I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of ScienceBasedMedicine.org for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about me • more about PainScience.com & Tim Taylor, MD
This is an online e-book: a detailed, current (2017), and practical tour of the science and treatment of muscle pain and trigger points (muscle “knots”), for both patients and professionals.
What are the controversies and myths about muscle pain? What works for muscle pain, what doesn’t, and why? Get many troubleshooting ideas for even the toughest cases — more than the popular Trigger Point Therapy Workbook,1 more readable (and modern) than the famous Travell texts, and more realistic and honest than any other source.
Many people suffer from sensitive spots in muscle, known as “trigger points.” And yet trigger point therapy is not rocket science.2 You just need a good selection of rational options: creative tips, tricks, insights and perspectives, based on recent science and years of clinical experience.
Trigger point therapy is experimental and a bit of a crapshoot, and yet learning even a little about trigger points can solve many pain problems easily. If you feel like you have problems with stubborn and unexplained aching and stiffness — and who doesn’t, really? — please keep reading!
About footnotes. There are 332 footnotes in this document. Click to make them pop up without losing your place. There are two types: more interesting extra content,1Footnotes with more interesting and/or fun extra content are bold and blue, while dry footnotes (citations and such) are lightweight and gray. Type ESC to close footnotes, or re-click the number.
and boring reference stuff.2“Boring” footnotes usually contain scientific citations from my giant bibliography of pain science. Many of them actually have pretty interesting notes.
It may be more literally true than you realized! Some evidence shows that a knot may be a patch of polluted tissue: a nasty little cesspool of waste metabolites. If so, it’s no wonder they hurt, and no wonder they cause so many strange sensations: it’s more like being poisoned than being injured. Back pain is the best known symptom of the common muscle knot, but they can cause an astonishing array of other aches and pains. Misdiagnosis is much more common than diagnosis.
Trigger point therapy is not a miracle cure for chronic pain — but it helps
Trigger point therapy isn’t “too good to be true” — it’s just ordinary good. It’s definitely not miraculous.3 It’s experimental and it often fails.4 Good trigger point therapy is hard to find (or even define).
But it’s also under-rated, and self-treatment has the potential to quickly, cheaply, and safely help with many common pain problems that don’t respond well — or at all — to anything else.5
pro Attention physicians & therapists: This massive tutorial is written for both patients and professionals. It includes analysis of recent research that you won’t find in any text, crafted to suit any skill level.6 Footnotes add a optional layer of advanced detail that you can take or leave.
Trigger points are more clinically important than most health professionals realize, and body pain seems to be a growing problem.7 It’s a rewarding topic for doctors and therapists, that makes clear path to helping quite a few people you probably couldn’t help before. Even if you already know about myofascial pain syndrome, you will get new ideas here.
For beginners with average muscle pain — a typical case of nagging hip pain or low back pain or neck pain — the advice given here may well seem almost miraculously useful. I get avalanches of email from readers thanking me for pointing out simple treatment options for such irritating problems. Many are stunned by the discovery that their chronic pain could have been treated easily all along.
For veterans who have already tried — and failed — to treat trigger points, this document is especially made for you. You should learn more and try more before giving up. This will get you as close to a cure as you can get; I can give you a fighting chance of at least taking the edge off your pain. And maybe that is a bit of a miracle.
There are no actual knots involved, of course — it just feels like it. Although their true nature is uncertain, the main theory is that a trigger point (TrP) is a small patch of tightly contracted muscle, an isolated spasm affecting just a tiny patch of muscle tissue (not a whole-muscle spasm like a “charlie horse”9). In theory, that small patch of muscle chokes off its own blood supply, which irritates it even more — a vicious cycle called a “metabolic crisis.” The swampy metabolic situation is why I like to think of it as sick muscle syndrome.
A “muscle knot” is a trigger point: a small patch of muscle tissue in spasm.
A few trigger points here and there is usually just an annoyance. Many bad ones is a syndrome: myofascial pain syndrome (MPS).
TrPs can be vicious. They can cause far more discomfort than most people believe is possible. Its bark is much louder than its bite, but the bark can be extremely loud. It can also be a surprisingly weird bark (trigger points can generate some odd sensations).
Why muscle pain matters so much
Muscle pain matters: it’s an important problem. Aches and pains are an extremely common medical complaint,10 and trigger points seem to be a factor in many of them.1112 They are a key factor in headaches (possibly including migraine and cluster headaches as well1314), neck pain and low back pain, and (much) more. What makes trigger points clinically important — and fascinating — is their triple threat. They can:
cause pain problems,
complicate pain problems, and
mimic other pain problems.
Muscle just hurts sometimes. Trigger points can cause pain directly. Trigger points are a “natural” part of muscle tissue.15 Just as almost everyone gets some pimples, sooner or later almost everyone gets muscle knots — and you get 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.16 A perfect example: shin splints.17
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 science of trigger points is a bit shabby. They are under-explained.
Unfortunately, “good information” is a challenge with trigger points. The science is a bit shabby.18 They are under-explained. They are over-hyped. They aren’t a flaky diagnosis,19 but they’re not exactly on a solid foundation either, and some critics have dismissed the entire concept.20
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 going on, and everyone agrees that something painful is going on. 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? What’s half-baked and obsolete? Who disagrees and why?
Half-baked ideas can turn out okay as long as they stay in the oven. Trigger point science may be a bit of a hot mess, but it also isn’t over.
Why are trigger points so neglected by medicine?
“Muscle is an orphan organ. No medical speciality claims it.”21 Muscle tissue is the largest organ in the body, complex and vulnerable to dysfunction, and 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.”22 Family doctors are particularly uninformed about the causes of musculoskeletal aches and pains23 — it simply isn’t on their radar. They are busy with a lot of other things, many of them quite dire. As serious as muscle pain can be, it’s minor compared to, say, diabetes or heart disease. And it’s also a harder topic than it seems to be on the surface. 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 tend to know about trigger points. But they also often limit their treatment methods exclusively to injection therapies — a bazooka to kill a mouse? — and anything less than really epic chronic pain 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 aren’t all that helpful to the average patient.
An appallingly high percentage of doctors and other practitioners are still pretty much out of the loop regarding trigger points.
Physical therapists and chiropractors are often preoccupied to a fault with joint function, biomechanics,24 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 world25), 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,26 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.
Must-have text books for any therapist treating trigger points.
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 Dysfunction27 — and “the blue book, Muscle Pain28 These are not easy reading!29
They don’t contain all the answers, but anyone who claims to treat muscle pain should still have the big red books books in their office — they are just too historically important not to have. If you don’t see dog-eared copies, ask about them — it’s a fair, effective and polite way to check a therapist’s competence. Muscle Pain (the blue one) is just as important. I highly 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.
A brief note about the relationship between fibromyalgia and myofascial pain syndrome
Fibromyalgia (FM) is an illness of “hurting all over” — widespread chronic pain and decreased pain threshold. It is also associated with fatigue, sleep disturbance, and “fibro fog” (mental confusion). It is defined by its symptoms,30 because we don’t know what actually causes it — so people have pain, but “no one has FM until it is diagnosed.”31 Here’s a good 1-minute primer on fibromyalgia from One-Minute Medical School:
Although unexplained, FM might be a more clearly neurological disease, while MPS may be more of problem muscle tissue. It would be nice if such a clear distinction were established someday. Fibromyalgia & myofascial pain syndrome are harder to tell apart than mischievous twins who deliberately impersonate each other.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. I think it’s almost likely that there is 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.32
Whatever the causes or labels, therapeutic approaches for MPS seems to be helpful for some FM patients as well,33 although pure FM cases seem to be mostly immune to massage.34 But this book is still useful for many FM patients, insofar as it overlaps with our main topic. Dr. Taylor’s advice about medical causes of pain are especially helpful; his wife is also a doctor and has fibromyalgia and has gotten considerable relief from the recommendations shared here. So this is not a fibromyalgia book, per se … but I certainly hope it’s of interest to fibromyalgia patients.
Trigger points may explain many severe and strange aches and pains
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 a muscle in their armpit (subscapularis).35 Seriously. I’m not making that up!
This odd phenomenon of pain spreading from a trigger point to another location is called “referred pain.” The neurology will be explained in detail below. Here are some other examples of interesting referred pain leading to misdiagnosis:36
Sciatica (shooting pain in the buttocks and legs) is often caused by pain in the piriformis or other gluteal muscles, and not by irritation of the sciatic nerve. Many other trigger points are mistaken for “some kind of nerve problem.”
Chronic jaw pain, toothaches, earaches, sinusitis, ringing in the ears (tinnitus), and dizziness may be symptoms of trigger points in the muscles around the jaw, face, head and neck.3738
A sore throat or a lump in the throat is often caused or aggravated by trigger points anywhere around the throat.39
“Appendicitis pain” often turns out, sometimes after surgery, to be caused by a trigger point in the abdominal muscles. Wow.
Severe MPS is often mistaken for fibromyalgia (and other causes of pain hypersensitivity).
Sometimes trigger points cause such severe 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. 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 and quickly relieved by massaging a trigger point in her psoas major muscle.40
I once suffered a dramatic case of a “toothache” that was completely relieved by a massage therapist the day before an emergency appointment with the dentist: a particularly vivid experience.
However, the vast majority of 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.
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 relationship between trigger points and mild-to-moderate pain is often so straightforward that therapy is nearly effortless. One of the nice things about working with trigger points is that sometimes they do make me seem like a miracle worker, because they are such a clinical “slam dunk” for garden variety persistent pain — pain undiagnosed and untreated by a string of other health professionals.
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.41 But she had a prominent gluteus maximus trigger point42 that, when stimulated, felt exactly like her symptoms — a deep ache in the region of the low back and upper gluteals. In just three appointments, her pain was completely relieved. 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 either a bursitis or a piriformis strain. I did not believe that either of these could be the case, 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 trigger point therapist has a seemingly endless list of such treatment success stories. 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!
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 shows 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.43 The idea is an annoyance to all honest, humble professionals who know better … and more or less impossible to believe if you know the basics about pain and muscle knots. The skill of a therapist is only one relatively minor factor among many that affect the success of massage therapy for trigger points — or any therapy, for any pain problem.
Even the best therapists can be defeated by a no-win situation & nearly any therapist can luck out & get great results with the occasional patient when all the planets are aligned.
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.44 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. It really depends.
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.
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 problems. Because of their medical obscurity and the half-baked science, they are often the last thing to be considered in spite of their clinical importance and many distinctive characteristics. There are several things you can look for that will help you to feel more confident that, yes, muscle pain is the problem instead of something else. The next several sections will discuss all of them in detail.
Whether you knew it or not, you were probably already familiar with trigger points even if you’d never heard of them before starting this tutorial.
Almost everyone has a head start in self-diagnosing trigger points, because almost everyone already more or less knows what it’s like to have a muscle knot. If you have ever had muscle stiffness, wrenched your neck around trying to stretch and wiggle your way free of discomfort, or gotten a friend or partner to dig into that annoying spot in your back, then you already have some experience with this — you have trigger points. You have pain and stiffness that feels like it’s in your muscles.
But there may be many things you don’t yet know about how trigger points behave and feel…
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TABLE OF CONTENTS PREVIEW
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all myths & controversies
all diagnostic issues
all treatment options
Science 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.
Correction () — Small but important correction about the value of opioids in severe cases that resemble fibromyalgia.
Simplified () — 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.
Safety update () — Updated for consistency with new CDC guidelines. Thorough editing of the section.
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Q Does your tutorial include diagrams showing common trigger points?
AYes, thirteen classic trigger points are explored, the “Perfect Spots” for massage, accounting for about 75% of common pain problems. Other reference material is reviewed and recommended, especially the best free online option, The Trigger Point Symptom Checker.
Q Will the tutorial solve my problem? What if it doesn’t?
AMaybe! But, naturally, I can’t guarantee “results” … and I don’t want to. I don’t believe in giving false hope, and trigger point therapy is far from perfect. My goal is to give you the best chance of success, and help you avoid wasting your time and money on bollocksy therapies. If that’s not worth $20, I should get out of the publishing business.
Q Does the tutorial include information on [insert your pain problem]?
AProbably not! Many specific pain problems are mentioned, but the book doesn’t go into detail about any of them. Once you understand the nature of trigger points, you don’t really need me to spell out their relationship to every common injury. Trigger points cause and complicate all injuries in quite predictable ways — that’s why they are clinically interesting!
Q Why not The Trigger Point Therapy Workbook?
A Clair and Amber Davies’ popular book is well-written. It is illustrated nicely, and offers detailed muscle-by-muscle reference material — something this tutorial actually deliberately lacks.
The Workbook promises too much and neglects relevant science.
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, and probably never will.
The strength of this tutorial is the delving into the nature of the beast (the science), while Workbook has fallen behind the times. The 3rd edition (2013) promises too much and neglects important new knowledge. Trigger point therapy has been challenged by many scientific disappointments and controversies, and new ways of understanding pain, but the Workbook doesn’t acknowledge any of that. This topic is too important for such neglect.
The goal of this tutorial is to offer a more realistic and balanced view of trigger point therapy, to meet the challenge of difficult cases head on, and to explore every possible treatment option — their potential and their limits and risks. I believe it has been doing a better job of that than the Workbook from the beginning… now more than ever.
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Appendix C: Trigger Point Therapy Resources
Where are Appendices A and B? They are included in the full, paid version of this document. Appendix D is included as a free sample, like the introductory sections.
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 rename nameless):
You say it’s hard for patients to find good trigger point therapy. You shouldn’t say that! We certify good trigger point therapists!
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.
Well, you still shouldn’t say that it’s hard to find them!
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.
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 shown with the pro and patient icons. For instance, although professional associations are rarely of much interest to patients, they may provide directories of professionals to help patients find practitioners.
With apologies to my international readers, this section is mostly American-o-centric. If you are aware of important resources and organizations elsewhere in the world, please let me know.
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 focussed on muscle pain.
The Pressure Positive Companypropatient — 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.
Certification Board for Myofascial Trigger Point Therapists — propatient 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.
David G. Simons Academy (DSGA)propatient — 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 Seminarspropatient — A post-graduate continuing education company focussing on myofascial trigger points, manual trigger point therapy, dry needling, and trigger point injections. Like DSGA, Myopain Seminars is focussed 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.
This document and all of PainScience.com was, for many years, created in my so-called “spare time” and with a lot of assistance from family and friends. Undying thanks to my wife, Kimberly, for countless indulgences large and small, and for being my “editor girlfriend”; to my parents for (possibly blind) faith in me, and much copyediting; and to Mike Gobbi, buddy and digital mentor, for many of the nifty features of this document (hidden and obvious). And thanks to all of the above, and many others, for many (many) answers to “what do you think of this?” emails.
Thanks finally to every reader, client, customer, and big tipper for your curiosity, your faith, and your feedback and suggestions and stories. Without you, all of this would be pointless.
Thank you finally to Dr. Tim Taylor, MD, author of this book’s vital sections about medical factors that perpetuate pain, new as of the summer of 2010. More than a collaborator, Tim is an idealistic and decisive volunteer, who didn’t just offer to contribute to this book, but made it happen quickly and well and all for the sake of helping people. In twenty years of writing and publishing, I have never seen a collaboration go that smoothly, and I am extremely grateful for it.
What’s new in this tutorial?
Regular updates are a key feature of PainScience.com 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 105 major and minor updates since I started logging carefully in late 2009 (plus countless minor tweaks and touch-ups).
Most links to sections shown here work for customers only. For access to all sections, buy the tutorial for $19.95. You’ll get the full version right away.
Science update (, section #7.5) — Added a few new citations about the prevalence of vitamin D deficiency and it’s correlation with chronic pain.See section #7.5, Vitamin D deficiency.
Rewrite (, section #8.5) — A new way of looking at how trigger points cause the sensation of “stiffness” and what happens when we try to stretch them out.See section #8.5, Like a knot in a bungie cord.
Important 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.
Major update (, section #5.38) — 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.See section #5.38, Troubleshooting negative reactions to treatment.
Major rewrite (, section #3.15) — 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!See section #3.15, “The bamboo cage” — what immobilization torture can tell us about the nature of muscle pain and massage.
Science update (, section #7.5) — 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.See section #7.5, Vitamin D deficiency.
Major 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.
Major update (, section #7) — 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.See section #7, Medical Factors That Perpetuate Pain: The effect of statin drugs, nutritional and hormonal deficiencies, infections, and inflammatory diseases.
Minor 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.
New cover () — At last! E-book finally has a “cover.”
New section (, section #11.2) — 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.See section #11.2, Appendix B: The Perfect Spots.
Major 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.
Many 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.
The most popular trigger point book for patients is still The Trigger Point Therapy Workbook: Your self-treatment guide for pain relief, by Clair & Amber Davies. Unfortunately, it was scientifically weak when the first edition was published in 2001, and it still is after a new edition in 2013. It ignores some important scientific findings and controversies of the last 20 years, and promises too much.
Many people have written to me over the years to tell me how the Workbook did not really do the trick for them, but this tutorial did. The Workbook’s qualities and limitations are reviewed more thoroughly elsewhere.
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. BACK TO TEXT
Sorry to be the bearer of bad news. The reality is harsh, a major downer. I will get back to this: the difficulties pain patients face in getting good, effective care is an serious and complicated problem. I’ll deal with it in considerable detail later on in the book. In particular, I’ll do my best to substantiate the accusation that a lot of care is poor quality — which many professionals take exception to, of course. BACK TO TEXT
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).” BACK TO TEXT
There is a bit of “neato” in any good research. Making it understandable and interesting for all kinds of readers is simply a matter of expressing that. BACK TO TEXT
It’s not certain that this is the case, nor why it would be. However, there is certainly plenty of suggestive evidence. Consider a recent Spanish study (Jiménez-Sánchez et al): studying health surveys of the population of Spain, researchers looked for changes in rates of serious musculoskeletal pain since the early 90s, finding that it “increased from 1993 to 2001, but remained stable from the last years (2001 to 2006). BACK TO TEXT
Simons writes, “Many authors through the years have ‘discovered’ a ‘new’ muscle pain syndrome ….” For instance, the popular Dr. John Sarno is still stubbornly calling it “tension myositis syndrome” to this day, the term he invented when he “discovered” MPS. Such discoveries are akin to Columbus ‘discovering’ America … much to the surprise of the natives. MPS has been named for the anatomical neighbourhood that a particular researchers 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. BACK TO TEXT
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. BACK TO TEXT
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!
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.” BACK TO TEXT
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).” BACK TO TEXT
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 migraine, 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.”
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. BACK TO TEXT
InteriorsAndSources.com [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.’”
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 shins splints can be easily treated … if you know where and how to rub the tibialis anterior muscle. BACK TO TEXT
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. BACK TO TEXT
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. BACK TO TEXT
Quintner, Cohen, and Bove think the most popular theory about the nature of trigger points (muscle tissue lesions) is “flawed both in reasoning and in science,” and that treatment based on that idea gets results “indistinguishable from the placebo effect.” They argue that all biological evidence put forward over the years is critically flawed, while other evidence leads elsewhere, and take the position that the debate is over. (They also point out that the theory is treated like an established fact by a great many people, which is definitely problematic.) However, their opinion is extreme, and most experts do not think we should throw out all the science so far (see Dommerholt et al).
This controversial opinion is discussed in more detail later.
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, see Massage Therapy In British Columbia, Canada — PI], are trained in how to find myofascial trigger points and frequently become skilled in their treatment.” BACK TO TEXT
“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 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 and neurology. 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.BACK TO TEXT
And not impossible reading, either. Over the course of a decade, I have seen several keen patients tackle Travell and Simons’ massive red texts and get good value from them. The diagrams are exceptionally clear, and the writing is generally quite good. 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. BACK TO TEXT
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.
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.
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. BACK TO TEXT
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 a much of the data did not even measure the effect on pain, just mood. So here’s my conclusion: whoopty-do. There’s really nothing here, except maybe massage for fibromyalgia being damned by faint, ambiguous praise.
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. BACK TO TEXT
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”. BACK TO TEXT
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.” BACK TO TEXT
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.
This is one I know well from personal experience: a couple of times per year, I get a disturbing achey 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. BACK TO TEXT
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?” BACK TO TEXT
For instance, what if trigger points are present mainly due to an incurable neurological disease like fibromyalgia? There are many significant medical factors that make treatment impossible or nearly so. A much more common example is smoking, which makes treatment so difficult that my co-author, Dr. Tim Taylor, will not accept smokers as patients. BACK TO TEXT
There are 288 more footnotes in the full version of this book. I like footnotes, and I try to have fun with them.