammatory: the myth of the inflamed myofascial trigger point” and “Common medications that might make a difference (and might not).” More advanced medication information to follow soon: this is just a summary of the basics so far.

2009A substantial new section today: Trigger point diagnosis is not reliable … but it may not matter that much. I wrote about this a while back on the front page and it will be there and free for a while longer, but I’ve also added more information here and included some references to other studies.

2009Several minor updates and refinements, not in any particular section.

2009It’s come to my attention that the trigger point treatment method of dry needling doesn’t have as much going for it as I used to think. I discuss the (lack of) evidence and problems in an overhaul of the section How about dry Needling and Intramuscular Stimulation (IMS) therapy? Since Dr. Chan Gunn is the doctor behind one of the most popular methods of dry needling (IMS), I also revised a section which was inspired by his ideas, “The bamboo cage” theory of muscle pain.

2009Completely re-wrote the section How about myofascial release and fascial stretching? which is accompanied by a new (free) general review of the clinical importance of fascia.

2009Rewrote the section How about chiropractic joint adjustment and popping? It’s been condensed into a more finely tuned summary, and links out to a much more detailed article on the topic.

2009Physiatrists and rheumatologists added to Types of therapists and doctors and their relationship to trigger point therapy.

2009New section: “Quick-start trigger points” (access for customers only) describing the clinical characteristics and significance of extremely fast-activating and severe trigger points.

2009Added an important point to the section, “From the frying pan of injury pain to the fire of trigger point pain,” about injuries that are so severely complicated and overshadowed by trigger point pain that the victims literally don’t even know that there is a physical trauma at the heart of the problem.

2009The visual design of the site was upgraded over the past several days. Although this is not an update to the content of this tutorial, it is nevertheless a significant upgrade for all of them — like publishing new editions of books with better typesetting and layout. The new design is even cleaner and reader-friendly; it now looks that good in most web browsers; and pages load as much as 50% faster. Many under-the-hood improvements will make it much easier for me to improve tutorial content. The tutorials are now well-oiled machines of digital publishing goodness, vastly superior to the low-production values of most eBooks. More information about the upgrade is published on the front page.

2009Another new advanced tip section today: “Don’t be fooled by reverse referral.” This one’s a head trip. It’s so confusing, I left it out of earlier versions of the tutorial simply because I still didn’t know how to explain it. But I decided it was time to tackle it, and here you go — I think I more or less got the point across.

2009This tutorial has always been strong in the “practical tips and tricks” department. Well, play to your strengths! Lately I’ve been in the mood to add even more tips, and here’s another one today, “focusing on one trouble spot versus ‘a little bit of everything’ — which is the better strategy?”

2009Added new information about Traumeel, a popular but questionable remedy that I often get asked about. See the section, “Reality checks: some self-treatments that don’t work at all (or not nearly as well as you would hope),” or the free article, Does Arnica Gel Work for Pain?.

2009Improvements to the section, “How about acupuncture?” Some optimism about acupuncture was removed from the section, and an important new reference was added. Recent scientific evidence has continued to hammer away at acupuncture, and optimism about it can no longer be justified. You can read about the most recent acupuncture evidence in, Does Acupuncture Work for Pain?.

2009New section! “Don’t get hung up on anatomy, and be persistent.” Sounds like a bit of a no-brainer, but there’s a couple ideas in there that patients often need to hear. It’s a nice addition in the “tip” category that really should have been there before.

2008A new section, “From the frying pan of injury pain to the fire of trigger point pain,” helps readers understand the unholy relationship between injury and trigger points. For readers who have been injured, this is an important addition to the tutorial. Similar information is also available in the form of a story in the article Muscle Pain as an Injury Complication: The story of how I finally “miraculously” recovered from the pain of a serious shoulder injury, long after the injury itself had healed. There is some overlap between the new section here and the stand-alone article, but they both offer different information in different ways. If you are injured, read both!

2008Added some information about some nice self-massage tools built by Beyond the tennis ball: some of the best commercial massage tools,” as well as some self-massage tools and products I don’t like, in the (now independent and expanded) section “Commercial massage tools to avoid.”

2008Added some information about the relationship between myofascial pain syndrome and disease that obviously affect the harmony of the musculoskeletal system, using Parkinson’s disease as an example. See the section “Are you a “triggery” person? The relationship between trigger points and other physiological disorders and diseases, especially fibromyalgia.”

2008Corrections and minor improvements have been made by the hundreds since the publication of the last major upgrade, which was three weeks ago. The polishing never really ends!

2008Massive upgrade published. This is by far the largest single update a PainScience.com tutorial has ever gone through. The trigger points tutorial has more than doubled the amount of information it offers, and is now book-length at around 80,000 words. Every single customer who ever purchased the tutorial received 2 weeks of free access to the upgraded tutorial. Here’s a summary of everything that’s changed:

October 2007 through May, 2008 — Fifteen substantive updates were published over eight months. All of them were made more or less made obsolete by and rolled into the major update of the whole tutorial, published July 28, 2008.