Detailed guides to painful problems, treatments & more

The Complete Guide to Trigger Points & Myofascial Pain

An extremely detailed guide to the unfinished science of muscle pain, with reviews of every theory and treatment option

Paul Ingraham • 950m read
Image representing trigger point pain. Very wide format photo of the back of a woman’s head and bare shoulders, in front of an out of focus green background. We can’t see her expression, but she’s looking up, and grasping both shoulders with both hands — apparently she has some pain, perhaps myofascial trigger points in her shoulders.

Trigger points (TrPs) or muscle “knots” are sore spots in soft tissue that cause deep aching. Myofascial pain syndrome (MPS) is a chronic pain disorder of too many trigger points. TrPs are usually described as micro-cramps, but the science is half-baked and their nature is controversial. Regardless, these sore spots are as common as pimples, often alarmingly fierce, and they seem to grow like weeds around injuries. They may be a major factor in back and neck pain, as a cause, a complication, or a bit of both.

There are many possible causes of unexplained aches and pains, but trigger points are an interesting piece of the puzzle for many people, and offer some potential for relief.

Trigger point therapy is mostly rubbing and pressing on trigger points, which can feel amazingly relieving. Dry needling is a popular (but dubious) method of stabbing trigger points into submission with acupuncture needles. TrP treatment is not rocket science1 — it’s much too experimental to be so exact! But most people can learn to get some relief safely and cheaply.

This is a huge tutorial for both patients and professionals, regularly updated for more than a decade now. It’s a plainly written guide to all the science (such as it is), the myths and controversies, with reviews of every conceivable treatment option.

Cartoon of a man with “toxic” trigger points. He is stooped over and facing away, with several signs stabbed into his back with toxic waste hazard waste symbols on them.

Does your body feel like a toxic waste dump?

It may be more true than you realized! Some data shows that a knot may be “polluted” with waste metabolites. If so, it’s no wonder they hurt … & hurt weird. It’s more like being poisoned than being injured. Back pain may be the best known symptom of the common muscle knot, but they can cause a startlingly wide array of other aches & pains.

Trigger point therapy is not a miracle cure for chronic pain

Trigger point therapy isn’t “too good to be true” — it’s probably just ordinary good. It’s definitely not miraculous.2 It’s experimental and often fails. “Dry needling,” the trendiest type, bombed a good quality scientific test in 2020.3 Good therapy is hard to find (or even define), because many (if not most) practitioners are amateurish4 and some treatment methods are way out in left field and potentially harmful, to your wallet if nothing else. They are often barking up the wrong tree, treating so-called trigger points when there’s actually another problem.

There are no “trigger point whisperers.” Trigger points are not little switches that can be flicked off (“released”) by anyone who has sufficiently advanced technique — they are a mysterious, cantankerous, complex phenomenon. Any therapist who is highly confident about their ability to banish your sore spots should probably be fired.

The good news

Good trigger point therapy is hard to find but under-rated.5 It can be a safe self-treatment with the potential to help with many common pain problems that don’t respond well — or at all — to anything else.6 Done with care and humility, it’s worth dabbling in.

For beginners with average body pain — a typical case of unexplained nagging hip pain or low back pain or neck pain — the advice given here may well seem almost miraculously useful. I get a lot of email from readers thanking me for pointing out simple treatment options for such irritating problems. Some are gobsmacked by the discovery that their chronic pain could have been treated so easily all along.

For veterans who have already tried — and failed — to treat severe trigger points, this document is especially made for you. You should learn more before giving up. This could give you a fighting chance of at least taking the edge off your pain, and maybe that is a bit of a miracle.

This isn’t a guide to “fixing” trigger points; it’s a guide to giving you a fighting chance with tougher cases.


What are trigger points?

A trigger point is a spot that is sensitive to pressure, mainly in muscle tissue, and often associated with aching and stiffness.1213 Almost everyone gets these spots, like pimples, but some people get more of them, and more painful ones, and no one really knows what they are. They have had many names over the decades,14 but myofascial trigger point (TrP) is the trendiest and most widely accepted label in the last 20 years.

For much longer, TrPs are also informally known as muscle “knots.” Obviously it’s not a clove hitch or a bowline: there are no actual knots in there, but it can feel like that. And sometimes there’s some muscle hardness or lumpiness at the site, maybe embedded in a taut band of muscle — but these abnormal textures are hard to detect reliably, and even professionals routinely mistake normal anatomy for trigger points (or other abnormalities). Please don’t assume every spot/bump in your body is a trigger point. 😜

A few TrPs can get vicious for a while, causing far more discomfort than most people believe is possible. Its bark is much louder than its bite — these episodes will pass like a headache — but the bark can be painfully loud. It can also be a weird bark — trigger points can generate some odd and troubling sensations, and the source may not be obvious.

What makes a trigger point sore?

Although their true nature is uncertain, the usual story is that a trigger point is a small patch of tightly contracted muscle, a micro-cramp of a tiny patch of muscle tissue (as opposed to a whole-muscle spasm like a “charlie horse”15). And the story goes on: that small patch of muscle chokes off its own blood supply, which irritates it even more, a vicious cycle dubbed a “metabolic crisis.” This swampy metabolic situation is why I sometimes think of it as sick muscle syndrome.

But that could be wrong. A couple major competing ideas are that it’s a more purely sensory disturbance, or the pain of slightly irritated peripheral nerves, a type of peripheral neuropathy.

Trigger points aren’t just sensitive to pressure; they are also associated with aching and stiffness that spreads out around the TrP, even when you aren’t poking it. The TrP may be in the center of the aching, like the yolk of an egg, or the aching may spread surprisingly far away (via the mechanism of referred pain, another major sub-topic for later). It’s this aching that really puts the “syndrome” in myofascial pain syndrome…

Growing a crop of trigger points

A few minor trigger points here and there is a common annoyance, but a bunch of bad ones is myofascial pain syndrome (MPS), and it can be disabling. TrPs are to MPS as pimples are to a serious acne problem.

The more severe trigger points, the more extensive and severe the associated aching and stiffness. There are many other possible causes of unexplained pain, but trigger points are an interesting piece of the puzzle for many people, and knowing about them offers some potential for relief.

This is a fairly detailed summary, but we’re really still just getting started.

A humourous graphical definition/translation of the jargon myofascial pain syndrome.


Quick checklist: classic trigger point symptoms

Although there are many causes of pain, confirming a trigger point diagnosis is simple enough for most people, most of the time. Check all that apply — if you have more than half of these, and no other apparent explanation for your pain, you probably have a trigger point or two.

Some symptoms that point away from trigger points: numbness, tingling, very sharp pain, joint pain, pain movement, abdominal pain, diffuse soreness or a widespread feeling of “fragility,” and malaise. But trigger points can and do co-exist with any other kind of painful problem.

We will go into even greater detail about symptoms below, because none of these items here are absolute, and the rules especially change for severe cases. For instance, no average trigger point will cause intense pain strongly linked to a specific movement… but severe ones can do that.


Why muscle pain matters

During a minor cyst removal from my chest many years ago, a potent stab of hot pain made me jump under the knife. “Very sorry,” the surgeon said. “I slipped and poked your pectoralis major with my scalpel, and only the superficial tissue is anaesthetized. Don’t worry, it won’t happen again.” And it didn’t. But I had learned a useful lesson: muscle tissue is sensitive stuff!17

Muscle pain matters. Aches and pains are an extremely common medical complaint,18 and trigger points seem to be a factor in many of them.1920 They are involved in headaches (including migraines),2122 neck pain and low back pain, and (much) more. What makes trigger points clinically important — and fascinating — is their triple threat. They can:

  1. cause pain problems,
  2. complicate pain problems, and
  3. mimic other pain problems.

Muscle just hurts sometimes. Trigger points can cause pain directly. Trigger points are a “natural” part of muscle tissue.23 Just as almost everyone gets some pimples, sooner or later almost everyone gets muscle knots — and then you have some pain with no other explanation or issue.

It’s complicated. Trigger points complicate injuries and other painful problems. They show up like party crashers: whatever’s wrong, you can count on them to make it worse, and in many cases they actually begin to overshadow the original problem.

“It felt like a toothache.” Trigger points mimic other problems. Many trigger points feel like something else. It is easy for an unsuspecting health professional to mistake trigger point pain for practically anything but a trigger point. For instance, muscle pain is probably more common than repetitive strain injuries (RSIs), because many so-called RSIs may actually be muscle pain.24 A perfect example: shin splints.25

The daily clinical experience of thousands of massage therapists, physical therapists, and physicians strongly indicates that most of our common aches and pains — and many other puzzling physical complaints — are actually caused by trigger points, or small contraction knots, in the muscles of the body.

The trigger point therapy workbook, by Clair Davies, p. 2


The shabby state of trigger point science

Trigger point science is as disappointing as an empty Christmas stocking.26 Trigger points are under-explained and over-hyped. They aren’t a flaky diagnosis,27 but they’re not exactly on a solid scientific foundation either. Some critics have harshly criticized conventional wisdom about them — criticisms I’ll cover in detail later.

None of that is a deal-breaker, though: muscle pain is still an important topic, “trigger points” is a useful work-in-progress label for whatever is actually going on, and everyone agrees that something painful is happening. So all the more reason to have a rational tour guide to take you through a murky subject. What’s useful in the theory of trigger points? Who disagrees and why? What’s half-baked and obsolete? What are the major pitfalls? I critically analyze the topic from all sides.28

Sometimes half-baked ideas turn out okay if you just keep them in the oven. Trigger point science may be a bit of a hot mess, but it also isn’t over: the controversy about trigger points is a legitimate, interesting controversy. And meanwhile, as far as I know, I am actually the only author out there who is both promoting and criticizing trigger point therapy.


Why are trigger points so neglected by medicine?

Cartoon of a man sitting in a doctor’s office. The doctor is holding a clipboard with a checklist with just two items on it: stress related and age related. The caption reads: “An extremely general practitioner.”

Family doctors aren’t really equipped for troubleshooting chronic pain.
Comic by Loren Fishman,

Trigger points are medically neglected because medicine has always had many much bigger fish to fry, and musculoskeletal medicine has only just recently started to get any real attention.29 Chronic pain with no obvious cause is a relatively unstudied epidemic and not many doctors know what to do with it and don’t even try.

If trigger points are a muscle tissue dysfunction or pathology — which is plausible but far from proven — that’s another reason they have fallen through the medical cracks: “Muscle is an orphan organ. No medical speciality claims it.”30 Muscle tissue is the largest organ in the body, complex and vulnerable to dysfunction, and full of biological puzzles.31 Although it is the “primary target of the wear and tear of daily activities,” nevertheless “it is the bones, joints, bursae and nerves on which physicians usually concentrate their attention.”32

Family doctors are particularly uninformed about the causes of musculoskeletal aches and pains33 — it simply isn’t on their radar. They are busy with a lot of other things, many of them quite dire. And the topic is just trickier than it seems to be, so it’s not really surprising that doctors aren’t exactly muscle pain treatment Jedi.

What about medical specialists? They may be the best option for serious cases. Doctors in pain clinics often know about trigger points, but they usually limit their methods to injection therapies — a bazooka to kill a mouse? — and anything less than a severe chronic pain problem won’t qualify you for admittance to a pain clinic in the first place. This option is only available to patients for whom trigger points are a truly horrid primary problem, or a major complication. Medical specialists may know quite a bit about muscle pain, but still can’t help the average patient for practical reasons.

An appallingly high percentage of doctors and other practitioners are still pretty much out of the loop regarding trigger points.

The trigger point therapy workbook, by Clair Davies, p. 2

Physical therapists and chiropractors are often preoccupied to a fault with joint function, biomechanics,34 and exercise therapy. These approaches have their place, but they are often emphasized at the expense of understanding muscle pain as a sensory disorder which can easily afflict people with apparently perfect bodies, posture and fitness. A lot of patient time gets wasted trying to “straighten” patients, when all along just a little pressure on a key muscle knot might have provided relief.

Massage therapists have a lot of hands-on experience of muscle tissue, but know surprisingly little about myofascial pain syndrome. Their training standards vary wildly. Even in my three years of training as an RMT (the longest such program in the world35), I learned only the basics — barely more than this introduction! Like physical therapists and chiropractors, massage therapists are often almost absurdly preoccupied with symmetry and structure. The right hands can give you a lot of relief, but it’s hard to find — or be — the right hands.

No professionals of any kind are commonly skilled in the treatment of trigger points. Muscle tissue simply has not gotten the clinical attention it deserves, and so misdiagnosis and wrong treatment is like death and taxes — inevitable! And that is why this tutorial exists: to help you save yourself, and to educate professionals.

Those clinicians who have become skilled at diagnosing and managing myofascial trigger points frequently see patients who were referred to them by other practitioners as a last resort. These patients commonly arrive with a long list of diagnostic procedures, none of which satisfactorily explained the cause of, or relieved, the patient’s pain.

Myofascial Pain and Dysfunction, by Janet Travell, David Simons, and Lois Simons, p. 36


Does your trigger point therapist have the big red books?

Photograph of the covers of the “big red books,” the massive 2-volume textbook set, Myofascial Pain and Dysfunction: The Trigger Point manual, by Janet Travell and David Simons.

The Big Red Books

Even atheists should be familiar with the Bible & every professional should have a copy of these books, despite their flaws.

In addition to many scientific papers, this tutorial is based on medical textbooks like the massive two-volume set, “the big red books” — Myofascial Pain and Dysfunction36 — and “the blue book,” Muscle Pain37 These are not easy reading.38

They don’t contain all the answers — indeed, they contain some nonsense — but anyone who claims to treat muscle pain should still have the big red books in their office. They are too historically important not to be familiar with. If you don’t see dog-eared copies of these books, ask about them — it’s a fair, polite clue about a therapist’s competence. Muscle Pain (the blue one) is just as important. I recommend it to any professional who works with muscle (or should). It’s more recent, and it covers a much wider range of soft tissue pain issues, putting trigger points in context.


Myofascial pain syndrome versus fibromyalgia

Fibromyalgia (FM) is the disease of “hurting all over.” Fatigue, sleep disturbance, and “fibro fog” (mental confusion) are classic symptoms too. Fibromyalgia is a syndrome, not a disease, which means that it is unexplained by definition.39 It is just the label we give to undiagnosed chronic widespread pain. So “no one has FM until it is diagnosed.”40

MPS is just one of many possible explanations for the pain of fibromyalgia, and/or it might be a distinct meaningful diagnosis on its own. It would be nice if such a clear distinction were established someday. FM and MPS are both imperfect, imprecise labels for closely related sets of unexplained symptoms, which makes them harder to tell apart than mischievous twins who deliberately impersonate each other. They may be two sides of the same painful coin, or overlapping parts on a spectrum of sensory malfunction, or different stages of the same process. Some cases are effectively impossible to tell apart. There may be no real difference between FM and severe MPS.

Add to that the fact that both conditions are controversial to the point where some people deny they even exist, and it’s understandable that they get confused.

Note that the “tender points” of fibromyalgia are not the same thing as trigger points.41

Whatever the causes or labels, therapeutic approaches to MPS seem to help some FM patients as well,42 although pure FM cases seem to be mostly immune to massage.43 But this book is still useful for many FM patients, insofar as it overlaps with our main topic.

The tender points of fibromyalgia.

Fibromyalgic Tender Points

The “tender points” of fibromyalgia are not the same idea as myofascial trigger points.


Trigger points may explain many severe and strange aches and pains

I once suffered from a brutal “toothache” that was completely relieved by a massage therapist the day before an emergency appointment with the dentist: a particularly vivid experience, and one of the reasons I first got keen on this topic. Pain is a trickster; it is often not always what it seems to be. Trigger points are a common alternative explanation.

Got a bizarre pain that just flared up one day? Sure, it might be something scary or rare. But in many cases it’s probably just a trigger point — about as serious as banging your funny bone. But it can feel worrisome.

This is where trigger points really get interesting. In addition to minor aches and pains, muscle pain often causes unusual symptoms in strange locations. For instance, many people diagnosed with carpal tunnel syndrome are actually experiencing pain caused by an armpit muscle (subscapularis).44 Seriously. I’m not making that up.

This odd phenomenon of pain spreading from a trigger point to another location is called “referred pain.” Here are some other examples of interesting referred pain leading to misdiagnosis:45

An example of the phenomenon of referred pain from a common trigger point in the supermedial gluteus maximus muscle.

Example of referred pain

The phenomenon of referred pain is one of the main reasons that trigger points can cause pain in unexpected places. This image shows a classic example. Many people have a sore spot in the upper gluteus maximus, but pain in this location often spreads either up into the low back and/or down into the rest of the gluteals & hamstrings. This pattern causes it to be widely misinterpreted as back pain and/or sciatica, when in fact it’s just a sore spot in the butt.

Sometimes trigger points cause such crazy symptoms that they are mistaken for medical emergencies. I treated a man for chest and arm pain — he had been in the hospital for several hours being checked out for signs of heart failure, but when he got to my office his symptoms were relieved by a few minutes of rubbing a pectoralis major muscle trigger point. “Heart attack cured!” The same trigger point sometimes raises fears of a tumor. Here’s a particularly excellent example sent to me by a physician who had this experience:

I narrowly escaped a breast biopsy because of trigger points in the pectoralis major. I’d had bad chest pain for a month. I was on the table, permit signed, draped. The doctor wasn’t sure: she said she wanted another mammogram. I left confused, relieved … but still hurting.

Then I lucked out: my regular internist was puzzled, but thought it might be “soft tissue.” That made me go to a physical therapist. The physical therapist pulled out the big red books on trigger points, and we read together. Treatment was a complete success. A month-old severe pain that I had been treating with ice packs in my bra and pain-killers — gone!

Janice Kregor, competitive swimmer, retired pediatrician and medical school instructor

Another client once spent three days in hospital for severe abdominal pain that doctors couldn’t diagnose — her pain was mostly relieved by massaging a trigger point in her psoas major muscle.51

But most symptoms caused by myofascial pain syndrome are simply the familiar aches and pains of humanity — millions of sore backs, shoulders and necks. Some of which can become quite serious.

Photograph of an aging gentleman grasping his shoulder with a pained expression, representing the potential severity of trigger point pain.

Is this like you?

Muscle knot pain can be savage. Over the years I have met many people who were in so much pain from muscle dysfunction that they could hardly think straight. Is muscle pain “trivial”? Not if you have it!


Two typical tales of trigger point treatment

The link between trigger points and mild-to-moderate body pain can be so straightforward that “therapy” is so easy it barely deserves to be called therapy. One of the nice things about working with trigger points is that, sometimes over the years, they have made me seem like a miracle worker… because they are such a clinical slam dunk for some cases of garden variety persistent pain.

For instance, Lois McConnell of Vancouver came to see me complaining that she’d had moderate, chronic back pain for several years. She’d received some common misdiagnoses, particularly sacroiliac joint dysfunction.52 But she had a prominent gluteus maximus trigger point53 that, when stimulated, felt exactly like her symptoms — a deep ache in the region of the low back and upper gluteals. Her pain was permanently relieved in three appointments. She was quite pleased, I can tell you!

Just wanted to give you a quick update … my back has been absolutely fine. Unbelievable … or perhaps not, considering what I’ve learned from you! A big thank you for all your help.

Lois McConnell, retired airline executive, suffered chronic low back and hip pain for a few years

Or consider Jan Campbell. Jan developed a hip pain sometime in early 2004 during a period of intense exercising. The pain quickly grew to the point of interfering with walking, and was medically diagnosed as a bursitis, piriformis strain, or arthritis. “Ain’t nobody got time for that.” I did not think any of these were likely, and treated a trigger point in her piriformis muscle once on June 12, 2004. Her symptom was 100% relieved for about eight months, before it slowly began to reassert itself (as trigger points often do, despite our best efforts — more about that to come).

One trigger point therapy treatment completely relieved a nasty stubborn hip pain that I'd had for five months!

Jan Campbell, retired French language teacher, Palm Springs, recovered easily from several months of hip pain

Every decent trigger point therapist has a pack of treatment successes like this. (Not that therapists are great judges of their own efficacy,54 but where there is this much smoke…) Although most such cases involve relatively minor symptoms, this is not to say that they were minor problems. In almost every such case, the pain was relatively mild but extremely frustrating and persistent for many years, then relieved easily by a handful of treatments — an incredible thing, when you think about it. So much unnecessary suffering!

But of course trigger points don’t always yield so easily…


The myth of the trigger point whisperer

Can a good enough massage therapist remove all trigger points in a session? Is there such a thing as a “trigger point whisperer”?

I got this question by email, and it exposes a common theme: the optimistic/desperate quest for the mystique of the magic super therapist who can fix anything in two or three sessions. Or even less.55 The idea is exasperating to all the honest, humble professionals who know better. And, if you know the basics about pain and muscle knots, it’s obviously foolish. The skill of a therapist is actually only one relatively minor factor among many that affect the success of massage therapy for trigger points — or any therapy, for any pain problem.

Trigger points are not little switches that can be flicked off (“released”) by anyone who has sufficiently advanced technique — they are a mysterious, cantankerous, complex phenomenon. Even the best therapists can be defeated by a no-win situation and factors beyond their control.56 And nearly any therapist can luck out and get great results with the occasional patient when all the planets are aligned: sometimes trigger points respond well to virtually any intervention.

For comparison, can a good enough dog trainer train any dog in a hour? Even Cesar “Dog Whisperer” Millan says he can’t if the dog is traumatized, sick, and/or injured, and requires hours of smart, gradual conditioning. It depends on the situation.

It depends, it depends, it depends. This is a major theme in this document, and it is why I am dedicated to teaching concepts and principles, not treatment recipes and formulae — and that’s why it’s an important thing to cover in the introduction.


Part 2


How can you tell if trigger points are the cause of your problem?

Trigger points have many strange “features” and behaviours, and can easily be confused with many other common undiagnosed causes of pain in general57 and muscle pain in particular. There are several common kinds of muscle pain, or pains that can seem like it: arthritis, medication side effects, exercise soreness, muscle tears, and the profound body aching caused by an infection like COVID-19.58 The only hope of telling these things apart is a good working knowledge.

Thanks to their medical obscurity and the half-baked science, trigger points are often the last thing to be considered. There are some clues you can look for that will help you to feel more confident that, yes, this kind of muscle pain is the problem instead of something else, maybe something scarier.

Whether you knew it or not, you were probably already familiar with trigger points even if you’d never heard of them before laying eyes on this page. Almost everyone more or less knows what it feels like to have a muscle knot, so almost everyone has a head start in self-diagnosing trigger points. If you’ve ever been inexplicably stiff — and really, who hasn’t? If you’ve ever wrenched your neck around trying to stretch and squirm your way free of discomfort. If you’ve begged a boyfriend to dig into that nagging sore spot in your back. If you had experiences like those, then you already know something about what trigger points feel like: pain and stiffness that feels like it’s in your muscles, sensitive patches of soft tissue in locations where there’s no obvious reason for it.

But, Padawan learner, there may be many things you do not yet know about how trigger points behave and feel…


Purchase full access to this tutorial for USD$1995. Continue reading this page immediately after purchase. See a complete table of contents below. Most content on is free.?

Almost everything on this website is free: about 80% of the site by wordcount, or 95% of the bigger pages. This page is only one of a few big ones that have a price tag. There are also hundreds of free articles, including several about trigger points. Book sales — over 73,600 since 2007?This is a tough number for anyone to audit, because my customer database is completely private and highly secure. But if a regulatory agency ever said “show us your math,” I certainly could! This count is automatically updated once every day or two, and rounded down to the nearest 100. Due to some oddities in technology over the years, it’s probably a bit of an underestimate. — keep the lights on and allow me to publish everything else (without ads).

Q. Ack, what’s with that surprise price tag?!

A. I know it can make a poor impression, but I have to make a living and this is the best way I’ve found to keep the lights on here.

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Paying in your own (non-USD) currency is always cheaper! My prices are set slightly lower than current exchange rates, but most cards charge extra for conversion.

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You can also keep reading more without buying. Here are some other free samples from the book, and other closely related articles on

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Paying in your own (non-USD) currency is always cheaper! My prices are set slightly lower than current exchange rates, but most cards charge extra for conversion.

Example: as a Canadian, if I pay $19.95 USD, my credit card converts it at a high rate and charges me $26.58 CAD. But if I select Canadian dollars here, I pay only $24.95 CAD.

Why so different? If you pay in United States dollars (USD), your credit card will convert the USD price to your card’s native currency, but the card companies often charge too much for conversion — it’s a way for them to make a little extra money, of course. So I offer my customers prices converted at slightly better than the current rate.

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Frequently asked questions about this book

Q. Does your tutorial include diagrams showing common trigger points?

A. Not really, but in a way: thirteen classic trigger points are explored in separate (free) articles, the “Perfect Spots” for massage (check out #1), which are associated with many common pain problems. But charts tend to put the focus on the wrong thing, and people need principles way more than they need diagrams. In any case, there are lots of good free/cheap charts out there. Please don’t buy this book and then ask for a refund because it doesn’t have charts: it’s like asking for a refund for your zoo admission because you didn’t see any cats, dogs, or squirrels!

Q. Does the tutorial include information on [insert your pain problem]?

A. Probably not, but maybe! Many specific pain problems are mentioned briefly, but the book doesn’t go into detail about any of them. You don’t really need the link to every common pain problem spelled out. Trigger points cause and complicate all injuries in fairly predictable ways — that’s why they are clinically intriguing!

There’s a lot of overlap with widepsread, non-specific chronic pain — like fibromyalgia — so I get into those topics quite a bit too.

Q. Why not The Trigger Point Therapy Workbook?

A. Clair and Amber Davies’ popular book is written well. It’s illustrated nicely, and offers detailed muscle-by-muscle reference material — things this tutorial deliberately lacks.

Cover image of The Trigger Point Therapy Workbook

The Workbook promises too much & neglects relevant science.

(This is a very short version of my full review.)

I used to wonder why I even bothered to create this tutorial! Why not just recommend the Workbook? Because this tutorial has grown to offer a lot that the Workbook doesn’t.

Delving into the nature of the beast — the science — is the strength of this tutorial. But the Workbook has fallen behind the times on that score. The current edition still promises too much and neglects important new knowledge. Trigger point therapy has been challenged by many scientific insights and new ways of understanding pain, but the Workbook doesn’t acknowledge any of that. This topic is too important for such neglect.

This tutorials offers a more realistic and balanced view of trigger point therapy, meets the challenge of difficult cases head on, and hard-nosed reviews of every possible treatment option. All for $20. Which is quite a bit less than even a single appointment with someone who claims to do trigger point therapy.

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Paying in your own (non-USD) currency is always cheaper! My prices are set slightly lower than current exchange rates, but most cards charge extra for conversion.

Example: as a Canadian, if I pay $19.95 USD, my credit card converts it at a high rate and charges me $26.58 CAD. But if I select Canadian dollars here, I pay only $24.95 CAD.

Why so different? If you pay in United States dollars (USD), your credit card will convert the USD price to your card’s native currency, but the card companies often charge too much for conversion — it’s a way for them to make a little extra money, of course. So I offer my customers prices converted at slightly better than the current rate.

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Summary of the basics

Decades of experience and study … reduced to a few bullet points. 😉

Trigger point symptoms

Trigger point causes

Trigger point therapy

Every one of those points is the tip of an iceberg. The devil is in the details, and that’s why there’s a very large book about them behind the paywall. But this summary should help give you a better sense of whether or not you want to learn more from this source.

Part 2.1


Appendix C: Trigger Point Therapy Resources

This is a list of resources relevant to chronic pain in general, but muscle pain in particular. I avoided publishing this section of the tutorial for many years, because I am generally not impressed by the resources available (to both patients and professionals), especially online resources. I remember a slightly testy conversation with someone from an American organization (that shall remain nameless):

THEM   You say it’s hard for patients to find good trigger point therapy. You shouldn’t say that! We certify good trigger point therapists!
ME   You have about fifty practitioners in your directory, concentrated in a handful of major cities, with a certification no one has ever heard of, for a country of more than 300 million people spread over almost 10 million square kilometres. That’s one certified therapist for about every 60,000 people and 200,000 square miles. If “needle in a haystack” is the new “easy to find,” then sure, I’ll say that your certified therapists are easy to find.
THEM   Well, you still shouldn’t say that it’s hard to find them!
ME   Call me when your organization has grown by at least an order of magnitude and your website doesn’t look like it was built by high school students.

Many years later that organization still has only a few dozen certified therapists in its directory, and yet it remains one of the few and largest directories of its kind. If you live in a big city, there’s a fair to middlin’ chance that you can find one of those therapists. But certification of trigger point therapists is generally an amateurish and fragmented mess, with many businesses and organizations competing to be the standard. (Even this document is part of the mess: a sanity-inducing part of the mess, hopefully, but nevertheless a good example of how everyone and their dog is out there trying to provide “the best” information/training/therapy in this field.)

For inclusion in this section, an organization or business must be defining the field in some way, and they must have a strong online presence.

The relevance of each listing to professional readers and/or patients is marked with [PRO] and [PATIENT]. For instance, although professional associations are rarely of much interest to patients, they may provide directories of professionals to help patients find practitioners.

National Association of Myofascial Trigger Point Therapists (NAMTPT) [PRO] [PATIENT] — The only organization dedicated to representing professionals specializing in myofascial pain and trigger point therapy. NAMTPT provides resources for both patients and professionals, such as a trigger point therapist directory ( just over 100 therapists) and a symptom checker.

The International Myopain Society (IMS) [PRO] — A nonprofit health professionals organization dedicated to the promotion of information about soft-tissue pain disorders like myofascial pain. IMS publishes the MYOPAIN, a Journal of Myofascial Pain and Fibromyalgia.

American Society of Pain Educators (ASPE) [PRO] — A nonprofit organization that trains Certified Pain Educators (CPEs). A CPE educates clinical peers, patients, families, and caregivers on ways to relieve pain by the safest means possible. ASPE training is not focused on muscle pain.

American Academy of Pain Management (AAPM) [PRO] [PATIENT] — The largest association of pain professionals in the United States with 6000 members. Similar to the ASPE in that members do not focus on muscle pain in particular: they are included here because they are chronic pain experts in general (although, interestingly, in 2016 they did “spontaneously” form a new “interest group” about myofascial therapy). They provide a directory of members and listings of pain clinics.

Massage Therapy Foundation (MTF) [PRO] — A nonprofit organization to advance the profession of massage therapy, founded by the American Massage Therapy Association. The MTF website has a strong focus on research and they publish the International Journal of Therapeutic Massage & Bodywork, which routinely publishes papers about myofascial pain syndrome. Their resources page offers a series of excellent short ebooks by authors I know and vouch for, and I particularly recommend Tracy Walton’s 5 Myths & Truths About Massage Therapy (written for therapists).

The Pressure Positive Company [PRO] [PATIENT] — The best and oldest American manufacturer of good quality massage tools, Pressure Positive has also been a superb corporate citizen, contributing to the advancement of trigger point therapy in many ways, such as collaborating with writers like myself and supporting and promoting scientific research — admirable qualities in a field so often afflicted with pseudoscientific hype. Their website provides many useful resources for both patients and professionals.

Trigger Point Therapy Workshops [PRO] [PATIENT] — A small trigger point workshop provider, for both professionals and patients, notable mainly because the founder is Amber Davies, NCTMB, daughter of Clair Davies and author of The Trigger Point Therapy Workbook — a popular primer on this topic (see my review).

Certification Board for Myofascial Trigger Point Therapists [PRO] [PATIENT] — A small professional organization for trigger point therapists dedicated to “advancing the professional standards of myofascial trigger point therapists through the establishment and maintenance of criteria and procedures for certification.” They offer a modest directory of a few dozen trigger point therapists around the United States.

Neil Asher Continuing Education for Manual Therapists [PRO] — “Neil Asher Technique” is branded approach to trigger point therapy, and the website is mostly built around a directory of NAT certified therapists.

David G. Simons Academy (DSGA) [PRO] [PATIENT] — Dr. Simons co-authored the famous big red texts — the seminal text on myofascial pain syndrome — with Dr. Janet Travell. DGSA is named in his honour, and has offered courses in dry needling and manual trigger point therapy worldwide since 1995 (although they seem to be primarily serving Europe). They are hardly the only provider of such workshops, but I single them out because I specifically appreciate their attitude towards certification: they offer to teach skills, not certification levels in a branded treatment “system.” (I don’t necessarily object to branding of training, but I prefer this more academic approach to training.) They maintain a decent bibliography of trigger point research. (See also Seminarios Travell & Simons, offering trigger point courses in Spain led by Orlando Mayoral — there is a regular exchange of experience between DGSA and Orlando Mayoral.)

Myopain Seminars [PRO] [PATIENT] — A post-graduate continuing education company focusing on myofascial trigger points, manual trigger point therapy, dry needling, and trigger point injections. Like DSGA, Myopain Seminars is focused more on teaching skills and knowledge and not a branded certification program, but they do have a directory of graduates of their courses (see their find a clinician feature) and more than a dozen faculty members all “provide high-level diagnostic and management services” for pain patients that may be of interest to many readers of this book. I have a friendly occasional correspondence with founder Dr. Jan Dommerholt, the author of several influential books and papers on this topic; although we don’t necessarily agree on everything — I’m not a fan of dry needling, primarily — I think of him as a mentor and have learned a great deal from him.


Reader feedback … good and bad

Testimonials on health care websites reek of quackery, so publishing them has always made me a bit queasy. But my testimonials are mostly about the quality of the information I’m selling, and I hope that makes all the difference. So here are some highlights from the kind words I’ve received over the years … plus some of the common criticisms I receive, at the end. These are all genuine testimonials, mostly received by email. In many cases I withold or change names and identifying details.

Paul thinks like a scientist, and he’s an excellent writer — a rare and valuable combination. He acknowledges that the trigger point science is “half-baked,” but he’s leaving the door open to debate, unlike some others. And he does this with the humor and aplomb of someone who’s actually read and studied the relevant science and is therefore humbled by it. He also admits that his trigger point manual is his bread and butter, so he’s also transparent about competing interests, which is more than I can say for many clinical researchers in the field of trigger points. Just read his stuff.

John Ware, Physical Therapist

This is, bar none, one of the finest endorsements I’ve ever received. What I particularly love about it is not that it will help sell my book, but something far better: it will help sell it for the right reasons. ~ Paul

Your evidence based approach to pain is to be applauded. You have consolidated and correlated many things that I have previously read as a chaotic patchwork quilt in diverse places and provided valuable additional information and insight that I have not previously found.

Alessandra Campbell

I really appreciate all of the time and effort you have put into your work. I have had arthritis and a hip replacement, with all of the attending issues. My goal has been to seek the proper information to rationally and practically address this. Your work has given me better direction and clarity in understanding some of the body dynamics from an honest perspectice. Many thanks for your work with this.

Phillippa Lutz

First of all thank you for what you do. I stumbled onto your site about six months ago and it has radically changed my perspective on myofascial pain and how I approach and treat patients. In the 16 years I have been a licensed acupuncturist and the 20 before that as a certified massage therapist this is far and away the most useful and eye opening information I have ever come across.

Alishia Livingston

Thank you for your website, it is really a great resource. I have purchased 2 tutorials (trigger points and PF). I also love the concept that you permanently update them and that we have permanent access. I have never seen this concept anywhere else but I find it is really worth the money and better than a book, in the long run.

Bryn Gonzalez

Firstly I would like to thank you for your Trigger Point therapy book, which is very easy to read and follow (and the witty sense of humor doesn’t hurt!).

Yusra Winters

First, thank you for the very informative e-book; I am thoroughly enjoying it — which is strange since it’s a medical text. That attests to your ability to write in a very engaging and easy-to-follow tone.

Safia Salinas

Thank you for delivering information about trigger points and resulting pain in a manner that is understandable to the general public. While I am a Physical Therapist most everything I read or listen to automatically gets translated into a more scientific jargon. This helps me to relay the message to my clients.

Kaydon Joyner, physical therapist

The clarity of your writing is very impressive, and you bring a great attitude to it.

Brittney Taylor

Thank you so much for taking the time to put this book together, and in a way that makes it feel like you wrote it just for me! You have a great writing style.

Hanna Beck

One more noteworthy endorsement, with regards to this whole website and all of my books, submitted by a London physician specializing in chronic pain, medical education, and patient-advocacy (that’s a link to his excellent blog):

I’m writing to congratulate and thank you for your impressive ongoing review of musculoskeletal research. I teach a course, Medicine in Society, at St. Leonards Hospital in Hoxton. I originally stumbled across your website whilst looking for information about pain for my medical students, and have recommended your tutorials to them. Your work deserves special mention for its transparency, evidence base, clear presentation, educational content, regular documented updates, and lack of any commercial promotional material.

Dr. Jonathon Tomlinson, MBBS, DRCOG, MRCGP, MA, The Lawson Practice, London

What about criticism and complaints?

Oh, I get those too! I do not host public comments on for many reasons, but emailed constructive criticism, factual corrections, requests, and suggestions are all very welcome. I have made many important changes to this tutorial inspired directly by critical, informed reader feedback.

But you can’t make everyone happy! Some people demand their money back (and get it). I have about a 1% refund rate (far better than average in retail/e-commerce). The complaints of my most dissatisfied customers have strong themes:



Thanks to every reader, client, and book customer for your curiosity, your faith, and your feedback and suggestions, and your stories most of all — without you, all of this would be impossible and pointless.

Writers go on and on about how grateful they are for the support they had while writing one measly book, but this website is actually a much bigger project than a book. was originally created in my so-called “spare time” with a lot of assistance from family and friends (see the origin story). Thanks to my wife for countless indulgences large and small; to my parents for (possibly blind) faith in me, and much copyediting; and to friends and technical mentors Mike, Dirk, Aaron, and Erin for endless useful chats, repeatedly saving my ass, plus actually building many of the nifty features of this website.

Special thanks to some professionals and experts who have been particularly inspiring and/or directly supportive: Dr. Rob Tarzwell, Dr. Steven Novella, Dr. David Gorski, Sam Homola, DC, Dr. Mark Crislip, Scott Gavura, Dr. Harriet Hall, Dr. Stephen Barrett, Dr. Greg Lehman, Dr. Jason Silvernail, Todd Hargrove, Nick Ng, Alice Sanvito, Dr. Chris Moyer, Lars Avemarie, PT, Dr. Brian James, Bodhi Haraldsson, Diane Jacobs, Adam Meakins, Sol Orwell, Laura Allen, James Fell, Dr. Ravensara Travillian, Dr. Neil O’Connell, Dr. Tony Ingram, Dr. Jim Eubanks, Kira Stoops, Dr. Bronnie Thompson, Dr. James Coyne, Alex Hutchinson, Dr. David Colquhoun, Bas Asselbergs … and almost certainly a dozen more I am embarrassed to have neglected.

I work “alone,” but not really, thanks to all these people.

I have some relationship with everyone named above, but there are also many experts who have influenced me that I am not privileged to know personally. Some of the most notable are: Drs. Lorimer Moseley, David Butler, Gordon Waddell, Robert Sapolsky, Brad Schoenfeld, Edzard Ernst, Jan Dommerholt, Simon Singh, Ben Goldacre, Atul Gawande, and Nikolai Boguduk.

Thank you finally to Dr. Tim Taylor, MD, who provided a great deal of the raw material that went into the original version of the book’s vital sections medical factors that perpetuate pain.


What’s new in this tutorial?

Regular updates are a key feature of tutorials. As new science and information becomes available, I upgrade them, and the most recent version is always automatically available to customers. Unlike regular books, and even e-books (which can be obsolete by the time they are published, and can go years between editions) this document is updated at least once every three months and often much more. I also log updates, making it easy for readers to see what’s changed. This tutorial has gotten 197 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).

Mar 4, 2024 — Science update: There is no significant new evidence, but the chapter was missing some significant old evidence. I added that, and did some general editing and revising while I was at it. Bottom line unchanged. [Updated section: How about Botox injection therapy?]

2023 — New content: Added an interesting sidebar about how we can actually lose sarcomeres. And I finally added two very complex new diagrams of muscle structure and sarcomere function — a project I avoided for years, because it was really hard! But also very important for this subject matter. [Updated section: Micro muscles and the dance of the sarcomeres.]

2022 — Science update: Added an interesting citation about the infectious roots of multiple sclerosis (Bjornevik). [Updated section: Many other causes of chronic widespread pain that should not be ignored.]

2021 — Correction: I excessively demonized gabepentin and pregabalin based on an oversimplification of their legal history and inadequate attention to the evidence on efficacy for neuropathy. In fact, these drugs are efficacious for some neuropathies. [Updated section: Nerve pain is overdiagnosed.]

2021 — Major upgrade: Dramatically improved quantity and quality of information about magnesium deficiency and using it as a treatment for pain or cramping. [Updated section: Magnesium deficiency.]

2021 — Upgrade: More and better information, especially a science-based revised of vitamin C dosing advice. [Updated section: Vitamin C deficiency.]

2021 — Science update: Almost an echo of last year’s science update on this topic: a second study of needling for neck pain, also quite good, and also quite negative. [Updated section: Maybe stabbing will help! Dry needling.]

2021 — Modernized: Dramatically improved the tone of the introduction to the “medical” section of the book with a healthy dose of skepticism. I’ve added what I hope is a persuasive warning about how easy and dangerous it is to start blaming things we don’t really understand. [Updated section: Medical Factors That Perpetuate Pain: The effect of statin drugs, nutritional and hormonal deficiencies, infections, and inflammatory diseases.]

2021 — Polishing: Long overdue proofreading of the entire book, correcting several dozen typos that have snuck into it over the years. This is by far the longest of my books, and so it had by far the most typos, and no doubt there are still a few — but it’s greatly improved. Also for this project, I updated all references made to my work as a massage therapist, a great many of which still read like I have appointments schedule next week, when in fact I haven’t seen massage therapy client in over a decade now.

2021 — Added anecdote: Added a solid anecdote from a physician reader about “appendicitis” cases treated with lidocaine injections in the abdominal muscles. Also added some extra medical information about pain in this area. [Updated section: Trigger points may explain many severe and strange aches and pains.]

2021 — Improvements: More detail and polish, strain-counterstrain chapter [Updated section: Strain-counterstrain (AKA positional release): find a neutral, comfy position and rest there.]

2021 — Upgrades: More and better information, mostly achieved in this case by consolidating information from other books in the PainSci library. [Updated section: Nerve pain is overdiagnosed.]

2021 — Upgrade: Today I dug much deeper into the idea that trigger points are a kind of “injury,” especially an overuse injury. I am quite pleased with this update — genuinely interesting stuff. [Updated section: Other ideas about the nature of the beast.]

2021 — Improved: I have added much clearer and more thorough information about the difference between a strain (clear mechanism involving structural damage) and a trigger point (unclear mechanism, no obvious structural component). [Updated section: Could it be ________? Regional pains that trigger points get confused with.]

2020 — More info: Added some context about trigger point therapy as a “modality” to introduce the section. [Updated section: Types of therapists and doctors and their relationship to trigger point therapy.]

2020 — Science update: Added a citation to Smuck et al. [Updated section: Smoking.]

2020 — Minor update: Added some thoughts on the theme of “What could possibly go wrong?” — inspired by a particularly bizarre example that is both disturbing and yet entirely too typical of the industry. [Updated section: Quality control and safety issues (“But I’ve already tried massage therapy … ”).]

2020 — Science update: A small science update, but a significant one: the best quality study with negative results available to date. [Updated section: Maybe stabbing will help! Dry needling.]

2020 — Rewrite: A substantial upgzrade. This chapter had become embarrassingly basic, falling behind my personal knowledge. It now has more summaries of competing hypotheses about the nature of trigger points, one particularly important new one, and a big and entertaining list of examples of bad ones. More improvements and refinements soon, but this is a good start. [Updated section: Other ideas about the nature of the beast.]

2020 — New chapter: No notes. Just a new chapter. [Updated section: CASE STUDY: Chronic hip pain decisively resolved by unusually intense massage.]

Archived updates — All updates, including 155 older updates, are listed on another page.

2001 — Publication.



  1. Here’s a funny quote:

    Rocket science isn’t all that difficult. It’s not brain surgery.

    a rocket scientist

  2. Big promises are common on the internet, and it’s a problem when a treatment method or product is presented as being “good for” nearly any kind of pain problem. There are too many kinds of pain for any one idea to work for all of them.
  3. Stieven FF, Ferreira GE, Wiebusch M, et al. No Added Benefit of Combining Dry Needling With Guideline-Based Physical Therapy When Managing Chronic Neck Pain: A Randomized Controlled Trial. J Orthop Sports Phys Ther. 2020 Apr:1–21. PubMed 32272030 ❐

    There’s a full chapter on this topic later. For now, this is the freshest example of a good quality controlled trial of dry needling — and the results were thoroughly unimpressive.

  4. Massage therapists are generally poorly educated, overconfident, and notorious for pseudoscientific beliefs (here’s a collection of outrageous examples of the bizarre things massage therapists say). Their ideas about trigger point therapy specifically are often a perfect example: simplistic, out-dated, and rather “imaginative.” This discussion between massage therapists on Facebook contains many examples that are disturbing to anyone who knows the subject matter well. It’s not just how wrong they are, it’s how confidently wrong they are.
  5. Morikawa Y, Takamoto K, Nishimaru H, et al. Compression at Myofascial Trigger Point on Chronic Neck Pain Provides Pain Relief through the Prefrontal Cortex and Autonomic Nervous System: A Pilot Study. Front Neurosci. 2017;11:186. PubMed 28442987 ❐ PainSci Bibliography 53617 ❐

    One of many seemingly promising examples of positive controlled trials of massage for trigger points — but “it’s complicated.” Much more on this later. Suffice it to say massage probably does work sometimes, but it definitely hasn’t been proven.

  6. Commenting on two fascinating 2008 research papers (Chen and Shah), Dr. David Simons wrote, “Currently, consideration of the possibility of a myofascial trigger point component of the pain complaint is commonly not effectively included in the differential diagnosis and therefore is missed cold turkey, which can be very expensive for the health care system (expensive examinations looking for a phantom diagnosis) and disastrous to the patient (wrong diagnosis, wrong treatment).”
  7. Is pain really on the rise? It’s not certain that this is the case, nor clear why it would be, but there is plenty of suggestive evidence. A 2005 study in England (Harkness et al.) examined then-and-now data, comparing with the 1950s, reporting a “much higher” prevalence of body pain. In 2010 (Jiménez-Sánchez et al.), surveys of the Spanish population were mined for rates of serious musculoskeletal pain since the early 90s, finding that it “increased from 1993 to 2001.” A 2017 study (Wallace et al.) found that knee arthritis doubled in the 20th Century compared to 19th and prehistoric humans, but not because we’re heavier and living longer — something else is doing it.
  8. I was a Registered Massage Therapist with a busy practice in Vancouver, Canada, from 2000–2010, RIP. After that, science journalism and this website took over my career and they remain my sole focus today. See my bio.
  9. Chronic pain has hundreds of possible hard-to-diagnose causes, and many of them overlap with myofascial pain syndrome significantly. MPS is a “good fit” for a lot of people and probably can “explain” a lot of pain (if something so poorly understood can explain anything).

    But it’s very important to remember that MPS definitely cannot explain all pain!

  10. Quintner JL, Bove GM, Cohen ML. A critical evaluation of the trigger point phenomenon. Rheumatology (Oxford). 2015 Mar;54(3):392–9. PubMed 25477053 ❐

    This paper harshly criticizes the conventional wisdom about trigger points, and will be discussed in more detail later.

  11. Stieven FF, Ferreira GE, Wiebusch M, et al. No Added Benefit of Combining Dry Needling With Guideline-Based Physical Therapy When Managing Chronic Neck Pain: A Randomized Controlled Trial. J Orthop Sports Phys Ther. 2020 Apr:1–21. PubMed 32272030 ❐
  12. Gerwin RD, Dommerholt J, Shah JP. An expansion of Simons' integrated hypothesis of trigger point formation. Curr Pain Headache Rep. 2004 Dec;8(6):468–75. PubMed 15509461 ❐

    This paper spells out a hypothesis for trigger points as a muscle lesion. Not everyone agrees! Of course. Lots more detail about later.

  13. I am not talking about the places on our bodies that are naturally delicate and sensitive, like the hollow under your ear, but an abnormal sensitivity to pressure (a low “pain-pressure threshold”) in tissue that is usually not sensitive to pressure.
  14. Simons writes, “Many authors through the years have ‘discovered’ a ‘new’ muscle pain syndrome … .” For instance, the late Dr. John Sarno called it “tension myositis syndrome” in his popular books, stubbornly sticking to that label for his whole life, after coining it when he “discovered” MPS early on. Such discoveries are akin to Columbus ‘discovering’ America … much to the surprise of the locals. MPS has been named for the anatomical neighbourhood that a particular researcher happens to find it in. It has been thoroughly confused with fibromyalgia. It has been called fibrositis and muskelharten and myofascitis and myelgelosis. It has been stuck with the labels non articular or soft-tissue, rheumatism, osteochondrosis, and tendomyopathy. Every last one of them is a historical artifact.
  15. Other muscle injuries are often confused with trigger points. But a trigger point is not a regular whole-muscle spasm, or a “muscle strain” (torn muscle), which is an actual rip in muscle tissue that occurs suddenly and is instantly very painful. The differences will seem more obvious as you learn more about trigger points.
  16. Chronic pain mainly on or near joints, where your tendons connect to your bones, is more likely to be enthesitis, and the possibility of a rheumatic disease should be considered. See Mease et al., here’s a good infographic, and here’s a diagram of the spots to be aware of:

    Diagram of the 18 sites of pain highlighted by the SPARCC Enthesitis Index.

    Diagram of the 18 sites of pain highlighted by the SPARCC Enthesitis Index.

  17. This may seem obvious, but it’s actually disputed by some people, believe it or not. Like everything in biology, “it’s complicated,” but I think the argument was settled by a little science experiment in 2004 (Graven-Nielsen et al.), which showed that subjects could still feel pressure and painful pressure on muscles even with anaesthetized skin. I’ll bring this up again later on when we get deeper into the biology of TrPs.
  18. Smith DR. Prevalence and Distribution of Musculoskeletal Pain Among Australian Medical Students. Journal of Musculoskeletal Pain. 2007 Aug 29;15(4).

    It’s amazingly difficult to find hard data on the prevalence of musculoskeletal problems. However, this Australian study of medical students found that almost 90% of them had some kind of body pain problem, mostly in the neck, lower back and shoulders — and these are young people. It may not be an exaggeration to say that virtually the entire population of planet Earth has musculoskeletal pain!

  19. Travell J, Simons D, Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Lippincott, Williams & Wilkins; 1999. p. xi. Or, as stated more eloquently and authoritatively by Drs. Travell and Simons, “Myofascial trigger points are a frequently overlooked and misunderstood source of the distressingly ubiquitous musculoskeletal aches and pains of mankind.”
  20. Much more recently than in the previous footnote, in 2008, Dr. Simons writes: “Currently, consideration of the possibility of an MTP component of the pain complaint is commonly not … included in the differential diagnosis and therefore is missed cold turkey, which can be very expensive for the health care system (expensive examinations looking for a phantom diagnosis) and disastrous to the patient (wrong diagnosis, wrong treatment).”
  21. Calandre EP, Hidalgo J, Garcia-Leiva JM, Rico-Villademoros F, Delgado-Rodriguez A. Myofascial trigger points in cluster headache patients: a case series. Head & Face Medicine. 2008 Dec 30;4(32):32. PubMed 19116034 ❐ PainSci Bibliography 55349 ❐

    Although this research was “preliminary and uncontrolled” and is not powerful enough to prove anything, its results were certainly noteworthy — the sort of results that can inspire more research, hopefully. All of 12 patients with chronic cluster headaches (a kind of severe primary headache, nicknamed “suicide headaches”) had myofascial trigger points, and treating them (with injection) produced “significant improvement in 7 of the 8 chronic cluster patients.” The authors speculate that trigger points are not the cause of cluster headaches, but a nasty complicating factor: “chronic pain or repeated acute pain sensitize muscular nociceptors creating active trigger points which, in turn, contribute to potentiate headache pain. This kind of vicious cycle explains why the number of active trigger points has been found to be higher in patients with chronic primary headaches than in healthy subjects or in patients experiencing less frequent headache attacks.”

    This is just one interesting example of research on this topic. For a bigger picture view, see the next note.

  22. Do TP, Heldarskard GF, Kolding LT, Hvedstrup J, Schytz HW. Myofascial trigger points in migraine and tension-type headache. J Headache Pain. 2018 Sep;19(1):84. PubMed 30203398 ❐

    There is good evidence that people who get headaches — both migraine and “tension” — also have a lot of trigger points in the musculature of the head and neck. Unfortunately, we still have no idea which came first, the chicken or the egg: headaches might be causing trigger points, or trigger points might be causing headache. There is evidence pointing each direction, but all of it is all low quality and inconclusive. However, the simple correlation is relatively unambiguous: they are linked, we know that much at least.

    Although the authors of this review are likely somewhat biased — “believers” in the clinical significance of trigger points, and interpreting the evidence through that lens — their conclusions are appropriately cautious, acknowledging the limitations of the evidence.

  23. I believe that trigger points may be a by-product of the “volatility” of muscle. It’s a truism of engineering that the chance of a breakdown goes up with the number of moving parts. Muscle tissue is more powerful and biologically complex than most people give it credit for, and like any finely-tuned machine, perhaps it breaks down easily. I suspect that we get trigger points as a relatively small price to pay for having high-functioning muscle tissue, an evolutionary compromise. Higher function would require an escalating risk of dysfunction. Reduced function would probably result in fewer trigger points … but also in weaker and less responsive muscle.
  24. [Internet]. Office Place RSIs Decreased in 1994; 1996 Sep [cited 10 Nov 9].

    Estimates of the incidence of repetitive strain injuries generally range from 3-6% of all cases requiring time away from work. In comparison, MPS is ubiquitous. In my own clinical experience, treating RSIs represent a negligible fraction of my work, whereas MPS is either a cause or complicating factor in nearly every case I treat — including the RSIs! In 1996, Interiors and Sources magazine reported that, “the total number of serious injuries or illnesses attributed to all repetitive motion was just ... four percent of the total number of cases requiring time away from work. Of those, the majority of cases or 53 percent were recorded in the manufacturing sector ... ‘Clearly, most repetitive motion injuries are not occurring in the offices of America,’ said PJ Edington and executive director of the Center for Office Technology (COT). ‘And the so-called epidemic of office-related repetitive motion injuries reported in the media has been a clear case of misdiagnosis.’”

  25. There are several types of shin splints, and most of them have nothing to do with trigger points. However, the meaty part of the shin — the tibialis anterior muscle — is often the culprit. At least a few seemingly unbeatable cases of shin splints can be easily treated … if you know where and how to rub the tibialis anterior muscle.
  26. Most importantly, the rubber has never hit the road in the form of well-designed clinical trials of outcomes for patients: that is, do people actually get their pain problems solved by good quality trigger point therapy, well enough and often enough to be worth the costs? If treating trigger points works well as a therapy, then there should have been such studies more or less easily proving it many years ago — but there still aren’t. That’s a concern at this point in history.
  27. I’d put them somewhere in the middle of the range: trigger points are nowhere near as bad as a lot of common pseudoscience and quackery gets, but they certainly do fall well short of “proven” and well understood. At worst, they may even be a bad idea — a “legitimate misunderstanding,” an idea that was reasonable 20 years ago but which now needs to be retired or heavily revised.
  28. I acknowledge, discuss, and embrace the skeptical sources, conceding many of their key points. This is not something any other book about trigger point therapy does, as far as I know. But I also critically analyze the skeptical sources. I discuss the baked half of the half-baked science — because it is there. And I provide therapists and patients with many evidence-based justifications for trigger point therapy. It can be done in an ethical, educated way; “experimental” therapy can be completely acceptable with informed consent.
  29. Ingraham. A Historical Perspective On Aches ‘n’ Pains: Why is healthcare for chronic pain and injury so bad? 4042 words.
  30. Simons D. Foreword of The Trigger Point Therapy Workbook. 1st ed. New Harbinger Publications; 2001. The full quote reads: “Muscle is an orphan organ. No medical speciality claims it. As a consequence, no medical specialty is concerned with promoting funded research into the muscular causes of pain, and medical students and physical therapists rarely receive adequate primary training in how to recognize and treat myofascial trigger points. Fortunately, massage therapists, although rarely well-trained medically [BC being one of the obvious exceptions. — PI], are trained in how to find myofascial trigger points and frequently become skilled in their treatment.”
  31. Halperin I, Chapman DW, Behm DG. Non-local muscle fatigue: effects and possible mechanisms. Eur J Appl Physiol. 2015 Oct;115(10):2031–48. PubMed 26330274 ❐

    Wear out your glutes or pecs … feel it in your cloits n dloits? Some experiments have been able to demonstrate this weirdness, others have not, and so it’s ontologically ambiguous (see Behm). If it exists, it seems to involve multiple pathways: “neurological, biochemical, biomechanical, and psychological.”

    And, if it exists, it obviously has Interesting Implications. If muscles you didn’t even exercise can feel exhausted, it’s equally plausible that they can also suffer other consequences. Like pain.

  32. Travell J, Simons D, Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Lippincott, Williams & Wilkins; 1999. Vol 1, p13.
  33. Doctors are unqualified to care properly for most common pain and injury problems, especially the stubborn ones, and this has been proven by other doctors: Stockard et al. found that 82% of graduates lacked “basic competency” in this area. For more information, see The Medical Blind Spot for Aches, Pains & Injuries: Most physicians are unqualified to care for many common pain and injury problems, especially the more stubborn and tricky ones.
  34. “Structuralism” is the excessive focus on crookedness and “mechanical” problems as causes of pain. It has been the dominant way of thinking about how pain works for decades, and yet it is a source of much bogus diagnosis. Structuralism has been criticized by several experts, and many studies confirmed there are no clear connections between biomechanical problems and pain. Many fit, symmetrical people have severe pain problems! And many crooked people have little pain. Certainly there are some structural factors in pain, but they are generally much less important than messy physiology, neurology, psychology. Structuralism remains dominant because it offers comforting, marketable simplicity. For instance, “alignment” is the dubious goal of many major therapy methods, especially chiropractic adjustment and Rolfing. See Your Back Is Not Out of Alignment: Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain.
  35. And it certainly felt like it at times.
  36. Travell J, Simons D, Simons L. Myofascial Pain and Dysfunction: The Trigger Point Manual. 2nd ed. Lippincott, Williams & Wilkins; 1999.
  37. Mense S, Simons DG, Russell IJ. Muscle pain: understanding its nature, diagnosis and treatment. 1st hardcover ed. Lippincott Williams & Wilkins; 2000.

    A dense text, important reading for professionals.

  38. And not impossible reading, either. Over the last twenty years, I have seen quite a few keen patients tackle Travell and Simons’ massive red texts and get some good value from them. The diagrams are exceptionally clear, and the writing is generally good. So it’s not out of the question for patients to try to work with them. But they are expensive reference books, filled with jargon, and intended for clinicians who are dealing with every area of the body on a daily basis. Also, they arguably have serious flaws, so there’s that too.
  39. Here’s Dr. Fred Wolfe’s technical but readable definition of fibromyalgia, from a 2013 blog post. Dr. Wolfe is a rheumatologist with a long history of expertise about trigger points and fibromyalgia:

    Fibromyalgia is a name given to a clinical syndrome whose main features currently are the presence of chronic pain simultaneously in many areas of the body together with multiple somatic symptoms. In particular, persistent and substantial fatigue, sleep disturbance and cognitive difficulties are among the most common of the symptoms. Decreased pain threshold is almost always found, and is strongly correlated with the extent of body pain. Because the symptoms and their intensity are variable, the boundaries of fibromyalgia are somewhat indistinct. The identification of fibromyalgia is based on the overall severity of symptoms. The gold standard for necessary severity was set by the 1990 American College of Rheumatology (ACR) criteria: roughly, it is the level of symptoms found in persons with ≥11/18 tender points when examined by capable examiners. As fibromyalgia symptoms at less than criteria level are often found before fibromyalgia is diagnosed, it is uncertain when fibromyalgia begins. There are no consistent clinical laboratory or imaging abnormalities.

  40. Ehrlich GE. Pain is real; fibromyalgia isn't. J Rheumatol. 2003 Aug;30(8):1666–7. PubMed 12913918 ❐ PainSci Bibliography 54771 ❐

    When one has tuberculosis, one has tuberculosis, whether or not it is diagnosed. The same is true for cancer, rheumatoid arthritis, hookworm infestation — really, of the gamut of diseases. But not for fibromyalgia (FM). No one has FM until it is diagnosed.

  41. The tender points are a diagnostic tool. They aren’t sore because there’s something wrong in that location: they are sore because FM makes everything sore, and it just happens to be most obvious at those carefully chosen spots.
  42. Staud R. Are tender point injections beneficial: the role of tonic nociception in fibromyalgia. Curr Pharm Des. 2006;12(1):23–27. “ … interventions aimed at reducing local FM pain seem to be effective but need to focus less on tender points but more on trigger points (TrP) and other body areas of heightened pain … .”
  43. Li YH, Wang FY, Feng CQ, Yang XF, Sun YH. Massage therapy for fibromyalgia: a systematic review and meta-analysis of randomized controlled trials. PLoS One. 2014;9(2):e89304. PubMed 24586677 ❐ PainSci Bibliography 53919 ❐

    This is a review of massage therapy for fibromyalgia that epitomizes the “garbage in, garbage out” problem with meta-analysis: there was virtually no research on this topic worth analyzing to begin with, and trying to pool the results of several weak studies is meaningless. To the extent that the study results are generally inconclusive and ambiguous, the conclusions of any review are going to have more to do with the authors’ opinions and biases than hard data. In this case, they report “significant” positive results without mentioning that they only mean “statistically significant,” and the effect size is barely-there — clinically insignificant. They also boast about traditional Chinese massage in the abstract, which is odd. And they fail to note that much of the data did not even measure the effect on pain, just mood. So here’s my conclusion: whoop-de-doo. There’s really nothing here, except maybe massage for fibromyalgia being damned by faint, ambiguous praise.

    I’ve written several more paragraphs about this paper in Does Massage Therapy Work?

  44. Travell et al., op.cit. (Virtually all information in this article is drawn from Travell and Simons, so I won’t cite page references for every instance.) The subscapularis case is a good example of how MPS is probably much more clinically significant than RSIs: not only is MPS a causal or complicating factor in many RSIs, it frequently imitates them and is the correct diagnosis! This is why at least some RSIs do not respond to conventional treatment.
  45. It’s possible to richly reference this section with individual scientific papers backing up every single example of trigger points mimicking some other health problem. This kind of information is everywhere in the MPS literature. For now, here’s just one of many, a 1995 paper, “Myofascial pain syndromes — the great mimicker”.
  46. There’s a large body of research about this, but Rocha is a good recent example. In 2007, these researchers found that “in 56% of patients with tinnitus and MTPs, the tinnitus could be modulated by applying digital compression of such points, mainly those of the masseter muscle.” And how many people with tinnitus had trigger points? Quite a few. The researchers found “a strong correlation between tinnitus and the presence of MTPs in head, neck and shoulder girdle.”
  47. Fernández-de-Las-Peñas C, Galán-Del-Río F, Alonso-Blanco C, et al. Referred pain from muscle trigger points in the masticatory and neck-shoulder musculature in women with temporomandibular disoders. J Pain. 2010 Dec;11(12):1295–304. PubMed 20494623 ❐

    This study compared 25 healthy women to 25 others with temporomandibular disorders (TMD). Trained examiners looked for trigger points (without knowing which group they were in), specifically in the neck and jaw muscles. According to the criteria they used, they found more and worse trigger points in the women with TMD (where by “worse” I mean larger areas of referred pain). The trigger points in the neck produced more referred pain that those in the jaw muscles.

  48. This is one I know well from personal experience: a couple of times per year, I get a disturbing achy lump in my throat, a hitch in my swallow. It used to get me worried and anxious and thinking about going to the doctor. Then I discovered that it’s closely associated with a recurring patch of sensitivity in the muscles under my jaw, in the upper throat … and it can be massaged away in about a minute. I have been doing this successfully for several years now.
  49. Note that appendicitis pain is usually located in the right iliac fossa (the lower right quarter of the belly), although it can vary. There are several many possible causes of pain in this area, and kidney infections are probably the most common. We have no idea how often trigger points are to blame, but at least “occasionally,” based on anecdotes (see next note). If the pain is caused by a trigger point, it (the sensitive muscle tissue) is most likely to be on the edge of the rectus femoris muscle, a little higher and further out than classic appendicitis pain. But the exact location of pain from either or any cause is somewhat variable.
  50. I received an interesting substantiating anecdote about this phenomenon from Dr. Mike Foley of Middlesbrough, UK, a “senior anaesthesiologist, used to managing post operative pain in a conventional way.” He writes:

    When I was a junior surgical resident my boss showed me how to locate trigger points at the lateral border of rectus abdominis in patients who’d been admitted with possible appendicitis but no signs of systemic illness, just pain. If we found a trigger point and injected a few millilitres of a local anaesthetic drug such as lidocaine, and if the pain disappeared, we’d rule out appendicitis as a diagnosis and save the patient an unnecessary surgery. I never saw any other surgeon do this unconventional trick but it impressed me as it clearly worked in some patients.

    If you can treat severe abdominal pain in some patients with a superficial injection of lidocaine, it’s not proof of anything specific wrong with abdominal muscles — no anecdote is “proof” of anything, of course. But it sure does strongly suggest that there is a painful non-appendicitis phenomenon going on! And it responds to an injection. And that’s remarkable, no matter how it works, even if it’s just a placebo that has nothing to do with muscle tissue.

  51. The iliopsoas muscle (“illy-oh so-ass”) is a two-in-one hip flexing pair, mostly only palpable through the guts. Its clinical importance is often curiously exaggerated, but sometimes it does need a massage. For more information, see Psoas, So What? Massage therapy for the psoas major and iliacus (iliopsoas) muscles is not that big a deal. Except when it is.
  52. As discussed above, such “structural” misdiagnoses are a common red herring, and almost always wrong. Mistaking a gluteus maximus trigger point for sacroiliac joint pain is a particularly common diagnostic error. See Massage Therapy for Low Back Pain (So Low That It’s Not In the Back) for more about this particular area.
  53. This is one of the “perfect spots” for massage: spot #12, specifically. SHOW SPOT 12 DIAGRAM For more information, see Massage Therapy for Low Back Pain (So Low That It’s Not In the Back).
  54. Literally every kind of therapy has stories like this, even complete and utter nonsense therapies, even treatments that are actually hurting people, like drinking mercury or bleach, or using old-timey radiation treatments. If many people can sincerely believe that such things are helping them — and they really do — then how are we to ever believe any treatment success story? Well, we really shouldn’t. The key is not to “believe,” to take everything with a grain of salt, and consider all factors. There are many reasons to suspect that at least some trigger point therapy testimonials are actually accurate — or I wouldn’t have written this book.
  55. Perhaps just a couple of magic touches. Here’s another question I received by e-mail: “If a massage therapist told you that all he had to do was touch a trigger point with one finger, then touch you somewhere else on the body far from the trigger point with his other hand, that the trigger point would vanish instantly. Is that true?”
  56. For instance, what if trigger points are present as a complication of the early stages of an undiagnosed disease like multiple sclerosis? This is possible! There are many medical factors that make treatment impossible or nearly so. A much more common example is smoking, which makes treatment so difficult that some physicians consider quitting a prerequisite for all other treatment.
  57. There are literally hundreds of obscure problems that can cause or significantly complicate pain, but you can narrow it down to a few dozen if you stick to the more common ones that are notorious for evading diagnosis and causing mainly pain. Classic examples include drug side effects, vitamin D deficiency, sleep disorders, spinal cord irritation (myelopathy), the early stages of some diseases, “inflammaging” (the slow but steady ramping up of widespread inflammation as we age and get out of shape, metabolic syndrome), and so on.

    And trigger points!

    For a more thorough tour through all the hair-raising possibilities, see 38 Surprising Causes of Pain. I’ll also discuss many of these as they relate to trigger points.

  58. All serious infections lower our pain thresholds so far that we can get into that “everything hurts” state. The body aching, fragility, exhaustion, and feverishness that kick off most systemic infections — COVID-19 more than most, actually — is a function of our immune system reaction to the invasion, rather than the actual damage done by the virus. This exposes existing vulnerabilities like a rock exposed by a low tide, but the pain threshold can get lowered so far that tissues hurt even if there’s nothing wrong with them at all. At its simplest, the clinical phenomenon of trigger points is defined by increased sensitivity to pain at a specific location. An infection causes the same thing, just much more spread out. It kind of turns your whole body into one giant trigger point!

There are 421 more footnotes in the full version of the book. I really like footnotes, and I try to have fun with them.

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